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Concise Anatomy

for Anaesthesia
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Concise Anatomy
for Anaesthesia

Andreas G Erdmann
Fellow in Pain Management
London
Specialist Registrar in Anaesthesia
East Anglian Deanery

London San Francisco


Greenwich Medical Media
4th Floor, 137 Euston Road,
London
NW1 2AA

870 Market Street, Ste 720


San Francisco
CA 94109, USA

ISBN 1841100692

First Published 2001

Apart from any fair dealing for the purposes of research or private study,
or criticism or review, as permitted under the UK Copyright Designs
and Patents Act 1988, this publication may not be reproduced, stored,
or transmitted, in any form or by any means, without the prior
permission in writing of the publishers, or in the case of reprographic
reproduction only in accordance with the terms of the licences issued
by the appropriate Reproduction Rights Organisations outside the UK.
Enquiries concerning reproduction outside the terms stated here should
be sent to the publishers at the London address printed above.

The rights of Andreas Erdmann to be identified as author of this work


have been asserted by him in accordance with the Copyright Designs
and Patents Act 1988.

The publisher makes no representation, express or implied, with regard


to the accuracy of the information contained in this book and cannot
accept any legal responsibility or liability for any errors or omissions that
may be made.

A catalogue record for this book is available from the British Library.

gm@greenwich-medical.co.uk

Distributed worldwide by Plymbridge Distributors Ltd and in the USA


by Jamco Distribution

Typeset by Phoenix Photosetting, Chatham, Kent


Printed by The Alden Group, Oxford
Contents

Foreword vii Lumbar 54


Preface ix Sacrococcygeal 56
18. The major peripheral nerves 60
Upper limb 60
Respiratory System Lower limb 62
1. The mouth 2 Abdominal wall 66
2. The nose 4 Intercostal nerves 66
3. The pharynx 6 19. The autonomic nervous system 70
4. The larynx 8 Sympathetic 70
5. The trachea 14 Parasympathetic 72
6. The bronchi and bronchial 20. The cranial nerves 76
tree 16
7. The pleura and mediastinum 18 Appendices
8. The lungs 20 1. Dermatomes of arm 88
9. The diaphragm 22 2. Dermatomes of leg 89
Sample questions 24 3. Dermatomes of trunk 90
Sample questions 91

Cardiovascular System
10. The heart 26 Vertebral Column
11. The great vessels 30 21. The vertebrae 94
Aorta 30 22. The vertebral ligaments 100
Great arteries of the neck 30 Sample questions 101
Arteries of the limbs 32
Major veins 34
12. Fetal circulation 38 Areas of Special Interest
Sample questions 40 23. The base of the skull 104
24. The thoracic inlet 108
25. The intercostal space 112
26. The abdominal wall 114
Nervous System 27. The inguinal region 116
13. The brain 42 28. The antecubital fossa 118
14. The spinal cord 44 29. The large veins of the neck 120
15. The spinal meninges and 30. The axilla 122
spaces 47 31. The eye and orbit 124
16. The spinal nerves 50 Sample questions 128
17. The nervous plexuses 52
Cervical 52
Brachial 52 Index 137
v
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Foreword

When I first started my anaesthesia job, it modern anaesthetic practice. It will be


did not take me long to realise that I was invaluable as a revision text for the
going to have to relearn a lot of anatomy FRCA, but will also help anaesthetists to
that had been implanted in my short- retain anatomy knowledge throughout
term memory during the second MB. I their careers. It will be useful for
was, incorrectly, under the impression consultants teaching trainees and also for
that anatomy was the sole preserve of the other theatre personnel to understand the
surgeon. procedures carried out by anaesthetists.
From the moment that a career in I am sure that generations of anaesthetists
anaesthesia is started, anatomy plays a will be grateful to Dr Erdmann for
part. Dr Andreas Erdmann decided to providing such a simple and
write this book following his experiences comprehensive review of an essential
during the final FRCA examination. The subject.
idea is a simple one, combining simple
line diagrams and succinct text to cover Richard Griffiths MD FRCA
all of the areas of anatomy essential to Peterborough, June 2001

vii
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Preface

The origin of this concise book of constraints of this book to provide in-
anatomy results from many comments depth detail and this should be obtained
from FRCA examination candidates. by reference to some of the larger
Anatomy has always played an important textbooks. Sample questions are included
role in the examination syllabus, as well at the end of each section, and include
as being of great practical importance in questions similar to those asked in
the everyday practice of anaesthesia. It is previous examinations.
also a subject that appears to demand a
disproportionately large amount of time It is hoped that this book may also be of
during examination preparation. help to those teaching anatomy to
However, neglect of the anatomical FRCA candidates, as well as to all
subject-matter is perilous and leads to the practising anaesthetists wishing to ‘brush
loss of valuable ‘easy’ marks. up’ on some forgotten anatomical detail.
Nurses, operating theatre practitioners
The idea behind this book is to present a and other healthcare professionals will
concise and easily digestible outline of also find this book of use when gaining a
anatomy that has been extensively based practical understanding of applied
on the current FRCA examination anatomy.
syllabus. I have attempted to present the
core anatomical knowledge required for Finally, all errors and omissions are my
the Primary and Final FRCA responsibility, and any comments and
examinations in a simple and advice for improvement will be gratefully
straightforward manner. There are accepted.
numerous diagrams to illustrate the
subject matter, as well as additional space Andreas Erdmann
for the addition of personal notes. It is, June 2001
however, impossible within the

ix
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Respiratory
System
1 The mouth

DESCRIPTION ● Soft palate – a suspended ‘curtain’


from the hard palate with a midline
The mouth extends from the lips uvula; a fibrous palatine aponeurosis
(anterior) to the isthmus of the fauces forms the skeleton of the soft palate
(posterior). There are two sections:
Vestibule – slit-like cavity between
the cheeks/lips and gingivae/teeth
Oral cavity – from the teeth to the VASCULAR SUPPLY
oropharyngeal isthmus
1. Vestibule – facial artery (via superior
and inferior labial branches)
RELATIONS 2. Teeth – maxillary artery (via superior
and inferior alveolar branches)
Roof – hard and soft palate
3. Tongue – lingual artery (venous via
Floor – tongue and reflection of the gum
lingual vein into internal jugular)
mucous membrane
4. Palate – mixed supply from facial,
Posterior – isthmus separates the oral
maxillary and ascending pharyngeal
cavity from the oropharynx
arteries

POINTS OF INTEREST
● Papilla – a papilla for the opening of
the parotid duct is present on the
NERVE SUPPLY
cheek opposite the upper second ● Vestibule:
molar tooth ● Sensory from the branches of the
● Midline frenulum – under the tongue, trigeminal nerve (V2 and V3)
has two papillae for the submandibular ● Motor from the facial nerve (VII)
duct openings and the sublingual fold ● Tongue:
(of mucous membrane) for numerous ● Taste – anterior two-thirds via the
tiny sublingual duct openings facial nerve (VII via chorda
● Isthmus – contains three structures: tympani), posterior one-third via
the palatoglossal folds (anterior), the the glossopharyngeal nerve (IX)
palatine tonsils (middle) and the ● Motor from the hypoglossal nerve
palatopharyngeal folds (posterior). It is (XII)
bounded by the soft palate above ● Palate:
● Hard palate – created by the maxilla ● Sensory and motor from the
(palatine process) anteriorly and trigeminal nerve (V2)
palatine bone posteriorly ● Taste from the facial nerve

2
The mouth

Respiratory
System
Fig 1.1
The mouth

3
2 The nose

DESCRIPTION ethmoidal recess, which drains the


sphenoidal sinus. Below the superior
A pyramidal structure of bone, cartilage concha lies the superior meatus,
and the nasal cavities. A midline nasal draining the posterior ethmoidal air
septum divides the nasal cavity into two cells. Respectively below each concha
separate areas, which open anteriorly via lie the middle meatus (draining
the nares and posteriorly via the choanae. ethmoidal, maxillary and frontal
sinuses) and the inferior meatus,
RELATIONS which drains the nasolacrimal duct
and tears from the eye
Roof – arch-like, nasal cartilages and ● Nose – lined by mucoperiosteum
nasal bones anteriorly, cribriform plate (highly vascular)
(of ethmoid) in the middle, and
sphenoid and clivus (occipital) bones
posteriorly VASCULAR SUPPLY
Floor – horizontal plate of the palatine
bone, palatine process of the maxilla 1. Ophthalmic (anterior and posterior
Medial wall – nasal septum (cartilage and ethmoidal branches) and maxillary
ethmoid/vomer) (sphenopalatine branch) arteries
Lateral wall – bony framework 2. Venous drainage via the facial vein to
(ethmoid/maxilla/palatine bone) and the internal jugular vein
bony conchae (superior, middle and
inferior)
NERVE SUPPLY
● Olfactory nerve (I) to the olfactory
POINTS OF INTEREST
zone
● Sinuses – drain into the nose interior ● Trigeminal nerve (V1 and V2), with
via numerous openings. Above the multiple sensory branches to the
superior concha lies the spheno- entire nose

4
The nose

Respiratory
System
Fig 2.1
The nose

5
3 The pharynx

DESCRIPTION ● Phase 2 – respiration is halted, the


oropharynx and nasopharynx close,
A midline muscular tube that provides a the larynx is elevated, constricted
common pathway for the ingestion of and pushed forward, and the bolus
food and for respiration. It arises from passes over (protective) the
the base of skull and ends at C6. It is epiglottis into the pharynx.
divided into three sections: naso-, oro- Constrictor muscles ensure the
and laryngopharynx. The wall has four consecutive propulsion into the
layers: mucosa, submucosa (tough fascia), oesophagus
muscular and loose connective tissue. ● Phase 3 – once it is in the
oesophagus, peristaltic waves
RELATIONS ensure the progression of the bolus
to the stomach
Anterior – nose and mouth
Posterior – retropharyngeal space,
prevertebral fascia and upper six
cervical vertebrae
Superior – sphenoid (body) and occipital VASCULAR SUPPLY
(basilar region) bones 1. Arterial – ascending pharyngeal,
Inferior – becomes continuous with the facial, maxillary, lingual (to epiglottis)
oesophagus and both thyroid arteries
2. Venous – via the pharyngeal plexus
POINTS OF INTEREST to the internal jugular vein

● Two groups of muscles:


● Constrictors – three paired
muscles: inferior, middle and
NERVE SUPPLY
superior constrictors
● Elevators – stylopharyngeus, ● From pharyngeal plexus:
salpingopharyngeus and ● Sensory – pharyngeal branches of
palatopharyngeus glossopharyngeal (IX) and vagus
● Swallowing: (X) nerves
● Phase 1 – food bolus is pushed ● Motor – vagus via the pharyngeal
towards the oropharynx by the plexus (except stylopharyngeus –
tongue IX)

6
The pharynx

Respiratory
System

Fig 3.1
The pharynx

7
4 The larynx

DESCRIPTION cornu also has a facet for


articulation with the cricoid
The larynx forms a functional protective cartilage
sphincter of the respiratory tract as well ● Cricoid cartilage (hyaline) –
as containing the vocal apparatus. It ‘signet ring’-shaped and situated at
consists of a complex arrangement of the C6 level. It articulates on its
muscles, cartilage, membranes and lateral border with the thyroid
ligaments. It extends from C3 to C6 in cornua, and on its upper border
the midline (adult). with the arytenoid cartilages
(paired)
RELATIONS ● Arytenoid cartilages (paired) –
pyramidal in shape, each with a
Anterior – superficial structure, is lateral muscular process (for
covered by the fascia (deep and insertion of both crico-arytenoid
superficial), platysma and skin muscles) and an anterior vocal
Posterior – pharynx, prevertebral muscles process (being the posterior
and cervical vertebrae attachment of the vocal ligament)
Superior – pharynx ● Corniculate cartilages (paired) and
Inferior – becomes continuous with the cuneiform cartilages (paired) –
trachea these provide attachments for
some intrinsic laryngeal muscles
and are both found within the
STRUCTURE
aryepiglottic folds (the fibro-elastic
1. Hyoid bone (at C3) – not strictly part membrane between the epiglottis
of the larynx but firmly attached and arytenoids – lower border of
above it which is free and forms the
2. Cartilages (nine) – three unpaired and vestibular ligament or false cord)
six paired: 3. Ligaments – four extrinsic and minor
● Epiglottis (elastic) – ‘leaf’-shaped; intrinsic (small synovial capsules):
the lower, narrower end is ● Thyrohyoid membrane – between
attached to the thyroid cartilage by the upper border of the thyroid
the thyro-epiglottic ligament, and and the hyoid bone. Strengthened
the upper broader end is free to anteriorly and laterally
project superiorly ● Hyo-epiglottic ligament –
● Thyroid cartilage (hyaline) – like a connects the hyoid bone to the
‘shield’. It is the largest of the lower part of the epiglottis
laryngeal cartilages and a midline ● Cricothyroid ligament – between
structure. Upper (at C4) and the thyroid above and the cricoid
lower (at C5) borders carry cornua below, the preferred site for
8 (horns) posteriorly – inferior cricothyrotomy
The larynx

Respiratory
System
Epiglottis
Hyoepiglottic ligament

Hyoid

Thyrohyoid ligament

Arytenoid Vestibular fold


Larynx sinus
Vocal fold

Cricovocal membrane

Cricothyroid ligament

Fig 4.1
The larynx

9
Concise Anatomy for Anaesthesia
● Cricotracheal ligament – connects POINTS OF INTEREST
the cricoid to the first ring of the
trachea ● Laryngeal nerve injuries:
4. Muscles – three extrinsic (connect ● External branch of the superior
larynx to its neighbours) and six laryngeal nerve is in close
intrinsic: association with the superior
● Extrinsic: thyroid vessels and may be
● Sternothyroid – depresses the damaged during surgery. As the
larynx, connects the posterior cricothyroid is the only muscle
manubrium sterni to the lateral supplied, there is loss of cord
thyroid lamina tension and hoarseness following
● Thyrohyoid – elevates the unilateral damage. This is
larynx, connects the lateral frequently temporary as the
thyroid lamina to the inferior opposite cricothyroid
greater horn of the hyoid compensates
bone ● Recurrent laryngeal nerve is in
● Inferior constrictor – close association with the inferior
constricts the pharynx, origins thyroid vessels and the lower lobe
from the thyroid lamina, the of thyroid, and may also be
tendinous arch over the damaged during thyroidectomy. In
cricothyroid and the side of the addition, an enlarged thyroid gland,
pharynx lymph nodes or cervical trauma
● Intrinsic: may involve the recurrent laryngeal
● Posterior crico-arytenoid – nerve. On the left side the thoracic
opens the glottis by the course of the nerve puts it at risk
abducting cords from malignant lung, oesophageal
● Lateral crico-arytenoid – closes or lymph node tumours, and even
the glottis by the adducting from aortic aneurysms or an
cords enlarged right atrium. Such injury
● Interarytenoid (unpaired) – results in a paralysed (cadaveric)
closes the glottis (especially midline vocal cord position – and
posteriorly) by connecting the hoarseness if unilateral, which
arytenoids. Some fibres become usually resolves following opposite
the aryepiglottic muscle cord over-activity. However,
laterally, which constricts the bilateral nerve injury results in total
laryngeal inlet somewhat loss of vocal cord function and the
● Thyro-arytenoid – relaxes the resultant flap-like valve effect can
cords by shortening, thus result in severe stridor and
pulling the arytenoids anteriorly dyspnoea
● Vocalis – fine adjustment of ● Local anaesthesia of the airway is
vocal cord tension (fibres come imperative for awake fibreoptic
from the thyro-arytenoid) intubation. The simplest method is
● Cricothyroid – only true tensor to use nebulised lignocaine to
and the only muscle that lies anaesthetise the whole airway, but
outside the cartilages. It works this is probably the least effective
by tilting the cricoid and method. Local anaesthetic may be
putting stretch on the vocal applied to the nose, mouth and
10 cords pharynx, and a spray-as-you-go
The larynx

Respiratory
System
Epiglottis

Vestibular cord
Vocal cord
Aryepiglottic fold

Arytenoid cartilage

Trachea
Fig 4.2
The larynx (view at laryngoscopy)

Fig 4.3
Laryngeal structures

11
Concise Anatomy for Anaesthesia
technique is used (under direct NERVE SUPPLY
vision) for the laryngeal structures.
This can be supplemented by a ● Branches of vagus (X) nerve:
cricothyroid membrane puncture ● Superior laryngeal nerve – passes
with an intratracheal spray of local deep to the internal and external
anaesthetic. Individual blockade of carotid arteries and then divides
the external branch of the superior into:
laryngeal nerve (at the greater horn External branch (small) – motor to
of the hyoid) and of its internal cricothyroid
branch (in the piriform fossa) has Internal branch (larger) – sensory
been arguably superseded by the above the vocal cords and the
prior methods inferior surface of the epiglottis
(superior surface of the epiglottis
is supplied by the
glossopharyngeal nerve)
● Recurrent (inferior) laryngeal nerve
– on the right side it leaves the
VASCULAR SUPPLY vagus as it crosses the subclavian
1. Arterial: artery, loops under it and ascends
● Superior laryngeal (from superior in the tracheo-oesophageal groove.
thyroid artery) – accompanies the On the left side it leaves the vagus
internal branch of the superior as it crosses the aortic arch, loops
laryngeal nerve under it and ascends in the
● Inferior laryngeal (from inferior tracheo-oesophageal groove. It
thyroid artery) – accompanies the supplies:
recurrent laryngeal nerve Motor to all intrinsic muscles of
2. Venous – into the corresponding the larynx (except cricothyroid)
superior and inferior thyroid veins Sensation below the vocal cords

12
The larynx

Respiratory
System
Vagus nerve

External carotid artery

Superior laryngeal
nerve
Internal laryngeal nerve
Internal carotid
artery
Thyrohyoid muscle

External laryngeal nerve

Cricothyroid muscle

Subclavian artery

Recurrent
laryngeal nerve

Fig 4.4
Nerve supply of the larynx

13
5 The trachea

DESCRIPTION ● Left – pleura, left common


carotid, left subclavian artery,
It is a roughly midline structure that aortic arch and left vagus
extends from C6 (at the lower edge of
the cricoid cartilage) to the carinal
bifurcation at T4. It is 15 cm long in the POINTS OF INTEREST
adult and has up to 20 C-shaped
● Tracheostomy:
cartilages joined by fibro-elastic tissue
● Positioning – all important. With
that is deficient posteriorly. The trachealis
full extension of the head and neck
muscle closes the posterior border.
it is achieved by using a sandbag
under the patient’s shoulders.
RELATIONS Keeping strictly to the midline
minimises the risk of major vessel
In the neck:
damage. During formal
Anterior – skin, superficial and deep
tracheostomy the skin incision is
fascia, thyroid isthmus (over second
deepened by blunt dissection, the
to fourth rings), sternothyroid and
thyroid isthmus is retracted or
sternohyoid muscles (lower neck)
divided, and a window is opened
and the anterior jugular vein
in the trachea between the second
communications and thyroidea ima
and fourth rings. Higher placement
artery (also lower neck)
may result in an increased
Posterior – oesophagus and recurrent
incidence of tracheal stenosis. The
laryngeal nerves
largest tracheostomy tube for a
Laterally – lateral lobes of the thyroid
comfortable fit is then inserted
and carotid sheath (with internal
● Percutaneous techniques – require
jugular vein, common carotid artery
less dissection, but the same
and vagus nerve)
principle of keeping strictly to the
In the thorax:
midline also applies
Anterior (in caudad direction) –
inferior thyroid veins, sternothyroid
origins, thymus remnants, VASCULAR SUPPLY
brachiocephalic artery, left common
carotid artery and aortic arch. The 1. Arterial – inferior thyroid arteries
pulmonary bifurcation lies behind 2. Venous – inferior thyroid veins
the carina
Posterior – oesophagus and left
NERVE SUPPLY
recurrent laryngeal nerve
Laterally: ● Recurrent laryngeal branch of the
● Right – pleura, azygos vein and vagus and sympathetic branches of the
14
right vagus nerve middle cervical ganglion
The trachea

Respiratory
System
Anterior jugular vein

Pretracheal fascia
(contains trachea, Sternomastoid
thyroid, oesophagus,
recurrent nerve)

External
jugular
vein
Sympathetic Carotid sheath
chain (containing internal jugular vein,
common carotid artery and vagus)
Body of C6
Fig 5.1
The trachea (cross-section)

Trachea Oesophagus
Right common
carotid artery First rib

Right subclavian Left subclavian artery


artery

Left common carotid artery


Brachiocephalic
artery
Aortic arch

Azygos vein

Left main bronchus

Fig 5.2
Relations of the trachea

15
6 The bronchi and
bronchial tree

DESCRIPTION 2. Left main bronchus terminates in two


lobar bronchi – upper and lower –
The trachea bifurcates at the T4 level also supplying the respective lung
into the right and left main bronchi. The lobes. The corresponding segmental
last tracheal ring is wider and larger, and bronchi are:
forms a ridge called the carina. ● Upper – apical, anterior, posterior,
The right main bronchus is shorter, superior lingual and inferior
wider and more vertical than the left lingual
(25°). After 2.5 cm, it gives off the right ● Lower – superior, medial basal
upper bronchus. The left main bronchus (small and variable), anterior basal,
is more angled (45°) and is 5 cm long. lateral basal and posterior basal
The layers of the bronchial wall are:
RELATIONS ● Mucosa – with ciliated cells and
goblet cells. In smaller bronchi, goblet
Right main bronchus – passes under the
cells become fewer. The alveoli are
azygos vein arch and lies above and
lined only with very thin epithelium
then behind the right pulmonary
● Basement membrane
artery
● Submucous layer – elastic fibres that
Left main bronchus – passes under the
provide elastic recoil to the air
aortic arch, in front of the oesophagus,
conduction system
thoracic duct and descending aorta,
● Muscular layer – unstriped and
and lies below and then behind the left
arranged to withstand pressures
pulmonary artery
(geodesic framework). The relative
thickness increases as bronchi get
STRUCTURE smaller – it acts as a sphincter beyond
the terminal bronchioles (at the
1. Right main bronchus terminates in
entrance to the alveolar ducts)
three lobar bronchi – upper, middle
● Cartilage – rings are replaced by plates
and lower – that supply the
in the intrapulmonary bronchi and
respective lung lobes. Each lobar
become progressively less complete
bronchus then terminates in
segmental bronchi as follows: The subdivisions are:
● Upper – apical, anterior and ● Bronchus
posterior ● Bronchiolus – cartilage disappears
● Middle – lateral and medial ● Respiratory bronchiolus
● Lower – superior, medial basal, ● Alveolar duct
anterior basal, lateral basal and ● Alveolar sac
posterior basal ● Alveolus

16
The bronchi and bronchial tree

Respiratory
System

Fig 6.1
The bronchial tree

17
7 The pleura and
mediastinum

DESCRIPTION POINTS OF INTEREST


The lungs are enveloped in a twin- ● Lines of pleural reflection (surface
walled serous sac – two layers of the markings):
pleura – that meet at the hilum to form ● Apex – lies 4 cm above the clavicle
the pulmonary ligament. A potential ● Behind the sternoclavicular joint
space exists between the two pleural ● Behind the sternum at the second
layers (visceral and parietal), which costochondral junction
contains a thin film of serous fluid. ● On the left – lateral sternal edge at
the fourth cartilage
The mediastinum is the space between
● On the right – down to the
the two pleural sacs and is divided into
costoxiphoid angle
four regions by the pericardium:
● Eighth rib – mid-clavicular line
Superior (below thoracic inlet)
● Tenth rib – mid-axillary line
Middle (contains pericardial contents)
● Twelfth rib – posterior to the
Anterior (behind sternum)
costovertebral angle
Posterior (above diaphragm)

18
The pleura and mediastinum

Respiratory
System
Right upper lobe 1 1 Left upper lobe

2 2

Horizontal fissure
3 3

4 4

Right middle lobe


5 5
Left lower lobe
Right lower lobe 6 6

Oblique fissure Cardiac notch


7 7

8 8

9 9

10 10

Lung
Pleura
Fig 7.1
The pleura and lungs

19
8 The lungs

DESCRIPTION correspond to the individual


segmental bronchi (see above).
The lungs are enclosed within the pleural 2. Right lung has two fissures:
sacs and separated by the mediastinal ● Oblique – separates the middle
structures. Each lung has an apex, base, and lower lobes (follows the line
hilum, three surfaces and three borders. from the second vertebral spine to
the sixth costochondral junction)
RELATIONS ● Horizontal (transverse) – separates
Apex – extends into the root of the the upper and middle lobes
neck. The suprapleural membrane and (follows the line from the fourth
pleural cupola are superior and the costochondral junction to join the
subclavian artery leaves a groove on oblique fissure in the axillary line)
the mediastinal surface of the lung 3. Left lung has only one fissure –
Base – concave in shape. The right lung oblique fissure separating the upper
is more concave (a higher diaphragm and lower lobes
on the right due to the liver’s position)
Hilum – structures enter and leave the POINTS OF INTEREST
lung. It is formed mainly by the
bronchi, pulmonary arteries, pulmonary ● Bronchoscopic anatomy – trachea
veins, bronchial arteries and veins, appears as a glistening tube structure
nerve plexuses, and lymph nodes: with a red mucosa and regular
● On the right – superior vena cava concentric white tracheal rings. The
and right atrium lie anterior to the carina is seen as a sharp ridge and lies
hilum, and the azygos vein arches slightly to the left of the midline:
over it ● Right main bronchus is wider and
● On the left – thoracic aorta is easier to enter:
posterior to the hilum; the aortic Upper lobe bronchus – 2.5 cm
arch is superior from the carina (three o’clock
● On both sides – phrenic nerve, position)
anterior nerve plexuses and minor Middle lobe bronchus – 4.5 cm
vessels lie anteriorly, the vagus from the carina (12 o’clock)
nerves and posterior nerve plexuses Lower lobe bronchus – 4.5 cm (six
lie posteriorly o’clock)
● Left main bronchus is longer (at 5
cm) and narrower:
STRUCTURE Upper lobe bronchus – 5 cm (nine
1. Lungs are divided into lobes – three o’clock) with lingular branch
on the right and two on the left. Each centrally at 5.5 cm
lobe is subdivided into triangular Lower lobe bronchus – 6 cm (six
20 bronchopulmonary segments that o’clock)
The lungs

VASCULAR SUPPLY NERVE SUPPLY

Respiratory
System
1. Pulmonary artery – provides a ● Tracheobronchial tree and lung:
capillary network for the exchange of ● Sensory – vagus (X), recurrent
the respiratory gases. The pulmonary laryngeal
artery and divisions are concerned ● Motor – vagus (X)
solely with alveolar gas exchange and (bronchoconstriction) and
closely follow the bronchial tree sympathetic fibres from T2 to T4
divisions. The capillaries in turn feed (bronchodilation and minor
into the pulmonary veins, which tend vasoconstriction)
to run between the lung segments. ● Pleura:
The two main pulmonary veins drain ● Parietal sensory – phrenic and
separately into the left atrium intercostal nerves
2. Bronchial arteries – provide the ● Visceral sensory – autonomic
blood supply to the lungs, bronchi, supply
pleura and lymph nodes. They supply
the actual stroma of the lung. There
are usually three (variable): one for LYMPHATIC DRAINAGE
the right lung and two for the left.
1. Superficial plexus drains visceral
They originate from the descending
pleura
aorta (on the left) and variably from
2. Deep plexus drains bronchi (as far as
the aorta, an intercostal, internal
alveolar ducts)
thoracic or right subclavian artery (on
the right). There are two bronchial Both drain into the bronchopulmonary
veins on each side draining into the lymph nodes – then into the
azygos (right) or hemi-azygos (left) tracheobronchial nodes – then into the
veins. Together with the Thebesian right and left bronchomediastinal trunks.
veins of the heart, the bronchial Variable termination – either directly
blood flow makes up the into great veins of neck, or into thoracic
‘physiological shunt’ duct (left) and right lymph duct (right).

21
9 The diaphragm

DESCRIPTION ● At T8 – inferior vena cava


(sometimes right phrenic nerve)
The diaphragm separates the thoracic and ● At T10 – oesophagus, vagi, and left
abdominal cavities and is the main gastric artery and vein
muscle of respiration. It consists of a ● At T12 – aorta, thoracic duct and
central tendinous portion and a azygos vein
peripheral muscular area. It is dome- ● Further openings transmit:
shaped in structure and reaches a higher ● Superior epigastric vessels –
level on the right (fifth rib) than on the between the costal and xiphoid
left (fifth intercostal space) during end- origins
expiration. ● Lymphatic vessels – between the
costal and xiphoid origins
RELATIONS ● Sympathetic trunk – behind the
medial arcuate ligament
Central trefoil tendon – blends with the ● Right phrenic nerve – pierces the
fibrous pericardium above central tendon close to the inferior
Muscle – has a complex origin: vena caval opening
● Costal origin – from the tips of the ● Left phrenic nerve – pierces muscle
last six costal cartilages just lateral to the pericardial
● Xiphoid origin – from the two attachment
small attachments to the posterior ● Respiration:
surface ● Diaphragm – moves downwards
● Arcuate ligaments (three): during inspiration and thus enlarges
● Medial – psoas fascial thickening the thoracic cavity. On expiration
● Lateral – quadratus lumborum it relaxes (and the elastic recoil of
fascial thickening the chest wall causes expiration).
● Median – fibrous arch between During quiet breathing the
two crura diaphragm is the dominant
● Crura: functioning muscle on inspiration
● Left – from the first and second ● Intercostal muscles – also known to
lumbar vertebral bodies contract on inspiration. This
● Right – from the first, second approximates the ribs, and elevates
and third lumbar vertebral and everts the rib cage increasing
bodies the intrathoracic volume.
Contraction is also seen on forced
expiration (this is presumed to aid
POINTS OF INTEREST
rib fixation)
● Three major openings allow for the ● Scalene muscles – play a role in
passage of structures between the inspiration, especially when
22 thorax and abdomen: respiration is deeper. They elevate
The diaphragm
the first rib and sternum. In forced NERVE SUPPLY

Respiratory
inspiration, the erector spinae and

System
pectoral muscles also assist ● Motor – phrenic nerve (C3–5)
● Forced expiration – strong ● Sensory – phrenic nerve to the central
contraction of the abdominal and tendon, lower thoracic nerves to the
latissimus dorsi muscles pushes the muscular regions
diaphragm upwards

At T8 – inferior vena cava,


right phrenic nerve

Left phrenic nerve

At T10 –
oesophagus,
10 gastric vessels,
vagi
11

12th rib T12

Iliohypogastric At T12 – aorta, thoracic duct,


nerve L2 azygos vein
Sympathetic chain
L3
Fig 9.1
The diaphragm

23
Sample questions –
respiratory system

1. Outline your technique for 5. How may the airway be anaesthetised


percutaneous tracheostomy with for awake fibreoptic intubation?
particular reference to the anatomy 6. How may nerve blockade be used to
involved. List the possible provide pain relief following chest
complications of this procedure. wall trauma?
2. Draw a simple diagram of the view 7. Describe the view seen during
of the larynx at direct laryngoscopy. bronchoscopic examination.
3. What are the effects of damage to the 8. Give a brief account, with a simple
nerve supply of the larynx? diagram, of the anatomy of the
4. Make a simple drawing, with labels, diaphragm.
to show the trachea and the main and
segmental bronchi.

24
Cardiovascular
System
10 The heart

DESCRIPTION muscle fibres (trabeculae) specialise


into papillary muscles, which attach
The heart is a four-chambered, conical, to the tricuspid valve cusps (in a
muscular pump in the middle similar fashion to the mitral valve on
mediastinum. Its borders are: the left side of the heart). The
Right border – right atrium pulmonary valve is tricuspid and leads
Left border – left auricular appendage into the pulmonary trunk
and left ventricle 3. Left atrium – receives oxygenated
Anterior surface – right ventricle blood from the lungs via the four
predominantly pulmonary veins, which open
Diaphragmatic surface – right and left superoposteriorly. The blood then
ventricles (right atrium) passes through the mitral (bicuspid)
Posterior surface – left atrium (right valve into the left ventricle
atrium) 4. Left ventricle – thickest-walled
chamber that distributes blood to the
The surface markings follow a body via the aorta. The aortic valve is
quadrilateral shape (distances from tricuspid – with right, left and
midline): third right costal cartilage (2 posterior cusps. Small sinuses lie
cm), second left costal cartilage (3 cm), above the cusps that give rise to the
fifth left intercostal space (7 cm) and two coronary arteries – right and left
sixth right costal cartilage (2 cm). respectively

POINTS OF INTEREST
STRUCTURE
● Conducting system:
The heart consists of four chambers: ● Sino-atrial node – in the superior
1. Right atrium – receives right atrial wall (near the superior
deoxygenated blood from the body vena caval opening) and initiates
via the venae cavae (inferior and conduction impulse. The node is
superior). The outflow of blood in direct contact with the atrial
occurs through the tricuspid valve cells and causes a wave of
into the right ventricle. The sino- depolarisation, resulting in
atrial node is situated in the upper contraction of both atria
part of the right atrium, and the ● Atrioventricular node – at the base
atrioventricular node lies near the of the right atrial septal wall (near
base of the tricuspid valve the tricuspid valve) and receives
2. Right ventricle – receives blood from impulses from the atrial
the right atrium and expels it through depolarisation. There is no direct
the pulmonary valve and trunk. neural route between the two
26 Some of the rough internal wall nodes, which allows for a slight
The heart

Cardiovascular
Brachiocephalic Left common carotid artery
artery Left subclavian artery

System
Right brachiocephalic vein Left brachiocephalic vein

Aortic arch

Left pulmonary artery


Right pulmonary
arteries
Left pulmonary veins
Superior vena cava

Right pulmonary
veins

Left ventricle

Right ventricle

Inferior vena cava Descending aorta


Fig 10.1
The heart

Clavicles

Aortic “knuckle”

Pulmonary trunk (hilum)

Left atrium (appendage)

Right atrium Left ventricle


(right ventricle
posterior)

Left lung

Right lung

Heart border
“X-ray” shadow
Fig 10.2
The heart on chest radiograph

27
Concise Anatomy for Anaesthesia
delay and prevents simultaneous inferior vena cava and
atrial and ventricular contraction pulmonary veins)
● Bundle of His – nerve fibre bundle
(AV bundle) that receives the
electrical impulse from the AV
VASCULAR SUPPLY
node and continues within the 1. Arterial:
interventricular septum. At the base ● Right coronary artery – from the
it divides into two terminal bundle right aortic sinus (previously
branches (right and left). These anterior) and descends between
continue in the walls of their the pulmonary trunk and right
respective ventricles, terminating in atrium to run in the anterior
Purkinje fibres, which penetrate atrioventricular groove. Inferiorly,
the muscular walls and initiate it anastomoses with the left
ventricular contraction coronary (circumflex) at the
● Pericardium: inferior interventricular groove. In
● Heart is enveloped within a conical addition to small atrial and
fibroserous sac – the pericardium. ventricular branches, it gives off
The outer layer is attached to the two main branches:
following structures: ● Right marginal branch – lower
Adventitia of the great vessels border of the heart
Sternopericardial ligament – to the ● Posterior interventricular branch –
posterior sternum anastomoses with the anterior
Central tendon of diaphragm – interventricular branch of the left
where it is fused inferiorly coronary
● Outer fibrous layer is a tough The right coronary artery supplies:
fibrous structure with openings to ● Right atrium
allow the aorta, pulmonary trunk ● Part of the left atrium
and superior vena cava to pass ● Right ventricle
through ● Posterior interventricular septum
● Serous pericardium has two ● Sino-atrial node (in 60%)
components: ● Atrioventricular node (in 80%)
Outer parietal pericardium – lines 2. Left coronary artery – from the left
the inner surface of the fibrous aortic sinus (previously left posterior)
sac and becomes continuous and it lies behind and then lateral to
with the visceral layer around the pulmonary trunk. It also gives off
the great vessels small atrial and ventricular branches,
Inner visceral pericardium – in and divides immediately into two
direct contact with the heart main branches:
and forms a potential space ● Circumflex artery – runs laterally
between the pericardial layers around the left atrioventricular
● During embryological folding, groove (anastomoses with right
sinuses develop in the pericardium: coronary as above). This also gives
Transverse sinus (superiorly) – off the left marginal branch
behind the aorta/pulmonary ● Anterior interventricular artery
trunk and in front of superior (formerly left anterior descending)
vena cava – runs down the anterior
Oblique sinus (inferiorly) – behind interventricular groove to
28 the left atrium (bordered by the anastomose with the posterior
The heart

Cardiovascular
interventricular (from right ● Small cardiac
coronary) as above ● Oblique

System
The left coronary artery supplies: ● One-third of the drainage is by
● Left atrium small veins, the venae cordis
● Left ventricle minimae, directly into the cardiac
● Anterior interventricular septum cavity
● Sino-atrial node (in 40%)
● Atrioventricular node (in 20%)
3. Venous:
NERVE SUPPLY
● Two-thirds of the drainage is by
veins accompanying the arteries – ● Autonomic supply:
either directly into the right ● Parasympathetic – from the vagus
atrium via the anterior cardiac nerve (cardio-inhibitory)
vein, or via the coronary sinus ● Sympathetic – cervical (C1–4, C5
(large venous dilatation and C6, C7–T1) and upper
posteriorly) into the right atrium. thoracic (T2–5) ganglia (cardio-
Four veins lead into the coronary accelerator) via the superficial and
sinus: deep cardiac plexuses
● Great cardiac ● Phrenic nerve (C3–5) supplies the
● Middle cardiac pericardium

Left coronary artery


Right coronary
artery Great cardiac vein
Coronary sinus
Circumflex artery
Oblique vein
Anterior interventricular
Middle artery
cardiac vein

Small
cardiac vein

Right marginal
artery Posterior
interventricular
artery

Fig 10.3
Blood supply of the heart 29
11 The great vessels

AORTA common hepatic and splenic)


● Superior mesenteric – supplies
Commences at the aortic valve and
the midgut (via inferior
terminates at its bifurcation into the
pancreaticoduodenal, jejunal,
common iliac arteries (L4 level). There
ileal, ileocolic, right and middle
are four parts:
colic)
1. Ascending – 5 cm long, posterior to ● Inferior mesenteric – supplies
sternum. It gives off: the hindgut (via left colic,
● Right coronary artery sigmoid and superior rectal)
● Left coronary artery
2. Arch – runs upwards, backwards and
to the left. It gives off:
GREAT ARTERIES OF THE NECK
● Brachiocephalic, which divides
into: 1. Brachiocephalic artery – first and
● Right common carotid largest branch of the aortic arch. It
● Right subclavian usually gives off no branches and
● Left common carotid divides into the right common
● Left subclavian carotid and right subclavian behind
● Thyroidea ima (occasionally) the right sternoclavicular joint
3. Descending thoracic aorta – starts at 2. Right common carotid artery –
level T4 and runs down to the aortic ascends within the carotid sheath to
opening in the diaphragm (T12). It divide (opposite the upper border of
gives off: the thyroid cartilage, C4) into the
● Visceral branches – pericardial, internal and external carotid arteries
bronchial, oesophageal, 3. Right subclavian artery – runs (over
mediastinal and phrenic the cervical pleura and lung apex) to
● Somatic branches – posterior the lateral border of the first rib
intercostals, dorsal, muscular, (grooved) where it becomes the right
lateral cutaneous and mammary axillary artery. It gives off five
4. Abdominal aorta – starts at the aortic branches: vertebral, internal thoracic,
opening in the diaphragm and ends at thyrocervical, costocervical and dorsal
the common iliac bifurcation. It gives scapular
off: 4. Left common carotid artery – second
● Lumbar arteries (paired) branch of the aortic arch and ascends
● Visceral arteries (paired) – inferior initially towards the left and then
phrenic, suprarenal, renal and behind the left sternoclavicular joint.
gonadal It usually has no branches
● Midline (unpaired) arteries: 5. Left subclavian artery – third branch
● Celiac trunk – supplies the of the aortic arch, and as on the right
30 foregut (via left gastric, side, it grooves the first rib
The great vessels

Cardiovascular
System
Thyroidea
ima Left common carotid
Right common
carotid
Left subclavian

Right
subclavian

Brachiocephalic
Aorta

Posterior intercostal (paired)

Coeliac trunk

Suprarenal
(paired)

Superior mesenteric
Renal
(paired)

Lumbar (paired)
Gonadal
(paired) Inferior mesenteric

Common iliac

Median Internal iliac


sacral

External iliac

Fig 11.1
The aorta and major arterial branches

31
Concise Anatomy for Anaesthesia
posteriorly before terminating at its ● Subscapular
lateral border to become the left ● Circumflex humeral (anterior and
axillary artery. It also has five posterior)
branches (see above) 2. Brachial artery – extends from the
6. External carotid artery – main blood teres major to the lower margins of
supply to the head and neck and the antecubital fossa, bifurcating into
gives off six branches before the radial and ulnar arteries. The
bifurcating within the parotid gland: branches are:
● Superior thyroid ● Profunda brachii
● Ascending pharyngeal ● Ulnar collateral (superior and
● Lingual inferior)
● Facial ● Nutrient to humerus
● Occipital 3. Radial artery – lies on the radius
● Posterior auricular along the medial border of the
● Superficial temporal (terminal brachioradialis, and it enters to the
branch) lateral aspect of the wrist (going
● Maxillary (terminal branch) through anatomical snuffbox) to
7. Internal carotid artery – main blood terminate in the deep palmar arch.
supply to the intracranial contents The branches are:
and lies initially posterior and lateral ● Radial recurrent
to the external carotid (before ● Muscular
becoming medial at C2), shortly after ● Carpal
which it enters the skull through the ● Metacarpal
carotid canal. There are no cervical ● Superficial and deep palmar arch
branches, but there are 10 branches 4. Ulnar artery – accompanies the ulnar
within the skull: nerve and lies on the flexor
● Caroticotympanic and pterygoid digitorum profundus (lateral to ulnar
(within petrous area) nerve) before entering the wrist
● Cavernous, hypophyseal and (superficial to flexor retinaculum) and
meningeal (within cavernous area) terminating in the superficial palmar
● Ophthalmic arch. The branches are:
● Anterior cerebral ● Ulnar recurrent
● Middle cerebral ● Common interosseous (divides
● Posterior communicating into anterior and posterior)
● Anterior choroidal ● Muscular
● Carpal
● Superficial and deep palmar arch
ARTERIES OF THE LIMBS

Upper limb Lower limb


1. Axillary artery – continuation of the 1. Common iliac – from the aortic
subclavian artery and proceeds to bifurcation at L4
become the brachial artery at the 2. External iliac – main continuation of
lower border of teres major. It gives the common iliac and travels down,
off: anteriorly and laterally, deep to the
● Superior thoracic mid-inguinal point and becomes the
● Thoraco-acromial femoral artery in the thigh. The
32 ● Lateral thoracic branches are:
The great vessels

Cardiovascular
System
Superficial temporal artery

Maxillary artery
Occipital artery

Right internal
carotid Facial artery

Vertebral artery Right external carotid

Thyrocervical trunk Right common carotid artery


Costocervical

Right subclavian Brachiocephalic


artery

Fig 11.2
Major arteries of the head and neck

Right subclavian
artery

Brachiocephalic artery

Circumflex Axillary artery


humeral
artery Subscapular artery

Profunda
brachii
Brachial artery

Ulnar collateral

Radial
collateral
artery
Ulnar artery

Common interosseous artery

Anterior interosseous artery


Radial
artery
Ulnar artery

Deep palmar arch

Superficial palmar arch

Digital artery

Fig 11.3
Arteries of upper limb 33
Concise Anatomy for Anaesthesia
● Inferior epigastric – pubic and MAJOR VEINS
cremasteric branches
● Deep circumflex iliac Head and neck
3. Internal iliac – bifurcates into two 1. External jugular vein – drains the
terminal trunks (anterior and scalp and face. It is formed from the
posterior) after running down and posterior division of the
posteriorly to end opposite the retromandibular vein and posterior
greater sciatic notch. Multiple auricular vein. It runs from the angle
branches supply the pelvic organs, of the mandible to the midpoint of
genitalia, body wall and lower limb the clavicle and then enters the
(anterior trunk), and gluteal muscles subclavian vein
(posterior trunk) 2. Internal jugular vein – continuation
4. Femoral artery – passes laterally to of the sigmoid sinus and runs from
the femoral vein in the femoral the jugular foramen and within the
triangle (and medial to the femoral carotid sheath to join with the
nerve) and descends to enter the subclavian vein (behind the sternal
popliteal fossa through the adductor end of the clavicle) forming the
hiatus. The branches are: brachiocephalic vein. It receives
● Superficial epigastric numerous tributaries within the neck,
● Superficial circumflex iliac including the facial vein, which itself
● External pudendal (superficial and receives the anterior division of the
deep) retromandibular vein
● Profunda femoris – with
perforating arterial branches
● Descending genicular branch Upper limb
5. Popliteal artery – continuation of the
femoral artery from the adductor 1. Cephalic vein – originates from the
magnus above to the popliteus below dorsal network of hand veins and
where it divides into the anterior and runs on the radial aspect of the
posterior tibial arteries forearm. It receives a median cubital
6. Anterior tibial – lies on the anterior branch before entering the anterior
surface of the interosseous membrane elbow area and ascends lateral to
and enters the ankle (deep to the biceps brachii before terminating in
extensor retinaculum) midway the axillary vein
between the malleoli, before 2. Basilic vein – also originates from the
becoming the dorsalis pedis artery. dorsal vein network, but runs on the
Branches supply the knee, anterior ulnar aspect of the forearm. It also
compartment, ankle and foot receives a median cubital branch
7. Posterior tibial – descends through before ascending on the medial aspect
the posterior leg compartment deep of the anterior elbow and forearm,
to the gastrocnemius together with and continues as the axillary vein
the tibial nerve, and terminates after beyond teres major
passing between the medial malleolus 3. Median vein of forearm – originates
and calcaneus in the medial and from the palmar venous network and
lateral plantar arteries. Branches ascends approximately in the midline.
supply the fibula, lateral It terminates variably in the basilic or
compartment, posterior compartment median cubital vein
34 and foot 4. Axillary vein – starts at the teres
The great vessels

Cardiovascular
Femoral

System
artery Right external iliac

Femoral ring
Superficial
circumflex Superficial epigastric
iliac
External pudendal
(deep + superficial)

Profunda Femoral artery


femoris

Descending genicular

Popliteal

Peroneal Anterior tibial

Posterior
tibial

Fig 11.4
Arteries of the lower limb
Superficial
temporal vein

Right maxillary
vein

Facial vein
Posterior
auricular vein
Retromandibular vein

Anterior and posterior divisions


of retromandibular vein
External jugular
vein
Anterior jugular vein
Right vertebral
vein Right internal jugular vein

Right subclavian Right brachiocephalic vein


vein

Fig 11.5
Major veins of head and neck 35
Concise Anatomy for Anaesthesia
major and ends opposite the first rib inferior vena cava (drains blood from
to continue as the subclavian vein below diaphragm)

Lower limb
Thorax
1. Great saphenous vein – from the
1. Brachiocephalic vein (bilateral
medial aspect of the foot and in front
venous, unilateral arterial) – formed
of the medial malleolus. It ascends on
from the junction of the internal
the medial side to the knee and up to
jugular and subclavian veins behind
the thigh where it enters the
the sternal clavicle. The longer left
saphenous foramen and joins the
and shorter right brachiocephalic
femoral vein
veins join behind the first costal
2. Small saphenous vein – from the
cartilage to become the superior vena
lateral aspect of the foot and behind
cava (drains blood from above
the lateral malleolus. It ascends in the
diaphragm)
midline posteriorly and joins the
popliteal vein after running between
the two heads of the gastrocnemius
Abdomen
3. Posterior tibial vein – runs with the
1. External iliac – continuation of the posterior tibial artery and unites with
femoral vein (draining the leg) and is the anterior tibial vein to form the
joined by the internal iliac (draining popliteal vein
the pelvis) to form the common iliac 4. Femoral vein – continuation of the
vein in front of the sacroiliac joint popliteal vein as it emerges from the
2. Common iliac – left and right ascend adductor canal and enters the femoral
and unite at the L5 level to form the triangle

36
The great vessels

Cardiovascular
System
Subclavian vein
Inferior
vena
External cava
iliac
Right common
iliac
Circumflex Axillary vein
femoral Great saphenous
vein Brachial vein
Cephalic
Femoral vein vein
Basilic vein

Popliteal
Small Median vein forearm
saphenous
Anterior tibial Median cubital vein

Peroneal Cephalic
vein vein
Posterior
tibial vein

Leg Arm
Fig 11.6
The veins of the leg and arm

37
12 Fetal circulation

● Umbilical vein – oxygenated blood the lungs and pulmonary trunk, and
enters the body via the umbilical vein. then via the ductus arteriosus into the
After mixing with deoxygenated aorta
blood in the ductus venosus, it reaches ● Transitional circulation – following
the right atrium (via inferior vena cava the clamping of the umbilical cord at
that receives blood from trunk and birth, and with the large decrease in
limbs) pulmonary vessel pressure with
● Right atrium – anatomical inspiration, significant pressure and
relationship of the venae cavae ensures flow changes occur. The fall in right
that most of the blood in the right atrial pressure and increase in left atrial
atrium (from the inferior vena cava) pressure causes the foramen ovale to
bypasses the right ventricle and goes close, as the septum secundum and
directly to the left atrium via the septum primum oppose. This is an
patent foramen ovale immediate functional closure only. As
● Left atrium – blood from the left a result, all blood from the right
atrium mixes with (deoxygenated) atrium is now forced into the right
blood from the lungs and is expelled ventricle. The ductus arteriosus also
via the left ventricle into the aorta, constricts due to the high partial
and ultimately around the body pressure of oxygen (functionally
● Mixing – some blood does not flow complete by 12 hours). The change to
directly from the right into the left adult circulation is complete by 3
atrium, but instead it is directed to the months, by which time the foramen
right ventricle (mainly blood from the ovale is anatomically fused (fossa
superior vena cava). This ovalis) and the ductus arteriosus is
deoxygenated blood flows through obliterated

38
Fetal circulation

Cardiovascular
System
Aorta

Superior Foramen Ductus


vena ovale arteriosus
cava

Aorta

Pulmonary trunk
Inferior
vena
cava Umbilical
arteries

Fig 12.1
The fetal circulation

39
Sample questions –
cardiovascular system

1. Describe, with the aid of a simple insertion and indicate the precautions
diagram, the blood supply of the required prior to insertion.
heart. Briefly indicate the areas of 3. Describe the venous drainage of the
myocardium supplied by the leg.
coronary arteries and their main 4. Using a simple diagram, indicate the
branches. special features of the fetal circulation
2. Give an account of the arterial supply and the subsequent changes following
of the upper limb. List the birth.
complications of intra-arterial cannula

40
Nervous
System
13 The brain

DESCRIPTION Hindbrain – consists of the pons, the


medulla oblongata (which exits the
There are three main parts of the brain: cranial cavity through the foramen
Forebrain: magnum) and the cerebellum
● Telencephalon – consists of the
two cerebral hemispheres
separated by a longitudinal
fissure. The cortex of each
VASCULAR SUPPLY
hemisphere is made up of gyri 1. Arterial – arterial supply to the brain
and sulci and is separated into comes from four arteries: the paired
lobes. Four major lobes are internal carotid arteries and the paired
commonly recognised: frontal, vertebral arteries. These form the
parietal, occipital and temporal circle of Willis from which the
● Diencephalon – lies between the anterior, middle and posterior
cerebral hemispheres and cerebral arteries arise
midbrain. It contains the 2. Venous – venous drainage of the
thalamus and the hypothalamus brain is via the numerous dural
Midbrain – connects the forebrain to venous sinuses, which drain into the
the hindbrain internal jugular vein

42
The brain

Parietal lobe

Nervous
Colliculi

System
Corpus callosum

Pineal gland

Frontal lobe

Occipital lobe
Third ventricle
Fourth ventricle

Mamillary body
Cerebellum Pituitary gland
Pons
Temporal lobe
Medulla
oblongata

Fig 13.1
The brain

Anterior
cerebral
artery

Anterior communicating artery


Internal carotid artery

Middle cerebral
artery

Posterior
Posterior communicating artery
cerebral artery
Superior cerebellar artery
Basilar
artery
Anterior inferior
cerebellar artery

Anterior spinal artery

Vertebral
Posterior inferior
artery
cerebellar artery
Fig 13.2
The vascular supply of the brain 43
14 The spinal cord

DESCRIPTION The anterior nerve roots, however, exit


without a corresponding groove.
The spinal cord is ~45 cm long in the
adult and has an approximately The following structures can be seen on
cylindrical shape, which is flattened cross-section:
somewhat in the lumbar region. It 1. Central canal – travels downward
extends from the cervical area as an from the fourth ventricle. It is
extension of the medulla oblongata and continuous throughout the cord and
continues to the lumbar region, where it is slightly dilated in the region of the
terminates in the conus medullaris. A conus medullaris
thin thread called the filum terminale 2. Grey matter – forms the ‘H-like’
continues to attach to the coccyx. structure in the central regions of the
There are normally 31 pairs of spinal cord. The lateral limbs of grey matter
nerve roots: eight cervical, 12 thoracic, are joined by the transverse
five lumbar, five sacral and one commissure. The limbs have an
coccygeal. The elongation of the lumbar anterior (wider) column or horn and
and sacral nerve roots, prior to their exit a posterior (narrower) column. The
from the intervertebral foramina, forms posterior horn has a group of
the cauda equina. There is a wide specialised nerve cells, the substantia
variation in the relations of the cord gelatinosa, at its tip. A lateral grey
throughout the course of life. The spinal column can also be seen in the
cord ends, on average, between L1 and thoracic and upper lumbar area
L2 in the adult – and in the newborn it (containing spinal sympathetic
may end at the lower border of L3. cells)
However, individual variation between 3. White matter – consists of
T12 and L3 in the adult is not longitudinal nerve fibres divided into
uncommon. the following major tracts:
● Descending lateral corticospinal
tract – major motor tract (fibres
cross the midline in the medulla –
STRUCTURE pyramidal decussation)
The spinal cord is roughly circular in ● Descending anterior corticospinal
cross-section, flattened in the tract – small motor tract (fibres do
anterior–posterior aspect. There are two not decussate until reaching the
major indentations: an anterior median distal anterior horn cells)
fissure and a posterior median sulcus ● Ascending posterior column –
(which extends further to form the divided into the fasciculus gracilis
posterior median septum). Further and cuneatus. These subserve fine
posterolateral sulci exist, along which the touch and proprioception (largely
44 posterior nerve roots are seen to exit. uncrossed)
The spinal cord

Nervous
System
ASCENDING DESCENDING

Fasciculus Fasciculus
cuneatus gracilis

Anterior
spinocerebellar
Lateral corticospinal tract
tract

Posterior Tectospinal tract


spinocerebellar
tract

Lateral Vestibulospinal
spinothalamic tract
tract

Anterior
spinothalamic
tract Grey Central Anterior corticospinal tract
matter canal

Fig 14.1
The spinal cord (transverse section)

45
Concise Anatomy for Anaesthesia
● Ascending spinothalamic tracts – anterior and posterior spinal
lateral (pain and temperature – arteries. These arise from the
cross midline) and anterior/dorsal cervical, thoracic and lumbar
(touch/deep pain – remain regions (usually number between
uncrossed) three and six larger vessels). One
● Ascending spinocerebellar tracts – vessel is often particularly large –
anterior and posterior (sensory arteria radicularis magna. It usually
proprioception to the cerebellum) arises distally and from the left,
and may provide the dominant
supply to the lower two-thirds of
VASCULAR SUPPLY the spinal cord
1. Arterial: Despite the extensive origin, the
● Anterior spinal artery – formed by arterial blood supply of the spinal
the union of the vertebral arteries cord is vulnerable. The anterior and
at the foramen magnum. It runs posterior spinal arteries do not have
on the anterior median fissure and direct anastomoses and cord
supplies the larger part of the infarction is possible after thrombosis,
anterior spinal cord hypotension, surgical occlusion,
● Posterior spinal arteries (one or trauma, and vasoconstriction.
two on each side) – formed from 2. Venous:
the posterior cerebellar arteries. ● By a series of venous plexuses or
These are smaller and reinforced channels (anterior, posterior and
by spinal branches from a number lateral), which in turn drain into
of nearby vessels segmental veins, including the
● Radicular arteries also provide vertebral, azygos, lumbar and
further blood supply to both the lateral sacral veins

46
15 The spinal meninges
and spaces

DESCRIPTION ● Arteries
● Veins (the valveless, vertebral,
The central nervous system is covered venous plexuses of Bateson –
with three contiguous membranes called forming a communication from
the meninges. These protect and support pelvic to cerebral veins)
the neural tissue. The three layers are the 2. Dura mater – dense, fibrous tissue as
dura mater (outermost), the arachnoid a double layer (the outer layer
mater and the pia mater (innermost). The attaches at foramen magnum [and to
subdural (potential) space separates the C2 and C3], the inner layer is the
dura and arachnoid mater, and the continuation of the cerebral dura).
subarachnoid (actual) space separates the The dura extends as far as the second
arachnoid and pia mater – latter closely sacral segment (variably L5–S3). It
applied to the neural tissue. also ensheathes the filum terminale
The spinal meninges are the equivalent (an extension of pia mater), which
of the cranial meninges. The spinal dura attaches to the coccygeal periosteum.
is separated from the periosteum by the The dura is attached anteriorly by
extradural (epidural) space. slips to the posterior longitudinal
ligament and laterally to
prolongations around the nerve roots,
STRUCTURE but it remains free posteriorly
1. Extradural (epidural) space – separates 3. Subdural space – a potential space as
the dura mater from the periosteum. the arachnoid mater is closely applied
It extends from the foramen magnum to the dura (with a thin film of serous
to the sacral hiatus. The space is fluid in between)
roughly triangular in cross-section, 4. Arachnoid mater – thin, delicate
with a small anterior and two larger membrane lining dural sheath (and
posterolateral compartments. The has similar small extensions along
space also extends a short distance nerve roots)
laterally through the spinal foramina 5. Subarachnoid (spinal) space – actual
(as the nerve roots exit). The distance space containing cerebrospinal fluid
from the posterior epidural space (CSF)
border to the dural sac varies from 6. Pia mater – vascular connective
~6 mm in the lumbar region to only sheath that closely invests the spinal
1 mm in the cervical region. The cord. It is thickened anteriorly (linea
epidural space is found variably splendens) and has lateral strands for
3–5 cm beneath the skin (range attachments to the dura (ligamentum
2–7 cm). The epidural space has the denticulatum). Posteriorly it attaches
following contents: to the dura by an incomplete sheet of
● Fat (semifluid) pia (posterior subarachnoid septum).
● Lymphatics The inferior attachment of the pia 47
Concise Anatomy for Anaesthesia
mater to the coccyx is via its Lushka and the median foramen of
continuation – filum terminale Magendie
● Absorption – ~80% is absorbed via
the arachnoid villi (projections of
arachnoid mater) in the cerebral
POINTS OF INTEREST
venous sinuses. The remaining 20%
● Cerebrospinal fluid (CSF): is absorbed by spinal arachnoid villi
● Volume – ~150 ml (roughly equal or by lymphatic drainage. The CSF
to daily production), only 25 ml of pressure is gravity-dependent and
which is contained in the ranges from 6 to 10 cm (of CSF)
spinal/subarachnoid space when lying, to subatmospheric
● Production – by the choroid cervically and 20–40 cm in the
plexuses of the lateral, third and lumbar area when sitting
fourth ventricles. It passes from the ● Composition – is approximately:
lateral ventricles to the third Osmolality = 280 mOsm
ventricle via the paired Specific gravity = 1005
interventricular foramina (of pH 7.4
Munro), and then via the cerebral Glucose = 1.5–4.0 mmol l–1
aqueduct to the fourth ventricle. Sodium = 140–150 mmol l–1
The CSF then flows from the Chloride = 120–130 mmol l–1
fourth ventricle to the Bicarbonate = 25–30 mmol l–1
subarachnoid spinal space through Protein = 0.15–0.3 g l–1
the paired lateral foramina of Cells = less than five lymphs mm–3

48
The spinal meninges and spaces

Nervous
System
T12

L1
Cord (in adult)

L2

L3

L4

Dural sheath
L5

S1

S2
Filum terminale
S3

S4

S5
Sacrococcygeal
ligament

Fig 15.1
The termination of the spinal cord

49
16 The spinal nerves

DESCRIPTION rami and divide into medial and


lateral branches. They are concerned
These number 31 pairs in total: eight with the innervation of the back
cervical, 12 thoracic, five lumbar, five (skin and muscles). The innervation is
sacral and one coccygeal. The nerves are characteristically segmental or
mixed (i.e. contain sensory and motor dermatomal in distribution. A few
fibres) and are formed from the fusion of dorsal rami are exceptional:
ventral (anterior) motor and dorsal ● First cervical dorsal ramus is
(posterior) sensory roots. Unlike the entirely motor, larger and does not
ventral roots, the dorsal sensory roots have medial and lateral branches.
contain a ganglion located just prior to It supplies the muscles of the
the fusion of the roots. suboccipital triangle
The spinal nerves exit from the vertebral ● Second cervical dorsal ramus is
canal through the intervertebral foramina, also large and divides into a large
and the nerve roots are sheathed in medial branch (which becomes
meningeal membranes – dura extending the greater occipital nerve) and a
as far as the fusion to form the spinal smaller lateral (motor) branch
nerve. ● Coccygeal dorsal ramus is very
small, undivided and supplies the
Once fused, the spinal nerves skin over the coccyx
immediately give off a small meningeal 2. Ventral (anterior) primary rami –
branch (which supplies the vertebral generally larger, these supply the arm,
structures) and then divide into two leg and the anterior/lateral aspects of
major nerves: the dorsal and ventral rami. the torso. Some ventral rami unite
There is also a branch that links to the and form nerve plexuses: cervical,
sympathetic ganglionic chain – these are brachial and lumbosacral. These are
called the rami communicantes. discussed below. The thoracic
ventral rami remain, however,
independent of each other, separated
STRUCTURE by the ribs. They, like the dorsal
1. Dorsal (posterior) primary rami – rami, innervate segmentally
generally smaller than the ventral (dermatomal distribution)

50
The spinal nerves

Nervous
System
Vertebra

Periosteal lining
Dorsal root
Epidural space
Ventral root Dura mater

Subarachnoid space

Dorsal Arachnoid mater


ganglion Pia mater

Fig 16.1
The spinal meninges

Medial + lateral branches

Dorsal
ramus
Dorsal root ganglion
Dorsal root

Ventral
ramus

Rami
communicantes

Ventral root
Sympathetic
ganglionic
chain

Lateral cutaneous
branch

Anterior cutaneous
branch

Fig 16.2
The distribution of the spinal nerve 51
17 The nervous plexuses

DESCRIPTION inferior vena caval opening. On the


left, the nerve crosses over the aortic
The ventral rami of the spinal nerves arch (in front of the vagus nerve) and
unite and form complex plexuses in the over the lung root and pericardium
cervical, brachial, lumbar and to pierce the diaphragm just lateral to
sacrococcygeal regions. These supply the the pericardial attachment
neck, arms and legs respectively. 3. Superficial branches – sensory to
neck. These can be divided into
three groups:
CERVICAL PLEXUS ● Ascending:
This is formed from the ventral rami of ● Lesser occipital nerve – (C2)
C1–4. It is responsible for the ● Great auricular nerve – (C2,
innervation of the skin of the head, neck, C3)
and the neck and diaphragmatic ● Descending – supraclavicular
musculature. The rami (except C1-motor nerves – (C3, C4)
only) divide into ascending and ● Transverse – anterior cutaneous
descending branches, which form the nerve of neck – (C2, C3)
three major loops of the plexus. These 4. Deep branches – motor to neck
further divide into deep (motor) and muscles. These supply the anterior
superficial (sensory) branches. vertebral muscles and send additional
small contributions to the scalenus
There are four major groups of branches: medius, levator scapulae,
1. Communicating branches – pass to sternomastoid and trapezius
the hypoglossal nerve, vagus nerve
and cervical sympathetic chain BRACHIAL PLEXUS
2. Phrenic nerve – motor nerve to the
diaphragm. It also transmits Formed from the ventral rami of C5–8
proprioceptive fibres from the and T1. Occasionally, there may be a
diaphragm as well as pleural and significant contribution from C4
pericardial branches. The phrenic (prefixed) or from T2 (post-fixed). The
nerve is derived from C3 to C5. The following arrangement is usually seen:
three roots unite at the lateral edge of 1. Roots – five roots emerge from the
scalenus anterior before descending intervertebral foramina and continue
medially and anteriorly over the between the scalenus medius and
muscle. The nerve then crosses over scalenus anterior. Here the roots
the subclavian artery and under the unite as follows into:
subclavian vein (through the thoracic 2. Trunks:
inlet). On the right side, the nerve ● Upper – from C5 and C6
follows the great veins and pierces ● Middle – continues from C7
52 the central tendon just lateral to the ● Lower – from C8 and T1
The nervous plexuses

Nervous
System
(DORSAL RAMI) ROOTS VENTRAL RAMI

Spinal accessory
Hypoglossal nerve
nerve

Posterior
neck Descendens Hypoglossi
muscles C1 Anterior
Ansa and cervicalis
neck
cervicalis muscles
Suboccipital
nerve

Greater occipital
nerve C2

Posterior
neck Lesser occipital nerve
muscles Great auricular nerve
C3

Anterior cutaneous
nerve of neck

C4

Supraclavicular
nerves

C5

Phrenic nerve

From here “true” cervical plexus

Fig 17.1
The cervical plexus

53
Concise Anatomy for Anaesthesia
The trunks emerge from between the ● Medial cutaneous nerve of the
scalene and pass downward over the arm (C8–T1)
posterior neck triangle and first rib. At ● Medial cutaneous nerve of the
the lateral border of the first rib the forearm (C8–T1)
trunks divide into: ● Posterior cord:
3. Divisions – each trunk divides into ● Upper subscapular nerve (C5,
an anterior and posterior division 6) – to the subscapularis
behind the clavicle. These divisions ● Lower subscapular nerve (C5,
continue on into the axilla and form 6) – to the subscapularis and
into: teres major
4. Cords – according to their position ● Thoracodorsal nerve (C5–7) –
around the axillary artery: to the latissimus dorsi
● Lateral – anterior divisions of ● Axillary nerve (C5, 6) – to the
upper and middle trunks deltoid
● Medial – anterior division of 3. Radial nerve (C5–T1) – formed from
lower trunk the posterior cord
● Posterior – posterior divisions of 4. Median nerve (C6–T1) – formed
all three trunks from the medial and lateral cords
5. Ulnar nerve (C8, T1) – formed from
The brachial plexus is surrounded by a the medial cord
sheath of fibrous tissue, from its origin
(interscalene sheath) to the axilla. The
important larger branches of the brachial
plexus are:
1. Supraclavicular branches: LUMBAR PLEXUS
● Dorsal scapular nerve (C5) – to
the rhomboids Formed from ventral rami of L1–4.
● Long thoracic nerve (C5–7) – to There may be a contribution from T12
the serratus anterior (in 50%) or from L5. The plexus
● Small branches to scalenus/longus assembles within psoas major (anterior to
colli muscles the transverse processes of the L2–5).
● Suprascapular nerve (C5, 6) – to The usual arrangement is:
the scapular area 1. L1 divides into upper and lower
● Nerve to subclavius (C5, 6) – to divisions. The upper division gives
the subclavius off the iliohypogastric and
2. Infraclavicular branches: ilioinguinal nerves. The lower
● Lateral cord: division joins with a branch of L2 to
● Lateral pectoral nerve (C5–7) – form the genitofemoral nerve
to the pectoralis major and 2. L2–4 divide into dorsal and ventral
minor divisions. The dorsal divisions of L2
● Musculocutaneous nerve and L3 form the lateral cutaneous
(C5–7) – to the biceps, nerve of the thigh and L2–4 form the
brachialis and skin (via the femoral nerve. The ventral branches
lateral cutaneous nerve of the join to form the obturator nerve
forearm) 3. L4 and L5 branches also join to form
● Medial cord: the lumbosacral trunk, which
● Medial pectoral nerve (C8–T1) becomes part of the sacrococcygeal
54 – to the pectoralis minor plexus
The nervous plexuses

Nervous
System
ROOTS TRUNKS DIVISIONS CORDS NERVES

Nerves to rhomboids

Suprascapular
C5
nerve

Lateral pectoral nerve


UPPER
C6
Clavipectoral
fascia

C7 Musculocutaneous
MIDDLE LATERAL nerve

C8
Median nerve

LOWER
MEDIAL
T1

Long thoracic nerve

Ulnar nerve
Thoracodorsal nerve

POSTERIOR
Axillary nerve
Quadrangular Radial nerve
space

Fig 17.2
The brachial plexus

55
Concise Anatomy for Anaesthesia
SACROCOCCYGEAL PLEXUS ● Brachial plexus block – large number
of techniques described, but each falls
There is a wide variation in constitution.
into one of four groups:
The sacral plexus is formed from L4–5
● Interscalene
and S1–4. The coccygeal part is formed
● Supraclavicular
from S4, S5 and the coccygeal nerve:
● Axillary
1. L4 and L5 form the lumbosacral ● Infraclavicular
trunk at the medial border of psoas ● No one technique is demonstrably
major. This travels over the pelvic better than the others, and each has
brim and joins S1 different benefits and complications.
2. Ventral rami of S1–4, with S5 and The more common complications
Co. 1 join the plexus within the include pneumothorax, phrenic nerve
pelvis palsy, stellate ganglion block,
The sacral plexus has numerous vessels recurrent laryngeal nerve palsy,
passing in between the nerve trunks. subarachnoid injection and vertebral
These are the inferior gluteal, superior artery injection. The details of how to
gluteal, iliolumbar and internal pudendal perform these blocks are well
vessels. The most important nerve described in the many excellent texts
branches are: of regional anaesthesia
● Cervical plexus block – provides good
1. Superior gluteal nerve (L4 and L5,
analgesia of the skin of the occipital
S1)
region, posterior neck and shoulders.
2. Inferior gluteal nerve (L5, S1 and S2)
The superficial branches of the plexus
3. Posterior femoral cutaneous nerve
provide the sensory supply. These are
(S1–3)
best located by turning the patient’s
4. Perforating cutaneous nerve (S2 and
head slightly away from the side to be
S3)
blocked. The point of needle entry is
5. Pudendal nerve (S2–4)
taken from a line drawn laterally from
6. Sciatic nerve (S2–4) – largest nerve in
the cricoid cartilage where it meets
the body and supplies (together with
the posterior border of the
the femoral nerve) the lower limb
sternomastoid. A needle inserted at
The coccygeal part of the plexus is small. this point at right angles to the skin
S4, S5 and Co. 1 join to form the will pop through the cervical fascia,
anococcygeal nerve, and this supplies the where 10 ml local anaesthetic is then
skin over the coccyx. injected
● Lumbar plexus block – provides
analgesia to the lower abdominal skin,
the skin over the hip and the proximal
lower limb:
POINTS OF INTEREST
● Classically, the original approach
● Regional anaesthetic blockade is was paravertebral. This involved
possible by injecting a local the patient lying prone, and a point
anaesthetic solution around the nerves 4 cm lateral to the spinal process of
of a plexus. Brachial plexus blockade L3 used as the entry point. The
is the most commonly performed transverse process is contacted at
major peripheral nerve block, but the ~5 cm depth, at which point the
cervical and lumbar plexuses may also needle is directed slightly cephalad
56 be targeted and medially, and ‘walked off’ the
The nervous plexuses

Nervous
System
T12

Iliohypogastric nerve L1

L2
Ilioinguinal nerve
L3

L4

L5
Femoral
nerve
Deep ring
Obturator
nerve
Lateral cutaneous
nerve of thigh Lumbosacral trunk
Superficial ring

Inguinal ligament

Ilioinguinal nerve

Genitofemoral nerve Genitofemoral nerve


(femoral branch L1) (genital branch L2)
Fig 17.3
The lumbar plexus

57
Concise Anatomy for Anaesthesia
process for a further 2 cm. Solution ● Modified three-in-one technique
(30 ml) is then injected may also be used. This relies on
● Direct lumbar plexus block the spread of the solution within
technique is identical, except that the inguinal canal reaching the
the needle is not angled medially, lumbar roots, and consequently
only cephalad, once the transverse higher volumes of solution are
process is contacted required

58
The nervous plexuses

Nervous
System
L4

L5
Lumbosacral trunk

Superior gluteal Superior gluteal artery


nerve PIRIFORMIS
MUSCLE S1
Inferior gluteal artery
Inferior gluteal S2
nerve

S3

Sciatic nerve Perforating


cutaneous S4
nerve

Posterior femoral S5
cutaneous nerve

Anococcygeal
nerve

Pudendal C1
nerve
Fig 17.4
The sacrococcygeal plexus

59
18 The major peripheral
nerves

These are divided into groups according into digital branches. It supplies
to the area of supply. the dorsal thumb base, radial side
of back of hand and the back of
the radial three and a half digits
UPPER LIMB
2. Musculocutaneous nerve – arises
1. Radial nerve – continuation of the from the lateral cord (C5–7). It runs
posterior cord of the brachial plexus from behind the pectoralis minor
(C5–T1). It descends posterior to the (lateral to axillary artery) and descends
axillary and brachial arteries and between the biceps and brachialis. It
crosses the tendons of latissimus dorsi terminates in the lateral cutaneous
and teres major. It passes between the nerve of the forearm. It supplies:
long and medial heads of triceps ● Muscular branches to –
(accompanying profunda brachii coracobrachialis, biceps and
vessels) before running posteriorly brachialis
around the spiral groove of the ● Sensory branches – from the
humerus. It then pierces the lateral lateral cutaneous nerve of the
intermuscular septum and runs forearm, supplying the skin over
forward between brachioradialis and the lateral forearm and wrist
brachialis muscles. It terminates over 3. Median nerve – arises from the
the lateral epicondyle in two medial and lateral cords (C6–T1).
branches – superficial radial nerve Initially anterior to the axillary artery,
and posterior interosseous nerve. The it then runs laterally and crosses the
radial nerve supplies: brachial artery at the mid-humerus
● Muscular branches to – triceps, level to become medial in the
anconeus, brachialis, antecubital fossa. Running on
brachioradialis and extensor carpi coracobrachialis and brachialis, it
radialis longus passes under the bicipital aponeurosis
● Cutaneous branches – posterior and enters the forearm between the
cutaneous nerve of the arm, flexor digitorum profundus and
posterior cutaneous nerve of the flexor digitorum superficialis. It
forearm and lower lateral emerges laterally at the wrist to run
cutaneous nerve of the arm under the flexor retinaculum (in the
● Posterior interosseous nerve – carpal tunnel) and terminates in two
entirely motor to the extensors of branches (medial and lateral). The
the forearm and hand, and runs median nerve supplies:
through the supinator muscle ● Muscular branches to – pronator
● Superficial radial nerve – entirely teres, flexor carpi ulnaris, palmaris
sensory and runs under longus, flexor digitorum
brachioradialis (with radial artery) superficialis, three thenar muscles
60 before dividing above the wrist and lateral two lumbricals
The major peripheral nerves

Nervous
System
Posterior cutaneous
nerve of arm

Lower lateral cutaneous


nerve of forearm
Long
Profunda Head of triceps
(to lateral
head of triceps) brachii Medial

Anconeus Lateral intermuscular septum

Posterior cutaneous Brachialis


nerve of forearm

Brachioradialis

Extensor
carpi radialis
longus
Supinator

Radial artery

Branches to
extensors of
forearm and hand

Brachioradialis

Abductor + extensor
pollicis longus
Posterior interosseous
nerve Superficial
radial nerve
Fig 18.1
The radial nerve

61
Concise Anatomy for Anaesthesia
● Sensory branches to – thenar ● Palmar cutaneous branch – arises
eminence and front of radial three in the mid-forearm and supplies
and a half digits the hypothenar skin
● Anterior interosseous branch – ● Dorsal branch – also arises in the
given off high up between the mid-forearm and supplies the
heads of the pronator teres, and ulnar border of the hand
descends to supply the flexor ● Terminal branches supply
pollicis longus, flexor digitorum sensation as above (superficial
profundus (radial half) and branch) and motor to hypothenar
pronator quadratus muscles (three), ulnar two
● Palmar branch – crosses lumbricals, interossei and adductor
superficially over the flexor pollicis
retinaculum and supplies sensation
to the ball of thumb and palm of
LOWER LIMB
the hand
● Lateral terminal branch gives off a 1. Femoral nerve – derived from L2–4
recurrent muscular branch to the and formed within the psoas major. It
abductor pollicis brevis, flexor descends between the psoas major
pollicis brevis and opponens (laterally) and iliacus, and enters the
pollicis. The medial branch thigh lateral to the femoral artery and
continues to supply the sensation under the inguinal ligament. Within
to the hand and fingers as above the femoral triangle it splits
4. Ulnar nerve – originates from the immediately into its terminal branches,
medial cord (C8, T1). It arises via the anterior and posterior
medially and continues on divisions. The femoral nerve supplies:
coracobrachialis, before passing deep ● Muscular branches to – pectineus
through the medial intermuscular and sartorius (anterior), and
septum. It approximates the medial quadriceps femoris (posterior)
head of the triceps to run behind the ● Sensory branches – intermediate
medial epicondyle and enters the cutaneous nerve of thigh and
forearm between the two heads of medial cutaneous nerve of thigh
the flexor carpi ulnaris. It continues (anterior), and the terminal
initially deep to the flexor carpi saphenous nerve (posterior)
ulnaris and then laterally (on top of ● Saphenous nerve – largest branch
the flexor digitorum profundus). It of the femoral nerve runs initially
crosses superficially to the flexor lateral and then medial over the
retinaculum to terminate (superficial femoral artery and descends
and deep terminal branches) over the between the sartorius and gracilis.
pisiform bone. The supply is: It runs down the medial border of
● Muscular branches to – flexor the tibia to pass anterior to the
carpi ulnaris, flexor digitorum medial malleolus and terminates in
profundus (medial half) and branches to the foot. It supplies an
intrinsic hand muscles (except extensive area of sensation to the
lateral two lumbricals and thenar medial aspect of the knee, lower
muscles) leg, ankle and foot
● Sensory branches to – front and 2. Obturator nerve – derived from L2–4
back aspects of medial hand and and continues from its formation
62 medial one and a half fingers within the psoas major along the
The major peripheral nerves

Nerve to
coracobrachialis

Nervous
System
Coracobrachialis

Nerve to biceps

Nerve to brachialis
Biceps

Deep fascia

Brachial artery

Lateral cutaneous nerve of forearm


Fig 18.2
The musculocutaneous nerve
Biceps
tendon
Ulnar artery

Anterior interosseous
artery

Pronator teres

Anterior interosseous nerve


Flexor carpi radialis

– flexor pollicis longus Palmans longus


Flexor digitorum superficialis
– flexor digitorum profundus (1/2)

– pronator quadratus Flexor digitorum


superficialis

Palmar branch
Flexor retinaculum

Recurrent branch
– abductor pollicis brevis 1st lumbrical
– flexor pollicis brevis 2nd lumbrical
– opponens pollicis Skin branches

Fig 18.3
The median nerve 63
Concise Anatomy for Anaesthesia
pelvic sidewall and posterior to the It leaves the fossa between the heads
common iliac vessels. After passing of the gastrocnemius to run on the
over the pelvic brim, it enters the tibialis posterior in the calf, gradually
obturator canal and divides into sloping medially. It winds behind the
anterior and posterior divisions. It medial malleolus (with the posterior
supplies: tibial artery medially and flexor
● Muscular branches to – adductor hallucis longus tendon laterally) to
longus and brevis, pectineus and enter the foot under the flexor
gracilis (anterior), and obturator retinaculum, and terminates into the
externus and half adductor magnus medial and lateral plantar nerves. The
(posterior) nerve supplies:
● Sensory branches to – hip joint ● Muscular branches to – popliteus,
and medial skin over thigh gastrocnemius, soleus and plantaris
(anterior) and knee joint (in popliteal fossa), and tibialis
(posterior) posterior, flexor digitorum longus,
3. Sciatic nerve – formed from L4 and flexor hallucis longus and soleus
L5 and S1–3 (on pyriformis) and (in the calf and foot)
passes back through the greater sciatic ● Sensory branches to – sural nerve
foramen and lies deep to the gluteus (in popliteal fossa) and medial
maximus. It runs down on the calcaneal nerve (foot)
gemellus superior and inferior, and ● Sural nerve – arises from the
lies initially posterior to the popliteal fossa and becomes
acetabulum. From a point midway superficial to run laterally down
between the greater trochanter and the lower leg. It passes behind the
ischial tuberosity, it runs directly lateral malleolus to supply
down on the quadratus femoris and sensation to the lateral foot
adductor magnus. It passes between ● Terminal branches supply the foot
the two heads of the biceps femoris via the medial and lateral plantar
and continues in the posterior branches. The sensory supply is to
midline of the thigh. It terminates in the medial two-thirds of the sole
the common peroneal and tibial of the foot and plantar medial
nerves above the knee. The sciatic three and a half toes (medial
nerve supplies: plantar) and lateral one-third of
● Muscular branches to – the sole of the foot and plantar
semitendinosus, lateral one and a half toes (lateral
semimembranosus, adductor plantar). Together with the
magnus (half) and biceps femoris branches of the common peroneal
● Nerve to quadratus femoris – also nerve they supply the intrinsic
inferior gemellus and sensory to muscles of the foot
the hip joint 5. Common peroneal nerve – derived
● Nerve to obturator internus – also from the sciatic nerve in the lower
superior gemellus third of the thigh. It runs in the
4. Tibial nerve – arises in the lower lateral part of the popliteal fossa
third of the thigh as the terminal before winding around the neck of
branch of the sciatic nerve. It passes the fibula. It then divides (deep to
down through the popliteal fossa, peroneus longus) into two branches –
deep to and between the superficial peroneal and deep
64 semimembranosus and biceps femoris. peroneal nerves. It supplies:
The major peripheral nerves

Nervous
System
Brachial
artery

Medial
epicondyle

Flexor carpi ulnaris

Flexor digitorum profundus

Ulnar
artery

Flexor carpi ulnaris


Dorsal branch
Flexor retinaculum
Palmar
branch
Superficial 3rd lumbrical
branches 4th lumbrical
(sensory)
Interossei
Hypothenar muscles L2
Adductor
pollicis
L3
Fig 18.4
The ulnar nerve Iliacus
L4

Inguinal ligament

Lateral circumflex
femoral artery

Pectineus
Quadriceps
Sartorius

Medial femoral cutaneous nerve

Superficial
Intermediate femoral cutaneous nerve
femoral artery
Deep fascia

Saphenous nerve

Fig 18.5
The femoral nerve 65
Concise Anatomy for Anaesthesia
● No muscular branches lumbar plexus) divides into the
● Sensory branches to – sural iliohypogastric and ilioinguinal
communicating nerve and lateral nerves. The course of these nerves
cutaneous nerve of the calf differs from the usual pattern. The
● Superficial peroneal (previously iliohypogastric nerve pierces the
musculocutaneous) nerve – lies internal oblique, to run deep to the
over the lateral surface of the external oblique, and supplies the
fibula and becomes subcutaneous pubic skin. The ilioinguinal nerve
and anterior over the ankle. It also pierces the internal oblique and
supplies muscular branches to the runs across the inguinal canal
peroneus longus and brevis. It (anterior to the spermatic cord). It
supplies sensation to the lower exits the canal via the external ring or
outer aspect of the lower leg and adjacent aponeurosis, and supplies the
terminates in sensory branches to scrotum/labium majus and upper
the dorsum of the foot thigh.
● Deep peroneal (previously anterior 3. Each nerve from T7 to T12 also
tibial) nerve – lies on the gives off a lateral cutaneous branch
interosseous membrane and passes (with anterior and posterior
anterior to the tibia at the ankle. branches), which divides in the mid-
Muscular branches pass to the axillary line. These branches supply
tibialis anterior, extensor the skin of the flank and back in the
digitorum longus, extensor hallucis relevant distribution. The
longus and peroneus tertius. The iliohypogastric and subcostal nerves,
terminal branches supply the however, do not have a divided
extensor digitorum brevis (lateral) lateral cutaneous nerve, but continue
and the web space between first down to supply the skin over the
and second toes (medial) upper lateral buttock. The
ilioinguinal nerve has no lateral
cutaneous branch.
ABDOMINAL WALL
1. The innervation of the abdominal
wall is by the ventral (anterior)
INTERCOSTAL NERVES
primary rami of T7–L1. The
segmental (dermatomal) distribution 1. These are derived from the ventral
is: the xiphisternum is supplied by (anterior) primary rami of T1–11.
T7, the umbilicus by T10 and the After emerging from the
groin by L1. The intercostal nerves, intervertebral foramen (and giving off
T7–11, and the subcostal nerve, T12, the dorsal primary ramus), the ventral
maintain a course between the rami have small branches that
second and third muscular layers. In communicate with the sympathetic
the thorax, these layers are the ganglia – rami communicantes. At
internal and innermost intercostal this point, the intercostal nerves lie
muscles. As the nerve muscles run for a short distance between the
into the abdominal wall, the pleura and inner muscle layer. The
arrangement remains similar – nerves pass posterior and then below
muscles now the internal oblique and the intercostal arteries to run in the
transversus abdominus. layer between the innermost and
66 3. The first lumbar nerve (from the internal intercostal muscle, and
The major peripheral nerves

L2

Nervous
System
L3
L4

Obturator foramen

Adductor brevis
Obturator
externus
Pectineus
Adductor longus

Adductor
Adductor brevis
magnus (1/2)

Gracilis

Knee joint Medial skin


Fig 18.6
The obturator nerve

L4
L5
S1
S2
S3

Piriformis

Nerve
to quadratus
femoris Nerve to obturator
internus
Semitendinosus

Semimembranosus
Adductor magnus (1/2)
Biceps femoris

Tibial Common peroneal

Fig 18.7
The sciatic nerve 67
Concise Anatomy for Anaesthesia
closely follow the subcostal grooves with atypical features. T1 has no
of the ribs. Typically, there are the lateral or anterior cutaneous branches,
following branches: and supplies the lower part of the
● Collateral branch – arises at the brachial plexus. T2 has an atypical
angle of the rib and supplies the lateral cutaneous branch, the
underlying muscle only intercostobrachial nerve, which
● Lateral cutaneous branch – arises arches over the axillary roof
at the mid-axillary line and (supplying the medial upper arm
supplies sensation to the overlying sensation). T7–11 have an abdominal
skin via anterior and posterior course but maintain their position
branches between the second and third
● Anterior cutaneous branch – arises muscular layers.
over the anterior chest/abdominal 3. T12 is called the subcostal nerve
wall to supply sensation to the (runs below the 12th rib), but has
overlying skin similar branches to the typical
2. There are some intercostal nerves intercostal nerve.

Plantaris

Gastrocnemius
Popliteal
artery
Popliteus

Deep fascia
Soleus

Tibialis
posterior

Posterior Sural nerve


tibal
artery
Flexor
digitorum Flexor hallucis longus
longus
Flexor hallucis longus

Medial Medial plantar Lateral plantar nerve


calcaneal nerve
nerve
Fig 18.8
68 The tibial nerve
The major peripheral nerves

Neck

Nervous
of fibula

System
Lateral cutaneous
Sural nerve of calf
communicating
nerve
Superficial Deep peroneal nerve
peroneal nerve

Extensor
digitorum
eroneus Peroneus longus Tibialis
ngus brevis Extensor anterior
hallucis
longus
Peroneus
Extensor tertius
retinaculum
Anterior
tibial
artery
Extensor
Lateral Medial digitorum Cutaneous branch
cutaneous cutaneous brevis
branch branch

ise Anatomy
naesthesia

Fig 18.9
The common peroneal nerve
Rectus sheath Anterior cutaneous nerve

Rectus muscle
External oblique muscle
Internal oblique muscle
Transversus abdominus muscle

Lateral cutaneous nerve

External intercostal muscle


Internal intercostal muscle
Innermost intercostal muscle
Anterior
primary
ramus Vertebra

Erector spinae muscle


Posterior primary ramus

Fig 18.10
A typical intercostal nerve 69
19 The autonomic
nervous system

The autonomic nervous system is divided Functionally, the sympathetic nervous


into two functionally and anatomically system is concerned with the stress
different nervous systems: sympathetic reactions of the body (‘fight or flight’).
and parasympathetic. Characteristically, The parasympathetic nervous system is
the autonomic nervous system has concerned with homeostasis and tends to
myelinated nerves, which emerge from antagonise the sympathetic activity to
the central nervous system, synapse in a return the body to its resting state.
ganglion and are then distributed to the
end organ as small non-myelinated fibres.
SYMPATHETIC NERVOUS
Anatomically, the sympathetic nervous SYSTEM
system has the ganglia close to the
outflow from the cord, and this is The sympathetic trunk (ganglionated)
facilitated by the sympathetic chain of extends from the base of skull to the
ganglia in close proximity to the coccyx, in close proximity to the
vertebral column. The cell bodies of the vertebral column. Sympathetic fibres
sympathetic system are found in the from T1 to L2 synapse in the ganglionic
lateral horn of the spinal cord, from T1 chain at the same level, or ascend or
to L2. The white rami communicantes descend to synapse in higher or lower
(preganglionic) relay the impulses from ganglia or plexuses. Somatic sympathetic
these cell bodies to the sympathetic fibres accompany each spinal nerve (grey
ganglia. The ganglion then transmits rami) to provide sympathetic supply to
sympathetic fibres to the same level via the skin of the respective dermatome.
the grey rami communicantes Visceral fibres supply sympathetic supply
(postganglionic), or may send to the head, neck and thoracic viscera
preganglionic fibres upwards or from specialised ganglia, and the
downwards. Preganglionic fibres may abdominal and pelvic viscera receive
also be sent from the ganglia to a distant fibres from nearby plexuses.
collateral ganglion, such as the coeliac 1. Sympathetic ganglia:
plexus or cervical ganglion, or the ● Cervical ganglia – three:
adrenal medulla. The parasympathetic ● Superior cervical ganglion
system is somewhat less well defined and (C1–4) – sends fibres to the
has its outflow from the third, sixth, internal and external carotid
ninth and tenth cranial nerves as well as artery, otic, ciliary and
S2–4. The ganglia are some distance submandibular ganglia, spinal
from the spinal cord and the nerve rami and cardiac plexus
preganglionic fibres relay close to the end ● Middle cervical ganglion (C5
organ. For this reason the postganglionic and C6) – sends fibres to the
fibres are necessarily much shorter than inferior thyroid artery, spinal
70 in the sympathetic system. nerve rami and cardiac plexus
The autonomic nervous system

Nervous
System
Sympathetic ganglion chain

Spinal nerve

Postganglionic grey rami


White rami communicantes communicantes
(preganglionic) Cardiac postganglionic

Ascending
and descending Splanchnic preganglionic
preganglionic nerves

Fig 19.1
Distribution of the (thoracic) sympathetic nerves

71
Concise Anatomy for Anaesthesia
● Inferior cervical ganglion (C7 ● Superficial cardiac plexus lies
and C8) – sends fibres to the anterior to the pulmonary
vertebral artery, spinal nerve artery and under the aortic
rami and cardiac plexus. arch. It receives the upper right
However, in 80% of cases, it is cervical ganglion branches and
fused with T1 to form the the left vagus lower cardiac
stellate ganglion branch
● Stellate ganglion – formed from ● Coeliac plexus – largest
C7 to T1. It has a close sympathetic plexus. It is found as a
anatomical relationship with the dense network of fibres anterior to
lower sympathetic chain. It is the aorta, around the origin of the
positioned anterior and between coeliac artery (at L1). It lies
the transverse process of T7 and behind the superior border of the
the first rib, and lies behind the pancreas and the stomach. It
vertebral artery. Stellate ganglion receives the greater, lesser and
blockade may be performed with lowest splanchnic nerves and the
the head in full extension. The coeliac branch of the right vagus.
transverse process of C7 is usually Some fibres relay directly to the
easily palpated with firm pressure adrenal medulla, and the
3 cm above the sternoclavicular remainder descend down the aorta
joint. The needle is inserted at to form the aortic plexus. The
right angles to the skin, and with celiac plexus may be also be
the sternomastoid muscle and blocked, usually with the patient
carotid artery retracted laterally, prone. A long spinal needle is
the transverse process is met ~3 inserted ~6 cm from the midline,
cm from the skin. The local at the lower costal margin. The
anaesthetic is then injected, after needle is angled towards the first
careful aspiration lumbar vertebral body and ‘slipped
● Thoracic ganglia – usually 12. off’ anteriorly for a short distance.
They supply fibres to the aorta, Careful aspiration should precede
spinal nerve rami, three splanchnic the injection (the aortic pulsation
nerves (greater, lesser, lowest) and can frequently be felt)
the cardiac, pulmonary and ● Hypogastric plexus – lies on the
oesophageal plexuses sacral promontory between the
● Lumbar ganglia – usually four. common iliac arteries. It receives
Branches go to the aortic and the presacral nerves (from lumbar
hypogastric plexuses, and lumbar trunks and aortic plexus) and the
spinal nerves sympathetic nerves spread further
● Sacral ganglia – four. Supply pelvic to the pelvis plexuses
plexuses and sacral spinal nerves
2. Sympathetic plexuses:
● Cardiac plexus: PARASYMPATHETIC NERVOUS
● Deep cardiac plexus lies in SYSTEM
front of the tracheal bifurcation
and receives branches from the The parasympathetic nervous system has
cervical and upper four thoracic cranial and sacral components:
ganglia as well as the vagal 1. Cranial – conveyed in cranial nerves
72 branches III, VII, IX and X. The functions
The autonomic nervous system

Nervous
System
Internal carotid artery branch C1
CERVICAL C2
Superior cervical ganglion
C3
External carotid C4
artery branch Cardiac branch
C5
Middle cervical ganglion
C6
Inferior thyroid
artery branch Cardiac branch

C7
Vertebral C8 Inferior cervical ganglion
artery branch
Cardiac branch
THORACIC
T1
T2
T3 Cardiac branches (T1–T5)
T4
T5
T6
T7 Greater splanchnic nerve (T5–T9)
T8
T9
T10
Lesser splanchnic nerve (T10–T11)
T11
T12 Lowest splanchnic nerve (T12)

LUMBOSACRAL
L1
L2
Lumbar splanchnic nerves (L1–L5)

Sacral splanchnic nerves (S1–S5)

Fig 19.2
The sympathetic outflow

73
Concise Anatomy for Anaesthesia
are, briefly, pupillary constriction, efferent fibres come from the
accommodation, salivary and lacrimal dorsal nucleus of the vagal
secretomotor, cardiac inhibition, medullary nucleus and distribute
bronchoconstriction and intestinal widely to the cardiac, pulmonary
motor activity: and abdominal plexuses
● III nerve (oculomotor) – relays in 2. Sacral – formed from the ventral
the ciliary ganglion primary rami of S2–4 and form the
● VI nerve (facial) – relays in the pelvic splanchnic nerves. These join
pterygopalatine and submandibular the sympathetic plexuses to then relay
ganglia in tiny end-organ ganglia.
● IX nerve (glossopharyngeal) – Functionally, the fibres provide rectal
relays in the otic ganglion and bladder motor function, inhibit
● X nerve (vagus) – most important sphincteric muscle and cause genital
parasympathetic outflow. The vasodilation

74
The autonomic nervous system

Nervous
System
Superior orbital fissure

Nerve to inferior oblique

III Short ciliary nerve (eye)

Edinger
Ciliary ganglion
Westphal nucleus

Internal auditory meatus Foramen lacerum Lacrimal


VII Zygomatico temporal
Nasopalatine
VII Branches
Greater palatine
Pterygopalatine Lesser palatine
Superior salivary
nucleus ganglion Pharyngeal

VII Lingual nerve


Chorda
tympani
Submandibular ganglion

IX
Foramen ovale
IX
Middle ear Mandibular nerve

Inferior salivary
nucleus Auriculotemporal nerve

IX
Parotid
branch
X Otic ganglion

Dorsal
motor nucleus
of vagus
Cardiac branches

Vagal trunks

Fig 19.3
The parasympathetic outflow

75
20 The cranial nerves

The cranial nerves can be thought of as ocular and papillary reflexes. The
the peripheral nerves of the brain. These lateral geniculate body then sends
originate from cranial nerve nuclei, fibres via the optic radiation to the
which are situated in the pons and occipital cortex
medulla (the embryological hindbrain). 3. Oculomotor nerve (III) – emerges
There are 12 cranial nerves, of which medial to the cerebral peduncle to
two are somewhat atypical: the olfactory reach the middle cranial fossa. It then
nerve (formed by extended olfactory runs forward, close to the posterior
sensory processes) and optic nerve (a tract communicating artery, and pierces
drawn out from the brain during the dura to enter the cavernous sinus
development). superiorly and laterally. It descends
medial to the trochlear nerve and
1. Olfactory nerve (I) – consists of an enters the orbit within the tendinous
olfactory tract with direct ring and through the superior orbital
connections to the anterior part of fissure. It divides into two divisions:
the brain. The cribriform plate allows ● Superior – supplying superior
the olfactory sensory cells to pass rectus and levator palpebrae
through, and these synapse with the superioris
olfactory bulb. The bulb leads to the ● Inferior – supplying medial rectus,
olfactory tract, which runs on the inferior rectus and inferior oblique
inferior surface of the frontal lobe In addition to the above muscular
2. Optic nerve (II) – fibres pass from supply, the oculomotor nerve also
the retina via the optic disc to the carries preganglionic fibres (to
optic nerve. This passes through the pupillary sphincter and ciliary muscle)
orbit within the muscle cone, and from the Edinger–Westphal
goes through the optic foramen (in parasympathetic nucleus. These relay
the sphenoid bone), above the in the ciliary ganglion situated in the
ophthalmic artery, into the middle lateral orbit
cranial fossa. Here it lies medial to 4. Trochlear nerve (IV) – emerges (after
the anterior clinoid process before decussating in the midbrain) lateral to
running laterally and then superior to the superior cerebellar peduncle. It
the sella turcica. The optic chiasma is runs into the mid-cranial fossa,
formed here, with the temporal fields between the superior cerebellar and
crossing to the opposite side. The posterior cerebral arteries, and enters
nerves continue on each side the cavernous sinus laterally. Here it
between the temporal uncus and the lies below, and is crossed medially by,
cerebral peduncle to reach the lateral the III nerve. It runs through the
geniculate body (in the thalamus). superior orbital fissure and terminates
Some fibres also extend to reach the by supplying the superior oblique
76 superior colliculus, subserving the muscle
The cranial nerves

Nervous
System
Olfactory bulb
Olfactory
tracts
Cribriform plate
Olfactory nerve

Optic tract
Optic chiasma

Lateral geniculate
Optic foraminae
bodies
Retina
Optic nerve
Optic nerve

Fig 20.1
The olfactory and optic nerves

Superior
orbital Superior rectus
Middle cranial fissure
III nucleus Levator palpebrae superior
fossa

Medial rectus
Edinger Westphal Inferior rectus
nucleus Cavernous sinus
Inferior oblique

Ciliary
Oculomotor nerve ganglion
Ciliary body
sphincter pupillae

Superior orbital
fissure
Middle cranial
fossa Superior oblique

IV nucleus
Cavernous sinus
Trochlear nerve
Fig 20.2
The oculomotor and trochlear nerves

77
Concise Anatomy for Anaesthesia
5. Trigeminal nerve (V) – largest cranial possible and careful aspiration is
nerve. It has a small motor and a required, prior to injection
large sensory root and is associated The three divisions of the trigeminal
with four autonomic ganglia. It is nerve are:
responsible for the majority of ● Ophthalmic nerve – smallest of
sensory supply to the face, nose, the three divisions. It provides
mouth and orbit, and supplies motor sensation only to the superior
fibres to the muscles of mastication, face and anterior scalp. Prior to
posterior digastric, mylohyoid, tensor entering the orbit, the
palati and tensor tympani. It also ophthalmic nerve divides into
communicates with the ciliary, three branches – all of which
pterygopalatine, submandibular and pass through the superior
otic ganglia. The motor nucleus is orbital fissure:
situated in the upper pons, just below Frontal nerve – divides into the
the floor of the fourth ventricle. The supra-orbital nerve (supplies
sensory nucleus is divided into three the upper eyelid and scalp)
parts: mesencephalic (high mid- and supratrochlear nerve
brain), superior (upper pons) and (supplies the skin of the
spinal tract (runs parallel to the pons forehead)
and medulla nuclei). These nuclei Nasociliary nerve – branches
each subserve different sensory inputs. are long ciliary nerves
The combined roots of the trigeminal (eyeball), ganglionic (ciliary),
nerve emerge from the ventrolateral ethmoidal nerves (ethmoid
aspect of the pons. The larger lateral and nasal cavity) and
sensory root develops a swelling after infratrochlear nerve (lacrimal
1 cm – the trigeminal ganglion: sac and eyelid)
● Trigeminal ganglion – lies near Lacrimal nerve – supplies the
the apex of the petrous temporal lacrimal gland and upper
bone (slightly hollowed). The eyelid
motor root of the trigeminal nerve ● Maxillary nerve – also purely
runs beneath it, above it lies the sensory, to the mid-facial
temporal lobe. Medially lie the region. It passes through the
posterior cavernous sinus and foramen rotundum into the
internal carotid artery. Fibres pass pterygopalatine fossa and via
posteriorly below the superior the fissure into the
petrosal sinus to reach the pons, infratemporal fossa. It exits
and anteriorly the nerve divides through the inferior orbital
into three divisions: ophthalmic, fossa and continues as the infra-
maxillary and mandibular orbital nerve. The maxillary
divisions. During local nerve nerve has numerous branches
blockade of the ganglion, the during its course:
needle is introduced below the Meningeal branches – within
posterior zygomatic bone and the cranium (dura mater)
behind the pterygoid plate. The Ganglionic branches – within
foramen ovale is located the pterygopalatine fossa (to
radiologically, and the needle the pterygopalatine ganglion)
advanced through this to a further Zygomatic nerve – within the
78 depth of 1 cm. Dural puncture is pterygopalatine fossa into
The cranial nerves

Nervous
System
Lacrimal
Supraorbital
Superior orbital
fissure Supratrochlear

Trigeminal ganglion
Medial
V1 Lateral Nasal
Long Anterior External
ciliary Ganglion Infra-
ethmoidal
trochlear Posterior
ethmoidal canal

V2 Foramen
rotundum
Inferior orbital
fissure
Meningeal
Inferior orbital
Ganglion foramen
V3
Posterior Palpebral
Middle
Zygomatic
Anterior
Nasal
Foramen ovale Superior alveolar
Superior labial
Foramen
spinosum
Medial pterygoid
Meningeal
ANTERIOR Deep temporal
Superficial POSTERIOR
temporal Auriculotemporal Buccal
Parotid
Lateral pterygoid
Chorda
tympani Masseter
T.M.J.
Lingual
External
acoustic Inferior Mental
alveolar foramen

Mylohyoid Mental
anterior digastric

Fig 20.3
The trigeminal nerve

79
Concise Anatomy for Anaesthesia
two branches (-facial and membrane of the mouth,
-temporal – to the cheek and tongue and gums)
temple) Inferior alveolar nerve (lower
Posterior superior alveolar teeth and gums, then
nerve – within the through the mental
pterygopalatine fossa (to the foramen to supply the
maxillary sinus, maxillary lower lip/chin, also gives
molar, cheek and gums) off the nerve to the
Middle superior alveolar nerve mylohyoid)
– from the infra-orbital 6. Abducent nerve (VI) – emerges from
nerve (to the maxillary sinus the lower border of the pons and
and upper premolar tooth) crosses the pontine basal cistern
Anterior superior alveolar nerve before piercing the dura inferolateral
– from the infra-orbital to the sella turcica. Arching over the
nerve (to the maxillary sinus petrous temporal bone, it runs on the
and canine and incisor teeth) medial wall of the cavernous sinus
Infra-orbital nerve (terminal) – and lateral to the internal carotid
divides into the palpebral, artery. It enters the orbit through the
nasal and superior labial superior orbital fissure to supply the
branches lateral rectus muscle
● Mandibular nerve – sensory 7. Facial nerve (VII) – mixed nerve
and motor. The nerve exits with complex arrangements. It
through the foramen ovale and supplies motor fibres to the muscles
gives off two branches (sensory of expression, carries parasympathetic
to the dura mater, motor to the innervation to the salivary, palatine
medial pterygoid muscle), and lacrimal glands, taste from the
before bifurcating into the anterior two-thirds of the tongue and
anterior (small) and posterior sensation to the external auditory
(large) trunks: meatus, tympanic membrane and ear.
Anterior trunk – gives off: It emerges from the pontomedullary
Buccal nerve (sensory to the junction as two roots – a visceral
cheek) efferent root and a mixed nervus
Masseteric nerve (motor to intermedius. It runs (together with
the masseter) the VIIIth nerve) into the internal
Deep temporal nerves auditory meatus (in the posterior
(motor to the temporalis) petrous bone), and runs in the facial
Nerve to lateral pterygoid canal and then in the lateral middle
Posterior trunk – gives off: ear. A sharp bend in the tortuous
Auriculotemporal nerve (five course of the facial nerve (at the
terminal branches supply medial wall between the inner and
the acoustic meatus and middle ear) marks the site of the
ear fibres, geniculate (facial) ganglion. The
temporomandibular joint, nerve continues down in the
temporal skin and parotid tympanic cavity posteriorly and exits
parasympathetic) through the stylomastoid foramen.
Lingual nerve (joined by the After winding laterally around the
chorda tympani (VII), styloid process, the facial nerve dives
80 sensory to the mucous into the posterior part of the parotid
The cranial nerves

Nervous
System
Foramen
Internal lacerum
Nervus auditory meatus Pterygoid canal
intermedius Greater petrosal Lacrimal
Nasal Glands
VII motor Palatine
nucleus Deep petrosal
Taste buds
(sympathetic)
Pterygopalatine
Chorda ganglion
tympani Petrotympanic
Geniculate
fissure
ganglion Submandibular Glands
External sublingual
auditory Taste-anterior
meatus Submandibular 2/ rds tongue
3
ganglion
Stapedius Stylomastoid
foramen
Mandibular Muscles lip/chin
Posterior Cervicofacial
auricular
Cervical Platysma
Digastric Temporafocial
Stylohyoid
Occipitofrontalis
Temporal Orbicularis oculi
Corrugator (ear)

Zygomatic Orbicularis oculi

Buccal Lips/buccinator

Fig 20.4
The facial nerve

81
Concise Anatomy for Anaesthesia
gland and divides into two divisions emerges from the cerebellopontine
(cervicofacial and temporofacial). The angle as a single nerve. It enters the
facial nerve has the following internal auditory meatus, where the
branches: cochlear part separates and pierces the
● Greater petrosal nerve – emerges temporal bone (to supply the
from the geniculate ganglion (and cochlear modiolus). The vestibular
contains the lacrimal secretomotor portion also pierces the temporal
fibres) to run underneath the bone after dividing into two upper
trigeminal ganglion, and then and lower divisions (to supply the
forwards to join the semicircular canals, utricle and
pterygopalatine ganglion saccule)
● Chorda tympani – branches off 9. Glossopharyngeal nerve (IX) – mixed
prior to the facial nerve leaving nerve derived from four cranial
the stylomastoid foramen. It runs nuclei. These are the rostral part of
along the tympanic membrane and nucleus ambiguous, the inferior
exits from the middle ear salivatory nucleus, the tractus
anteriorly through the solitarius and the dorsal sensory
petrotympanic fissure. It joins the nucleus. The nerve emerges from the
lingual nerve and conveys upper medulla as a number of
secretomotor fibres to the rootlets (four or five). It runs in a
submandibular ganglion and taste groove between the inferior
from the anterior two-thirds of cerebellar peduncle and the olive,
the tongue and descends to leave the skull
● Muscular fibres – after exiting the through the jugular foramen. It then
stylomastoid foramen, the facial runs between the internal jugular
nerve is entirely motor: vein and internal carotid artery before
● Posterior auricular – to the curving anteriorly, and enters the
extrinsic ear muscles and pharynx between the superior and
occipitofrontalis middle constrictors. The supply is:
● Digastric branch – to the ● Superior and inferior ganglion –
posterior digastric within the jugular foramen, serve
● Stylohyoid branch – to the as relay stations
stylohyoid muscle ● Tympanic branch – supplies the
● Cervicofacial division – has two tympanic cavity and continues as
branches. The mandibular branch the lesser petrosal nerve
supplies the lower lip and chin (parasympathetic) to the otic
muscles, the cervical branch ganglion (parotid secretomotor)
supplies platysma ● Carotid nerve – runs down the
● Temporofacial division – usually internal carotid artery and supplies
has three branches. The temporal the carotid sinus (pressor) and
branches supply the ear muscle, body (chemo)
occipitofrontalis and orbicularis ● Terminal branches – contribute to
oculi. The zygomatic branches the pharyngeal plexus and supply
also supply the orbicularis oculi. sensation to the tonsils, pharynx,
The buccal branches supply the soft palate and posterior one-third
lips and buccinator of the tongue
8. Vestibulocochlear nerve (VIII) – also 10. Vagus nerve (X) – large and widely
82 called the auditory nerve. This distributed cranial nerve. It arises
The cranial nerves

Nervous
System
Cochlear
Internal
Cochlear auditory
nucleus meatus

Vestibular Semicircular canals


nucleus Utricle & saccule

Vestibulocochlear nerve

Inferior salivary Dura


nucleus
Dorsal sensory Foramen ovale
nucleus
Nucleus Jugular foramen Lesser
ambiguus Parotid
petrosal
Nucleus
solitarius Tympanic Otic ganglion

Ganglion
Petrous Middle ear
bone

Stylopharyngeus

Tonsils
Pharynx
Soft palate
Carotid
Taste and sensation – posterior 1/3rd tongue
Glossopharyngeal nerve
Fig 20.5
The vestibulocochlear and glossopharyngeal nerves

83
Concise Anatomy for Anaesthesia
from three cranial nuclei: dorsal oesophagus through the oesophageal
nucleus of vagus, nucleus ambiguus hiatus. Apart from branches to the
and nucleus of the tractus solitarius. It lower stomach and pylorus, a hepatic
emerges from the upper medulla branch is also given off. The branches
alongside the glossopharyngeal nerve of the vagus nerve are:
as a set of rootlets (nine or ten), and ● In jugular foramen – meningeal
continues similarly in the and auricular branches
posterolateral groove. The vagus soon ● In neck – pharyngeal branch,
forms a single trunk and exits the superior laryngeal nerve, right
skull through the jugular foramen. recurrent laryngeal nerve and
Two small ganglia are present on the cardiac branches
vagus nerve within the jugular ● In thorax – cardiac branches, left
foramen: superior (with cell bodies recurrent laryngeal nerve,
from the ear and dura) and inferior pulmonary, pericardial and
(other afferents). The cranial part of oesophageal branches
the accessory nerve fuses with the ● In abdomen – gastric, hepatic and
vagus just below the jugular foramen. coeliac branches
The distal course of the vagus nerve 11. Accessory nerve (XI) – derived from
differs somewhat on each side. Both two roots, a cranial (from nucleus
vagi descend within the carotid ambiguus) and a spinal root (from C1
sheath and lie in front of the cervical to C5). After emerging as numerous
sympathetic chain. On the right, the rootlets behind the olive, the nerve
vagus descends in front of the right fuses with the spinal root (having
subclavian artery and gives off the ascended through foramen magnum)
right recurrent laryngeal nerve. and exits the skull through the
Passing behind the right jugular foramen. The cranial root
brachiocephalic vein, it descends into joins the vagus, and the spinal root
the thorax against the trachea and descends laterally in front of the atlas
behind the root of the right lung. It to supply motor fibres to the
gives branches to the right posterior sternocleidomastoid and trapezius
pulmonary and oesophageal plexuses, 12. Hypoglossal nerve (XII) – emerges as
and enters the abdomen behind the a series of small rootlets from the
oesophageal hiatus. It proceeds to anterolateral medulla. These fuse
give branches to the upper stomach along their course behind the
before forming the coeliac branch (to vertebral artery and into the
the coeliac plexus). The left vagus hypoglossal canal. It emerges
runs down between the left carotid anteriorly and laterally to the neck
and left subclavian artery to pass vessels, before passing over the hyoid
behind the left brachiocephalic vein. greater cornu, and terminates under
It crosses over the aortic arch, giving the submandibular gland. The
off the left recurrent nerve, and hypoglossal nerve supplies motor
descends into the thorax behind the fibres to the intrinsic muscles of the
left lung root. Branches are also given tongue, hyoglossus, genioglossus and
to the posterior pulmonary and styloglossus (as well as receiving fibres
oesophageal plexuses, but the nerve from the cervical ventral rami for
now runs anteriorly and close to the distribution to the neck muscles)

84
The cranial nerves

Nervous
System
Jugular foramen

Auricular
Nucleus
solitarius
Nucleus Superior and
ambiguus inferior ganglion
Internal and external
Dura
carotid arteries
Dorsal
nucleus Pharyngeal

Accessory
(cranial) Superior laryngeal
Cricothyroid
External

Thyrohyoid membrane
Mucosa above
Internal vocal cords

Superior cardiac Recurrent laryngeal Intrinsic laryngeal


muscles

Inferior cardiac Mucosa below


vocal cords

Pulmonary, pericardial,
oesophageal
Gastric, hepatic, coeliac
Fig 20.6
The vagus nerve

85
Concise Anatomy for Anaesthesia

Cranial
roots

Jugular foramen
Spinal
roots Foramen
magnum

Vagus nerve

Atlas

Trapezius Sternocleidomastoid

Accessory nerve

Internal and external


Hypoglossal
carotid arteries
Hypoglossal canal
roots
Intrinsic tongue muscles
Hyoglossus
Genioglossus
Styloglossus

Hyoid bone
Descendens Branches
hypoglossi to C1 to C1

Hypoglossal nerve
Fig 20.7
The accessory and hypoglossal nerves

86
Appendices
Concise Anatomy for Anaesthesia

C4
C4

T2
T3
T2 T3 C5
C5

T1

C6 T1
C6
C8

C8
C7 C7

Anterior Posterior

Upper lateral Supraclavicular


cutaneous nerve of arm
Upper lateral
cutaneous nerve of arm
Lower lateral Intercostobrachial
cutaneous nerve of arm Lower lateral
cutaneous nerve of arm
Posterior cutaneous
nerve of arm
Medial cutaneous
Lateral cutaneous
nerve of arm
nerve of forearm Lateral cutaneous
nerve of forearm
Medial cutaneous Posterior cutaneous
nerve of forearm nerve of forearm

Median Radial
Ulnar

Anterior Posterior

App 1
Dermatomes and cutaneous nerves of arm

88
Appendices

Nervous
System
T12

S4
L1 S3
S5 L2

L2 L3

L3 L3

L4 L4
L5
L5

S1 S1

L4 L5

Anterior Posterior

Ilio hypogastric
Subcostal Ilioinguinal
Subcostal
Femoral (of
Lateral Posterior femoral
genitofemoral)
femoral cutaneous
cutaneous
Cutaneous branch Lateral femoral
of obturator cutaneous
Intermediate
femoral Medial femoral
cutaneous cutaneous Lateral sural
Lateral
sural Superficial peroneal
Saphenous

Medial
calcaneal Sural
Sural Medial and
Superficial peroneal
lateral plantar
Deep peroneal

Anterior Posterior
App 2
The dermatomes of the leg

89
Concise Anatomy for Anaesthesia

C4

C5
T2
T3
T4
T5
T6
T7

T8

T9

T10

T11

T12

L1

App 3
The dermatomes of the trunk

90
Sample questions –
nervous system

1. Describe, with the aid of a diagram, 7. Draw a labelled diagram of the


the blood supply to the brain. relations of the stellate ganglion.
2. Using a simple diagram, detail the How is it blocked and what are the
path of a typical intercostal nerve possible complications?
from its origin to its terminal 8. Describe your technique for a coeliac
branches. plexus block with reference to the
3. What is the nerve supply of the important anatomical features.
abdominal wall? 9. How is an ankle block performed?
4. Draw a cross-sectional labelled Explain how the sensory innervation
diagram of the spinal column to of the foot is related to individual
illustrate the relationships of the nerves.
epidural space. 10. Describe the course of the
5. Discuss, in point form, the anatomy femoral/sciatic nerve. How do you
of the brachial plexus. Briefly perform a femoral/sciatic nerve
describe one method of performing a block?
brachial plexus nerve block. 11. Draw a labelled diagram of the
6. Describe how you would carry out anterior aspect of the wrist. How
an axillary brachial plexus nerve may this knowledge be of use in
block. anaesthetic practice?

91
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Vertebral
Column
21 The vertebrae

1. Vertebral column – midline structure each side projects laterally and provides
extending from the base of the skull additional surface area for muscular
above to the pelvis below. It provides attachment. There are also two costal
protection for the spinal cord and processes on each vertebral body, which
transfers weight through the pelvis, as are well developed in the thoracic area.
well as having an extensive area for The detailed structure of the individual
muscular attachment. It consists of vertebrae varies considerably:
bony vertebrae connected by
intervertebral fibrocartilaginous discs Cervical vertebrae – the typical
2. Twenty-four true vertebrae – seven cervical vertebra is found from C3 to
cervical, 12 thoracic and five lumbar. C6. It has a relatively small and wide
There are nine false vertebrae, which body, and has two lateral processes (for
consist of the sacrum (five fused the synovial joints of Lushka) on the
vertebrae) and the vestigial coccyx superior surface of the body. The
(four fused vertebrae) transverse processes also contain a
3. Vertebral column – also has a foramen (transversarium) for the
number of curved segments. In the passage of the vertebral artery, venous
adult, there are two areas that are and sympathetic plexuses. The spinal
convex anteriorly: cervical and nerve exits from the vertebral column
lumbar curvatures. The thoracic and via a shallow neural groove, between
sacral areas show anteriorly concave the anterior and posterior tubercle of
curvatures the transverse processes. The laminae
are flat and long, and terminate in
bifid spinous processes (often single at
DESCRIPTION
C6). The neural canal is roughly
A typical vertebra has an anterior body triangular in cross-section and widest
and a posterior neural arch. The lumbar at C5. The atypical cervical vertebrae
bodies are the largest, having to support are:
proportionately more weight. The ● Atlas (C1) – has no true body and
vertebral bodies are each separated by a essentially consists of a ring of bone.
tough fibrocartiligenous disc. The neural It supports the weight of the skull
arch is connected to the vertebral body and articulates with the occipital
by two strong pedicles of bone. The condyles on its superior articular
pedicles each have articular facets facets. The inferior facets articulate
(superior and inferior), which articulate with the axis below. It also has a
with similar facets of the adjacent rounded facet on the anterior arch
vertebra as a synovial joint (facet joint). for articulation with the odontoid
The neural arch is completed posteriorly peg of the axis. The skull rocks
by the two bony laminae joining to form backward and forward on the
94 a spinous process. A transverse process on atlas
The vertebrae

Vertebral
Column
Spine

Transverse process
Lamina

Facet for rib tubercle

Pedicle
Superior view
Vertebral
foramen

Body

Superior articular facet

Lateral view

Facet for rib head


Inferior articular process

Spine

Fig 21.1
A typical vertebra

95
Concise Anatomy for Anaesthesia
● Axis (C2) – allows the head to Lumbar vertebrae – largest vertebrae
rotate. It is also somewhat ring-like and lack foramina transversaria and
in shape. It has a projection of bone costal facets. The bodies are large and
from the body – odontoid peg or kidney-shaped, the pedicles short and
dens, which is attached to the strong, and the transverse processes
occipital bone by apical ligaments. relatively small. The superior and
The laminae are particularly strong inferior articular facets are vertically
and the transverse processes short orientated. The body of L5 is wedge-
● Vertebra prominens (C7) – largest shaped – thicker posteriorly than
cervical vertebra. It has a anteriorly.
particularly large spinous process
Sacrum – formed by the fusion of the
and is transitional between the
five sacral vertebrae. It forms the
cervical and thoracic vertebrae.
central axis of the pelvic girdle, and
Occasionally, a cervical rib may also
articulates above with the fifth lumbar
be seen, extending from the
vertebra, on the sides with the
transverse process
innominate bone (at the sacroiliac
joints), and below with the coccyx. It
Thoracic vertebrae – have articular
is concave anteriorly and roughly
facets on the vertebral bodies and
wedge-like in shape, and has four pairs
transverse processes for articulation
of foramina for the exit of the ventral
with the head and neck of the rib.
spinal nerves posteriorly.
The vertebral bodies are somewhat
heart-shaped and have lateral half- The sacral canal is within the sacrum,
facets (superiorly and inferiorly) for the with anterior and posterior margins
articulation of the head of the rib. The created by the fused sacral vertebrae. It
transverse processes are directed contains:
backwards and laterally, and carry ● Cauda equina
facets on the anterior aspect for ● Filum terminale
articulation with the tubercle of the ● Meninges (spinal)
rib. The spinous processes are ● Coccygeal/sacral nerves
generally slender, long and are ● Epidural fat and veins
directed caudad. The atypical vertebrae
The lower part of the sacrum shows
are:
that the fifth sacral laminae frequently
● T1 – similar to C7, with a broader
fail to fuse. This is called the sacral
and wider body. The upper costal
hiatus. The hiatus is bounded above
facet is complete for articulation
by the fused fourth sacral laminae,
with the first rib and a transverse
laterally by the deficient lamina
process facet placed more
margins of S5 (bearing the sacral
anteriorly. An articular shelf is also
cornua) and below by the posterior
present, providing additional
body of S5.
support to prevent backward
displacement of C7 on T1 The hiatus is covered over by the
● T9 and T10 – may only show sacrococcygeal ligament, and this
single costal articular facets provides a convenient entry route into
● T11 and T12 – transitional between the caudal epidural space. The cornua
the thoracic and lumbar vertebrae are identified with a fingertip, and a
(being stronger and having smaller needle introduced at 45° to the skin.
96 transverse processes) Once the sacral canal is entered, the
The vertebrae

Vertebral
Column
Ventral (anterior) primary ramus Odontoid peg of C2
Transverse ligament of atlas

Foramen transversarium

Dorsal (posterior) Vertebral artery


primary ramus

C1 nerve root

Fig 21.2
The atlas (C1)

Spine

Superior articular process

Transverse process
Superior view
Pedicle

Body

Superior articular process

Lateral view

Pedicle
Spine
Transverse
process Inferior articular process
Fig 21.3
A lumbar vertebra

97
Concise Anatomy for Anaesthesia
needle is advanced a short distance and Coccyx – formed from the fusion of
the solution injected. Care must be four small and rudimentary coccygeal
taken to avoid entering the subdural vertebrae. The surfaces provide
space, especially in children where the attachment for nearby pelvic and
dural sac may end unusually low. gluteal muscles

98
The vertebrae

Vertebral
Column
Median crest Superior articular process

Posterior view

Posterior
Sacral hiatus
sacral
foramina Cornu

Promontory
Ala

Anterior view

Anterior sacral foramina

Coccyx

Fig 21.4
The sacrum and coccyx

99
22 The vertebral ligaments

DESCRIPTION Interspinous ligaments – connect the


shafts of the spinous processes
There is a complicated series of ligaments Supraspinous ligaments – tough fibrous
and joints that connect the various column that connects the tips of the
components of the vertebral column. spinous processes
These may be summarised as follows: Ligamentum nuchae – superior
Intervertebral discs – connect the extension of the supraspinous
vertebral bodies and make up 25% ligaments and extends from C7 to
of the height of the spinal column. the occiput
These consist of an outer annulus
fibrosus and an inner annulus
pulposus. The superior and inferior
surfaces of the vertebral bodies are
also lined with hyaline cartilage,
which allow adhesion to the
POINTS OF INTEREST
intervertebral discs ● The epidural space may be entered by
Anterior longitudinal ligament – runs inserting a needle between the spinal
along the anterior surface of the vertebral laminae, either directly in
vertebral bodies, from C2 to the the midline, or via a para-midline
sacrum. It adheres to the anterior approach. The needle will pass
surface of the vertebral bodies and thorough the following structures as it
the discs advances:
Posterior longitudinal ligament – ● Skin
extends along the posterior aspect of ● Subcutaneous tissue and fat
the vertebral bodies and discs ● Supraspinous ligaments (tough)
Ligamenta flava – series of thick, ● Interspinous ligaments (thin)
elastic, vertical fibres that connect ● Ligamentum flavum (tough)
adjacent vertebral laminae ● Epidural space (and contents)

100
Sample questions –
vertebral column

1. Describe the anatomical structures caudal canal with the aid of a simple
though which the spinal needle passes diagram.
during a lumbar puncture. 3. Draw and label a cross-sectional
2. How do you perform a caudal block? diagram of the epidural space.
Detail the important relations of the

101
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Areas of Special
Interest
23 The base of the skull

The skull provides protection to the pharyngeal artery. It lies just


intracranial contents and the face, and anterior to the foramen magnum
consists of the neurocranium and anterior ● Foramen magnum – largest skull
facial (splanchnocranium) structures. The opening and transmits the medulla
brain rests on the base of the skull, which oblongata and meninges, as well as
itself can be divided into three areas or the vertebral arteries and the spinal
cranial fossae: posterior, middle and accessory nerve
anterior. 2. Middle cranial fossa – houses the
temporal lobes of the brain. It is
1. Posterior cranial fossa – largest and bounded by the wings of the
deepest fossa. The sphenoid, temporal sphenoid bone anteriorly, the
and basi-occipital bones bound it temporal bone laterally, and the
anteriorly, and the occipital bone petrous temporal crests posteriorly.
laterally and posteriorly. Posteriorly, The sphenoid body houses the
the transverse sinuses create deep hypophyseal fossa centrally (for the
grooves, which pass laterally, and the pituitary gland) and has two small
occipital prominence lies centrally. posterior clinoid processes for
This extends to form the internal attachment to the tentorium
occipital crest, which attaches to the cerebelli. The middle cranial fossa
falx cerebelli. The posterior fossa communicates with the orbit through
houses the medulla, pons and two structures: optic canal and the
cerebellum below and the occipital superior orbital fissure. These and
lobes above (separated by the other openings transmit the following
horizontal tentorium cerebelli). The structures:
following openings transmit various ● Optic canal – placed anteriorly,
structures: this transmits the optic nerve and
● Internal acoustic meatus – situated ophthalmic artery
in the posterior petrous part of the ● Superior orbital fissure – transmits
temporal bone, and transmits the all the other structures from the
facial and vestibulocochlear nerves orbit
and labyrinthine vessels ● Ophthalmic nerve
● Jugular foramen – lies just below ● Oculomotor, trochlear and
the internal auditory meatus. It abducens nerves
transmits the sigmoid and inferior ● Ophthalmic veins
petrosal sinuses, and the ● Foramen rotundum – lies
glossopharyngeal, vagus and anteriorly in the greater wing of
accessory nerves the sphenoid bone. It transmits the
● Hypoglossal canal – transmits the maxillary division of the
hypoglossal nerve and meningeal trigeminal nerve
104 branches of the ascending ● Foramen ovale – placed just
The base of the skull

Areas of special
interest
Frontal sinus
Cribriform plate Frontal bone

Foramen caecum
Anterior and posterior
Hypophyseal fossa ethmoidal canals

Lesser wing of sphenoid Optic canal

Foramen rotundum Sulcus chiasmaticus

Foramen ovale Anterior and


posterior clinoid
Foramen spinosum processes
Sella turcica
Foramen lacerum
Petrous
temporal bone
Internal auditory
meatus

Jugular foramen

Hypoglossal canal Groove for transverse sinus

Foramen magnum

Occipital bone
Fig 23.1
The base of the skull

105
Concise Anatomy for Anaesthesia
behind the foramen rotundum and 3. Anterior cranial fossa – houses the
transmits the mandibular division frontal lobes and is bounded by the
(trigeminal), and the lesser petrosal frontal bone anteriorly and the lesser
nerve wings of sphenoid posteriorly. The
● Foramen spinosum – placed floor of the fossa is made of the
further posterolateral to the above, ethmoid bone centrally and this has a
and contains the middle meningeal projection – the crista galli – for the
vessels, and the meningeal branch attachment to the falx cerebri. The
of the mandibular nerve lesser wings of the sphenoid project
● Foramen lacerum – at the junction laterally and terminate medially in the
between the sphenoid and anterior clinoid processes (attach to
temporal bones posteriorly. It the tentorium cerebelli). Between the
transmits small meningeal branches anterior clinoid processes is a slightly
(of ascending pharyngeal artery) indented plateau of bone upon which
and emissary veins the optic chiasma lies (sulcus
● Carotid canal – allows the internal chiasmatus). The following openings
carotid artery (and accompanying are present:
sympathetic plexus) entrance to the ● Foramen caecum – anterior to the
cranium. The artery runs through crista galli and transmits an
its large intracranial opening to run emissary vein
anteriorly and medially, lateral to ● Cribriform plate – transmits the
the sphenoid body olfactory sensory nerves
● Stylomastoid foramen – has an ● Anterior ethmoidal canal – just
opening only present on the lateral to the cribriform plate and
underside of the skull base. This for the passage of anterior
transmits the facial nerve and ethmoidal nerves and vessels
branch of the posterior auricular ● Posterior ethmoidal canal – for the
artery and these enter the facial posterior ethmoidal vessels
canal

106
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24 The thoracic inlet

The thoracic inlet is the area where the ● Brachial plexus roots
neck and thorax meet, and is filled with ● Medially:
a large number of important structures. It ● First part of subclavian artery
is roughly kidney-shaped and is bounded and branches (vertebral,
by the superior manubrium anteriorly, internal thoracic, thyrocervical,
the anterior surface of the first vertebral costocervical)
body posteriorly, and the first ribs and ● Common carotid artery
cartilages laterally. The lung apices (inferiorly)
project above the clavicle for ~3 cm, ● Vagus nerve (inferiorly)
covered over by the pleura and the ● Sympathetic trunk
suprapleural membrane. The lungs are 2. First rib – shortest, flattest and most
grooved anteriorly by the subclavian curved of the ribs. It has a head, a
vessels and posteriorly by the stellate facet for the body of T1, a neck and
ganglion, superior intercostal artery and a tubercle for the transverse process
the first thoracic ventral nerve ramus. of T1. There are a number of
grooves and tubercles on the superior
The scalenus muscles and the first rib are
surface of the first rib and these will
useful structures to understand the
be described from posterior to
relationships in this area:
anterior:
1. Scalenus muscles – three: scalenus ● Insertion for scalenus medius – on
anterior, scalenus medius and scalenus the long neck of the first rib and
posterior. The scalenus anterior provides for the attachment of the
originates from the anterior tubercles muscle. Immediately in front of
of C3–6, and passes down and the muscle lie the trunks of the
laterally, to attach to the scalene brachial plexus
tubercle of the first rib. It lies behind ● Groove for subclavian artery – just
the sternomastoid muscle. The anterior to the scalenus medius
following structures are related to the muscle groove. It is grooved for
scalenus anterior: the lower trunk of the brachial
● Anteriorly: plexus (posterior) and the
● Phrenic nerve subclavian artery (anterior)
● Thoracic duct (on left) ● Tubercle for scalenus anterior –
● Carotid sheath – superiorly on the inner medial curve of the
only; inferiorly only the first rib, anterior to the subclavian
internal jugular vein is anterior groove
(others medial) ● Groove for subclavian vein – just
● Subclavian vein anterior to the insertion of
● Posteriorly: scalenus anterior. The subclavian
● Subclavian artery (divided into vein runs over this groove and
108 parts) behind the clavicle
The thoracic inlet

Areas of special
interest
First rib

C7
Brachial plexus
Subclavian artery

Scalenus anterior

Subclavian vein

Clavicle

Sternum
Fig 24.1
The thoracic inlet

109
Concise Anatomy for Anaesthesia
● Insertion of serratus anterior – on suprapleural membrane attaches to
the outer lateral curve of the first the inner margin. The subclavius
rib, opposite the insertion of muscle attaches to the anterior upper
scalenus anterior extremity. The intercostal muscles
Other structures also attach attach to the lateral margin.
themselves to the first rib. The

110
The thoracic inlet

Areas of special
interest
Head Neck
Tubercle

Insertion of scalenus medius

Groove for subclavian artery


Insertion of scalenus anterior
Insertion of serratus anterior

Groove for subclavian vein

Fig 24.2
The first rib

111
25 The intercostal space

The spaces between the ribs are filled by the innermost and internal intercostal
layers of muscle and fibrous tissue, muscle layers for almost their entire
between which are the vessels, nerves course:
and lymphatics. ● Veins – have complex
terminations and consist of the
1. Muscles: posterior and anterior intercostal
● External intercostals (11 pairs) – veins. The posterior veins
these outermost muscles pass from eventually drain into the superior
the lower border of the upper rib vena cava via the azygos and
to the upper border of the lower hemi-azygos systems, and the
rib. They extend anteriorly anterior veins drain into the
towards the costochondral junction musculophrenic vein (lower
becoming gradually more fibrous, spaces), or the internal thoracic
and merge into the external vein (upper spaces)
(anterior) intercostal membrane ● Arteries – the posterior and
● Internal intercostals (11 pairs) – anterior intercostal arteries. The
run deep, and with the fibres posterior intercostal arteries arise
running at right angles, to the directly from the thoracic aorta
external intercostals. They extend from T3 to T11, and from the
from the sternum, laterally around superior intercostal artery (T1 and
to the angle of the rib, where they T2). The anterior intercostal
become fibrous and merge to arteries (T1–9) are derived from
form the internal (posterior) the two internal thoracic arteries,
intercostal membrane which themselves are branches of
● Innermost intercostal – largely the subclavian artery, and run
incomplete and consist of behind and just lateral to the
numerous slips of muscle tissue. sternal edge. The last two
They are individually named as intercostal spaces are supplied by
the transversus thoracis the posterior intercostal arteries
(anteriorly), intracostal (laterally) only. The anterior intercostals
and subcostalis (posteriorly) eventually anastomose with the
muscles. These are bound together posterior intercostal arteries
by a continuous sheet of fascia. ● Nerves – ventral (anterior) rami of
The innermost muscles are also the thoracic nerves from T1 to
separated from the parietal pleura T11. The lower five nerves from
by a further layer of fascia, the T7 to T11 continue to supply the
endothoracic fascia abdominal wall and maintain their
2. Neurovascular bundles – each consist position between the innermost
of (from above down) a vein, an and internal muscle layers (the
112 artery and a nerve. They lie between internal oblique and transversus
The intercostal space

Areas of special
abdominus respectively). The ● Anterior cutaneous – to the
typical intercostal nerve has the anterior wall skin and

interest
following branches: muscles
● Rami communicantes – Atypically, the first intercostal
to/from the sympathetic trunk nerve forms the lower trunk of
● Collateral – to the intercostal the brachial plexus, and the
muscles and pleura second intercostal nerve forms the
● Lateral cutaneous – to the intercostobrachial nerve (supplies
lateral wall skin and muscles axilla)

Intercostal vein
Intercostal artery
Intercostal nerve

Innermost
Intercostal
Internal
muscles
External

Fig 25.1
The intercostal space

113
26 The abdominal wall

This extends from the xiphoid process (at inferiorly below the arcuate line
thoracic level T9) and subcostal margin (where the aponeuroses all pass
superiorly to the iliac crest, inguinal anteriorly to the rectus muscle). In
ligament and pubic symphysis inferiorly. the central region the rectus
The umbilicus is a convenient central sheath lies directly on
point to divide the abdomen into upper extraperitoneal fat and
and lower, and right and left, quarters. It peritoneum. The rectus sheath
is positioned opposite the third lumbar contains the rectus abdominus, the
vertebra (and has dermatomal nerve superior and inferior epigastric
supply from T10). A line joining the iliac vessels, the terminal branches of
crests passes through the body of the the intercostal nerves T7–11, and
fourth lumbar vertebra, and this is also a the subcostal vessels and nerves
useful point of reference when performing ● External oblique – outermost
an epidural or spinal procedure. abdominal wall muscle and
extends from the lateral edge of
The anterior abdominal wall is essentially
the rectus abdominus (linea alba),
a layered fibromuscular sheet and has its
pubis and anterior iliac crest to the
own blood and nerve supply. Inferiorly,
rib insertions. The fibres run
the inguinal region contains numerous
downward and medially
structures of importance.
● Internal oblique – lies deep to the
1. Muscles external oblique and is continuous
● Rectus abdominus – band-like with the internal intercostal
central pair of muscles arising from muscles above. The fibres pass
the pubic crest and inserting into upwards and laterally
the fifth, sixth, and seventh costal ● Transversus abdominus –
cartilages. The muscle has at least innermost muscle and its fibres
three horizontal fibrous bands on pass horizontally
the anterior surface (preventing 2. Blood supply – extensive, and the
easy spread of local anaesthetic main supply comes from the inferior
solution anteriorly). Each muscle epigastric (from the external iliac
is enclosed by the rectus sheath, artery) and superior epigastric
which is formed by the splitting of (terminal branch of the internal
the inferior oblique aponeurosis. thoracic artery) arteries. The
This is further reinforced behind corresponding veins carry the blood
by the transversus abdominus away and also lie within the rectus
aponeurosis and in front by the sheath
external oblique aponeurosis. The 3. Nerve supply – from the ventral
posterior part of the rectus sheath (anterior) primary rami of T7 to L1.
is deficient superiorly at the costal The details of supply have been
114 margin (muscular insertions), and described earlier.
The abdominal wall

Areas of special
interest
At the umbilicus
External oblique muscle

Internal oblique muscle


Superior epigastic artery
Transversus abdominus Posterior
rectus
Peritoneum sheath
Rectus abdominus

Anterior rectus sheath

Below the arcuate line


External oblique muscle

Internal oblique muscle Inferior epigastric artery

Transversus abdominus Peritoneum

Extraperitoneal fat

Fig 26.1
The abdominal wall (cross-section)

115
27 The inguinal region

The inguinal canal is obliquely placed, (common tendon of internal oblique


passing through the lower part of the and transversus muscles)
anterior abdominal wall. It extends from ● Floor – inguinal ligament, and lacunar
the deep inguinal ring (transversalis fascia ligament medially
opening), down and medially to the ● Roof – arching fibres of the
superficial ring (external oblique transversus abdominus and internal
aponeurosis opening). It lies above and oblique
follows the inguinal ligament. The The inguinal canal has the following
inguinal ligament is the rolled-up edge of contents:
the external oblique, which runs from ● Male – ilioinguinal nerve and
the pubic tubercle to the anterior spermatic cord (containing the vas
superior iliac spine. The boundaries of deferens, testicular, deferens and
the inguinal canal are: cremasteric arteries, pampiniform
● Anterior – aponeurosis of the external plexus, sympathetic plexus and genital
oblique branch of genitofemoral nerve)
● Posterior – fascia transversalis, and ● Female – ilioinguinal nerve and round
conjoint tendon in the medial third ligament

116
The inguinal region

Areas of special
interest
Anterior superior iliac spine

External oblique aponeurosis

Superficial

Inguinal ligament
Superficial inguinal ring

Pubic tubercle

Ilioinguinal nerve
Spermatic cord

Anterior superior iliac spine

Transversus abdominus
Deep

Inguinal ligament

Transversalis fascia
Conjoint tendon
Deep inguinal ring

Pubic tubercle
Spermatic cord

Fig 27.1
The inguinal canal (relations)

117
28 The antecubital fossa

DESCRIPTION ● Median nerve


● Brachial artery – considerable
This is the triangular hollowed area on variations may occur. The artery may
the anterior aspect of the elbow. It bifurcate high in the upper arm, and
contains a number of vessels and nerves superficial radial and ulnar branches
that enter and exit the forearm, and may also be found. The superficial
which can easily be damaged. ulnar artery variation (found in 2%) is
at particular risk during antecubital
RELATIONS venepuncture attempts
● Biceps tendon
Inferomedial – pronator teres ● Radial nerve (with posterior
Inferolateral – brachioradialis interosseous branch)
Superior – a line joining the two
epicondyles of the humerus (medial
and lateral) SUPERFICIAL VEINS
Roof – deep fascia (reinforced by
bicipital aponeurosis). Lying superficial These also show considerable variation:
to the fascia are the median cubital 1. Cephalic vein – drains the radial
vein and the medial cutaneous nerve forearm
of the forearm, and the basilic vein 2. Basilic vein – drains the ulnar
(medial) and cephalic vein (lateral) forearm
Floor – supinator (laterally) and brachialis 3. Medial cubital vein – joins the basilic
(medially) and cephalic vein to form an ‘H’
arrangement. It frequently receives
the median vein of the forearm, and
CONTENTS may bifurcate to form an ‘M’
From medial to lateral: arrangement

118
The antecubital fossa

Areas of special
interest
Biceps brachii

Brachialis
Radial nerve

Brachial artery

Median nerve

Superficial branch of
radial nerve

Radial artery

Ulnar artery
Pronator teres

Common interosseous artery

Pronator teres
Flexor carpi radialis

Medial Lateral
Fig 28.1
The antecubital fossa

119
29 The large veins of
the neck

These have been briefly discussed earlier, 3. Anterior jugular vein – drains the
and a more detailed description follows. anterior neck and passes over the
thyroid isthmus, diving deep to the
1. Internal jugular vein – runs sternomastoid, to enter the external
downwards from the jugular foramen jugular vein
(draining the sigmoid sinus) and joins 4. Subclavian vein – continuation of the
the subclavian vein behind the sternal axillary vein, and extends from the
clavicle to form the brachiocephalic first rib outer border to the scalenus
vein. It lies lateral to the internal anterior medial border. It joins the
carotid artery, and lower down, the internal jugular vein to form the
common carotid artery, within the brachiocephalic vein behind the
carotid sheath. The vagus nerve lies sternoclavicular joint. It runs over
just behind and between the two and grooves the first rib in its arch-
major vessels, within the sheath. The like course. It also receives the
sympathetic chain runs immediately thoracic duct on the left
posterior to the carotid sheath and 5. Brachiocephalic vein – formed by the
the relations of these two nerves and internal jugular and subclavian veins.
two vessels are thus similar. The It receives inferior thyroid, internal
internal jugular vein receives the thoracic and vertebral veins. The left
following tributaries: brachiocephalic vein is 6 cm long and
● Pharyngeal veins runs behind the manubrium sterni to
● Common facial vein terminate in forming the superior
● Thyroid veins (superior and middle) vena cava (with the right
● Lingual vein brachiocephalic vein), behind the first
2. External jugular vein – receives the costal cartilage. It runs in front of the
posterior division of the brachiocephalic artery, trachea and
retromandibular vein (the anterior left common carotid artery, and
division joins the facial vein) and superior to the aortic arch. The right
crosses anterior to the sternomastoid brachiocephalic vein is 3 cm long and
in the neck. It passes deep to the runs vertically down behind the right
neck fascia above the clavicle and border of the manubrium sterni to
enters the subclavian vein (not the form the superior vena cava (as
internal jugular vein) above)

120
The large veins of the neck

Areas of special
interest
Vertebral vein
Inferior thyroid veins

Right internal jugular vein Left external jugular vein

Subclavian vein

Left brachiocephalic vein


Right brachiocephalic vein

Superior vena cava Internal thoracic

Fig 29.1
The large veins of the neck

121
30 The axilla

DESCRIPTION CONTENTS
This is roughly pyramidal in shape and ● Axillary artery – continuation of the
allows major structures to pass from the subclavian artery and becomes the
neck to the upper limb. The roof brachial artery at the lower border of
extends into the neck and is bounded by teres major. It is invested in a
the clavicle in front and the scapula connective tissue sheath – axillary
behind. The base is bounded by the sheath. The pectoralis minor divides
anterior pectoralis major, the posterior the axillary artery into three parts
teres major and medially by the chest ● Axillary vein – receives the upper
wall (and serratus anterior muscle), and is limb venous drainage and becomes
covered over by a layer of skin. the subclavian vein. It lies medially
along the axillary artery
● Brachial plexus – cords of the brachial
plexus surround the axillary artery
within the axillary sheath. Initially all
cords lie above the axillary artery (in
RELATIONS its first part), but take their respective
Anterior wall – pectoralis major and positions (medial, lateral and posterior)
minor muscles, and clavipectoral in relation to the more distal second
fascia part of the artery
Posterior wall – subscapularis, latissimus ● Axillary lymph nodes – these drain
dorsi and teres major muscles the lateral breast and chest wall, and
Medial wall – serratus anterior muscle, the upper limb. There are six groups
and upper five ribs and spaces that drain into the thoracic duct on
Lateral wall – coracobrachialis and biceps the left and the right lymphatic truck
brachii muscles on the right

122
The axilla

Areas of special
interest
Anterior
Pectoralis major
Pectoralis minor

Heads of biceps brachii


Coracobrachialis
Axillary artery
Axillary vein

Medial cord (with med. pectoral n.)


Lateral cord (with lat. pectoral n.)
Posterior cord (with subscapular n.)

Lateral Medial

Subscapularis
Serratus anterior

Humeral head

Scapula
Rib
Posterior
Fig 30.1
The axilla

123
31 The eye and orbit

DESCRIPTION lacrimal fossa is formed between the


two lacrimal crests on the medial
The orbit is roughly conical in shape, wall. Anterior and posterior
with the apex directed posteriorly and ethmoidal foramina on the medial
slightly medially towards the middle wall transmit ethmoidal nerves and
cranial fossa. The base is directed towards vessels
the face and has strong bony margins to Floor – formed from the orbital
protect the orbital contents. The margins surface of the maxilla and orbital
are formed as follows: process of the palatine bone. The
Superior – frontal bone (with supra- inferior orbital fissure transmits the
orbital notch) infra-orbital artery and nerve
Lateral – frontal process of the Lateral wall – formed from the frontal
zygomatic bone process of the zygomatic bone in
Inferior – frontal process of the front and the greater wing of the
zygomatic bone (laterally) and sphenoid behind. The superior
anterior lacrimal crest of the maxilla orbital fissure lies between the roof
(medially) and lateral wall, and transmits the
Medial – frontal bone (superiorly), cranial nerves III, IV and VI, the
posterior lacrimal crest of the ophthalmic divisions of the
lacrimal bone (inferiorly) trigeminal nerve (V), and the
superior ophthalmic vein.
The lacrimal apparatus is contained
within a fossa on the medial wall of the
orbit, and between the anterior and CONTENTS
posterior lacrimal crests. ● Fat
● Lacrimal apparatus
RELATIONS ● Optic nerve
● Orbital vessels
Each orbit has the following boundaries: ● Eyeball – spherical structure
Roof – formed from the orbital plate occupying the anterior half of the
of the frontal bone (anteriorly) and orbit. It has three coats: an exterior
lesser wing of the sphenoid bone fibrous coat (opaque sclera and
(posteriorly). The optic canal is in transparent cornea), a middle vascular,
the posterior roof and transmits the pigmented coat (choroid, ciliary body
optic nerves, meninges and and iris), and an inner, delicate, retinal
ophthalmic artery coat. Within the eyeball are the
Medial wall – formed from the orbital refractive structures: lens, aqueous
lamina of the ethmoid bone, frontal humour and vitreous body. A thin
process of the maxilla, lacrimal bone fascial sheath surrounds the eyeball,
124 and body of the sphenoid. The except the cornea. This bulbar sheath
The eye and orbit

Areas of special
interest
Trochlear nerve Superior rectus

Superior oblique
Oculomotor nerve

Medial rectus
Abducens nerve
Optic nerve
Ophthalmic artery
Lateral rectus

Inferior rectus
Ciliary ganglion

Inferior oblique

Fig 31.1
The eye and orbit

125
Concise Anatomy for Anaesthesia
(or Tenon’s capsule) separates the terminate in the superior
eyeball from the surrounding fat and ophthalmic vein or the cavernous
orbital structures. The extra-ocular sinus
muscles attach to the corneoscleral ● Central vein of the retina – usually
junction, and six muscles are passes directly to the cavernous
responsible for the movement of the sinus (occasionally joining the
eyeball. There are four rectus muscles superior ophthalmic vein)
(medial, lateral, superior, inferior) that
arise from a tendinous ring encircling
the optic canal and nerve. The two
remaining oblique muscles, superior
NERVE SUPPLY
and inferior, arise from the sphenoid May be divided into three groups:
bone and orbital surface of the ● Motor nerves:
maxilla. Levator palpebrae superioris ● Abducens – within the tendinous
also arises from the tendinous ring and ring to supply the lateral rectus
inserts into and elevates the upper ● Trochlear – outside the tendinous
eyelid. ring to supply the superior oblique
● Oculomotor – inside the tendinous
ring to supply other intra-ocular
VASCULAR SUPPLY muscles
1. Arterial: ● Sensory nerves:
● Ophthalmic artery – provides the ● Optic nerve (as discussed above)
major blood supply to the orbit ● Frontal nerve – from the
and eye. It arises from the internal ophthalmic division of the
carotid artery (near the cavernous trigeminal nerve to supply the skin
sinus) and enters the orbit through of the upper eyelid, forehead and
the optic canal. It gives off a scalp
number of branches: ● Lacrimal nerve – sensory only to
● Lacrimal artery the gland
● Posterior ciliary arteries ● Nasociliary nerve – sensory to the
● Muscular arteries and anterior eyeball via numerous branches,
ciliary branches including the long and short (also
● Supra-orbital, supratrochlear, nasal autonomic) ciliary nerves
and posterior ethmoidal branches ● Autonomic fibres:
● Central artery of the retina ● Maxillary fibres from the
2. Venous: pterygopalatine ganglion –
● Superior ophthalmic vein – passes secretomotor to the lacrimal gland
over the optic nerve and through ● Oculomotor nerve – posterior
the superior orbital fissure to division carries preganglionic
terminate in the cavernous sinus. parasympathetic fibres to the ciliary
It also anastomoses with the facial ganglion
vein ● Short ciliary nerves – carry
● Inferior ophthalmic vein – passes postganglionic fibres from the
under the optic nerve and through ciliary ganglion to the sphincter
the inferior orbital fissure to pupillae and ciliary muscles

126
The eye and orbit

Areas of special
interest
Lacrimal nerve

Frontal nerve Optic canal


Trochlear nerve
Superior Superior ophthalmic vein Optic nerve
orbital Oculomotor nerve
fissure (sup. branch) Ophthalmic artery
Nasociliary nerve
Abducens nerve

Oculomotor nerve
(inf. branch)

Tendinous ring (with rectus


Inferior Inferior ophthalmic vein muscle attachments)
orbital
fissure
Infra-orbital artery and nerve

Fig 31.2
The orbital cone structures

127
Sample questions – areas of
special interest

1. Using the skull/diagram provided, associated with the right jugular vein.
describe the foraminae marked and List the complications of cannulation
list the structures that pass through of this vessel, mentioning how each
them. may be avoided.
2. Describe the anatomy of the first 5. Describe the anatomy of the inguinal
rib. canal. How may nerve blockade be
3. What are the important relations and used to allow surgery under local
boundaries of the antecubital fossa? anaesthesia?
What structures may be damaged 6. What are the bony components of
during attempts at venepuncture in the orbit? Which structures may be
this area? damaged during peribulbar and
4. Make a simple diagram, labelled to retrobulbar nerve blockade for eye
show the anatomical structures surgery?

128
Notes

129
Notes

130
Notes

131
Index
Index

Note: a. = artery/ies; l. = ligament/s; m. = muscle/s; n. = nerve/s; v. = vein/s

abdominal wall 114–15 autonomic nervous system 70–5


blood supply 36, 114 parasympathetic ns 72, 74, 75
muscles 114 sympathetic ns 70–2
nerve supply 114 axilla 122–3
abducent n. 80, 125–7 axillary a. 32–3, 54, 122–3
accessory n. 84, 86 axillary lymph nodes 122–3
acoustic meatus 104 axillary n. 55
acoustic n. 79 axillary v. 34–6, 37, 122–3
adductor brevis m. 64, 67 azygos v. 14–15, 20, 22–3
adductor longus m. 64, 67
adductor magnus m. 64, 67 basilic v. 34, 37, 118
airway anaesthesia 10 biceps femoris m. 64, 67
alveolar n. 79, 80 brachial a. 32–3
anconeus m. 60–1 brachial plexus 52, 54, 55, 109, 122–3
anococcygeal n. 56 brachial plexus block 56
antecubital fossa 118–19 brachial v. 37
anterior interosseus n. 62–3 brachialis m. 60–1, 119
anterior tibial (deep peroneal) n. 66 brachiocephalic a. 15, 27, 30–1, 33
aorta 30–1 brachiocephalic v. 27, 35, 36, 37, 120–1
abdominal 30 brachioradialis m. 60–1
aortic arch 15, 27 brain 42–3
aortic sinus 28 cranial n. 76–86
knuckle 27 vascular supply 42–3
major branches 30–1 bronchi and bronchial tree 16–17, 20
appendices 87–91 lymphatic drainage 21
arachnoid mater 47, 51 vascular supply 21
arcuate ligaments 22 buccal n. 79–80
arm see upper limb bundle of His 28
arteries 30–5
head 33 calcaneal n. 64, 68
lower limbs 32, 34, 35 cardiac n. 84–5
neck 30–2, 33 cardiac notch 19
upper limbs 32, 33 cardiac plexus 72
see also named arteries cardiac postganglionic n. 71
aryepiglottic folds 11 cardiac v. 29
arytenoid cartilage 8–9, 11 cardiovascular system 25–40
atlas vertebra 94, 94–6, 97 carotid a. 11, 13, 15, 30–2, 43
atrioventricular node 26 bifurcation 11
auditory (vestibulocochlear) n. 82, 83 cervical ganglia 73
auricular n. 81–2, 85 carotid canal 106
138 auriculotemporal n. 75, 79–80 carotid n. 82–3
Index
cavernous sinus, brain 77 cutaneous n.
cephalic v. 34, 37, 118 lower limb 89

Index
cerebellar a. 43 upper limb 88
cerebral a. 43
cerebrospinal fluid 48 deep peroneal n. 66, 69
cervical ganglia 70–3 dermatomes
cervical n. 81 lower limb 89
cervical plexus 52, 53 trunk 90
cervical plexus block 56 upper limb 88
cervical vertebrae 94–6, 97 diaphragm
cervicofacial n. 81 central trefoil tendon 22, 28
chorda tympani 75, 81–2 muscles 22
ciliary a. 126 nerve supply 23
ciliary ganglion 75, 125–6 respiration movements 22–3
ciliary n. 126 diencephalon 42
circumflex a. 28–9 dorsal root ganglion 51
circumflex femoral v. 37 ductus arteriosus 38–9
circumflex iliac a. dura mater 47, 49, 51
deep 34
superficial 35 Edinger–Westphal nucleus 75, 76
clavicle 109 elbow, antecubital fossa 118–19
clavipectoral fascia 55 epidural space 47, 51
coccygeal n. 56 epigastric vessels 22, 115
coccygeal vertebrae 98, 99 epiglottis 8–9, 11
coeliac plexus 72, 84 ethmoid bone 4–5
coeliac trunk 31 ethmoidal a. 126
common interosseous a. 119 ethmoidal canal 79, 105–6
common peroneal n. 64, 66, 69 eye and orbit 124–7
communicating a. 43 nerve supply 126
conjoint tendon 116–17 orbital cone 127
constrictors, pharynx 6–7 vascular supply 126
coracobranchialis m. 123
corniculate cartilage 8 facial a. 32–3
coronary a. 26, 28–9 facial (geniculate) ganglion 80–1
corrugator m. 81 facial n. 74, 80–2
corticospinal tract 44–5 facial v. 35, 120
costocervical a. 30, 33 fasciculus cuneus and gracilis 44–5
costochondral junction 18 femoral a. 34–5
costoxiphoid angle 18 femoral cutaneous n. 56
cranial fossae 104–6 femoral n. 62, 65
cranial nerves 72–4, 76–86 femoral v. 37
orbit 125–7 fetal circulation 38–9
cribriform plate 4–5, 105–6 filum terminale 49
cricoarytenoid m. 10 foramen caecum, skull 105–6
cricoid cartilage 8–9, 11 foramen lacerum, skull 105–6
cricothyroid l. 8–9 foramen magnum 104–5
cricothyroid m. 7, 10, 13 foramen ovale
cricothyroid membrane 11 heart 38–9
puncture 12 skull 104–5
crura 22 foramen rotundum, skull 104–5
cubital v. 118 foramen spinosum, skull 105–6
cuneus fasciculus 44–5 frenulum 2 139
Concise Anatomy for Anaesthesia
frontal n. 78–9, 126–7 intervertebral discs 100
isthmus 2–3
gastrocnemius m. 64, 68
geniculate bodies 77 jugular foramen 104–5
geniculate ganglion 80–1 jugular v.
genitofemoral n. 57 anterior 15, 34–5, 120–1
glossopharyngeal n. 12, 74, 82, 83 internal and external 15, 34–5, 120–1
gluteal a. 59
gluteal n. 56, 59 lacrimal glands 81
gracilis fasciculus 44–5 lacrimal n. 78–9, 126
gracilis m. 64, 67 laryngeal n. 12–13, 84–5
great vessels 30–7 injuries 10
larynx 8–13
head arteries 30, 33 laryngoscopy view 11
head veins 34, 35 vascular supply 12
heart 26–9 latissimus dorsi 23
autonomic nerve supply 29 ligamenta flava 100
blood supply 29 ligamentum nuchae 100
cardiac notch 19 lingual n. 75, 79–80
chest radiograph 27 lingual v. 120
fetal circulation 38–9 liver, vagus n. 84–5
great vessels 30–7 longus colli m. 54
vascular supply 28–9 lower limb
Thebesian v. 21 arteries 32, 34, 35
hepatic n. 84–5 cutaneous n. 89
hilum 18, 20 dermatomes 89
hyoepiglottic l. 9 nerves 57, 62–8
hyoglossus m. 7 veins 36–7
hyoid, pharynx 6–7 lumbar ganglia 72–3
hypogastric plexus 72 lumbar n. 66
hypoglossal canal 105 lumbar plexus 54, 57
hypoglossal n. 53, 84, 86 lumbar plexus block 56–8
lumbar vertebrae 96, 97
iliac a. 31, 32, 34–5 and iliac crests 114
iliac crests, and lumbar vertebrae 114 lumbosacral trunk 57
iliac v. 36–7 lungs 18–19, 20–21
iliohypogastric n. 23, 57, 66 bronchial supply 17
ilioinguinal n. 57, 66, 116–17 cardiac notch 19
inferior vena cava 27, 36 fissures 19–20
infraclavicular n. 54 lobes 19–20
inguinal canal 116–17 lymphatic drainage 21
inguinal l. 57 nerve supply 21
inguinal region 116–17 vagus n. 84–5
interarytenoid m. 10 vascular supply 21
intercostal a. 31, 112–13 lymphatic drainage
intercostal m. 22, 66, 69, 112–13 bronchial tree 21
intercostal n. 66–9, 112–13 pleura 21
intercostal space 112–13
neurovascular bundles 112–13 mamillary body 43
intercostal v. 112–13 mandibular n. 75, 79, 80, 81
intercostobrachial n. 68, 113 mandibular v. 35
140 interosseous a. 32–3, 62–3, 119 masseteric n. 79–80
Index
maxillary a. 32–3 palatopharyngeal arch and folds 2–3
maxillary n. 78–9 palmar n. 63

Index
median n. 55, 60, 62, 63, 119 palpebral n. 79
median v., upper limb 34 parasympathetic ns 72, 74, 75
mediastinum 18–19 parotid n. 75, 79
meningeal n. 50, 79, 84 pectineus m. 62, 65
meninges 47–9, 51 pectoral n. 54–5
mental n. 79–80 perforating cutaneous n. 56, 59
mesenteric a. 31 pericardium 28
middle ear, nerve supply 83 peripheral nerves 60–9
mouth 2–3 abdominal wall 66
nerve supply 2 intercostal 66, 68–9
vascular supply 2 lower limb 62–9
musculocutaneous n. 55, 60, 63, 66 upper limb 60–2
mylohyoid digastric n. 79 peroneal n. 64, 66, 69
peroneal v. 37
nasal glands 81 petrosal n. 81–3
nasal n. 79 petrotympanic fissure 81–2
nasociliary n. 78–9, 126–7 petrous temporal bone 105
neck a. 30–3 pharyngeal v. 120
neck v. 15, 34, 35, 120–1 pharynx 6–7
nose/nasal cavity 4–5 nerve supply 6, 83, 85
nerve supply 4 vascular supply 6
vascular supply 4 phrenic n. 20, 22–3, 29, 52–3
physiological shunt 21
oblique m., orbit 125–6 pia mater 47, 51
obturator n. 57, 62, 64 pineal gland 43
occipital a. 32–3 piriformis m. 59, 67
occipital lobe 43 pituitary gland 43
occipital n. 53 plantar n. 64, 68
occipitofrontalis m. 81 plantaris m. 64, 68
oculomotor n. 74, 76, 77, 125–7 platysma m. 81
oesophagus, vagus n. 84–5 pleura 18–19
olfactory n. 76, 77 lymphatic drainage 21
ophthalmic a. 125–7 nerve supply 21
ophthalmic n. 78–9 plexuses 52–9
ophthalmic v. 126–7 brachial 52, 54, 55
optic canal 79, 105–6 cervical 52, 53
optic chiasma 76–7 lumbar 54, 57
optic n. 76, 77, 125–7 sacrococcygeal 56, 59
orbiculoris oculi m. 81 popliteal a. 34–5, 68
orbit popliteal v. 36–7
cranial nerves 125–7 popliteus m. 64, 68
rectus m. 125–6 pronator teres 119
orbital cone 127 psoas major 62
otic ganglion 75, 83 pterygoid n. 79
pterygomandibular raphe 7
palate 2–3, 5 pterygopalatine ganglion 75, 78, 81, 126
nerve supply 2, 83 pubic tubercle 117
vascular supply 2 pudendal n. 56, 59
palatine glands 81 pulmonary vascular supply 20, 21, 27
palatoglossal arch and folds 2–3 Purkinje fibres 28 141
Concise Anatomy for Anaesthesia
pyramidal decussation 44 spinal meninges and spaces 47–9, 51
spinal cord termination 49
questions spinal nerves 50–1
areas of special interest 128 distribution 51
cardiovascular system 40 dorsal and ventral rami 50–1
nervous system 91 roots 44
respiratory system 24 spinal meninges 51
vertebrae 102 spinal plexuses 52–9
spinocerebellar tract 45–6
spinothalamic tract 45–6
radial a. 32–3, 119 splanchnic n. 73
radial n. 54–5, 60–2, 119 splanchnic preganglionic n. 71
radicular a. 46 stapedius m. 81
rami communicantes 51 stellate ganglion 72
rectus abdominis 114–15 sternocleidomastoid n. 86
rectus m., orbit 125–6 sternohyoid m. 10
recurrent laryngeal n. 10, 12, 13, 14, 84–5 sternopericardial l. 28
respiratory system 1–24 stylohyoid m. 81
retromandibular v. 35 stylomastoid foramen 81–2, 106
rib cage 19 stylopharyngeus m. 83
axilla 123 subarachnoid space 47
first rib 108–110, 111 subclavian a. 13, 27, 108–9
subclavian v. 35, 37, 108–9, 120–1
saccule, nerve supply 83 subcostal n. 68
sacral ganglia 72–3 subdural space 47
sacral vertebrae 96, 99 submandibular ganglion 75, 81
sacrococcygeal l. 49, 96 suboccipital n. 53
sacrococcygeal plexus 54, 56, 59 subscapular n. 54
salivary nucleus 75 subscapularis m. 123
saphenous n. 62, 65 sulcus chiasmaticus 105
saphenous v. 36–7 superficial peroneal n. 66, 69
sartorius m. 62, 65 superior orbital fissure 79
scalenus m. 22–3, 54, 108–9 superior vena cava 20, 27, 121
sciatic n. 56, 59, 64, 67 supraclavicular n. 53, 54
semicircular canals 83 suprapleural membrane 110
semimembranosus m. 64, 67 suprascapular n. 54–5
semitendinosus m. 64, 67 swallowing 6
septum primum/secundum 38–9 sympathetic nerve supply 15, 70–2
serratus anterior m. 110, 123 sympathetic ganglia 51, 70, 72, 73
sinoatrial node 26 sympathetic plexuses 72
sinuses, nose/nasal cavity 4–5
skull base 104–6 telencephalon 42
anterior cranial fossa 106 temperofacial n. 81
middle cranial fossa 104, 106 temporal a. 32–3
posterior cranial fossa 104 temporal n. 79, 81
soleus m. 64, 68 temporal v. 35
spermatic cord 116–17 Tenon’s capsule 126
spinal a. 43, 46 Thebesian v., heart 21
spinal accessory n. 53 thoracic ganglia 72–3
spinal cord 44–6 thoracic inlet 108–11
termination 44, 49 thoracic n., long 55
142 vascular supply 46 thoracic sympathetic nerve supply 71
Index
thoracic v. 121 umbilical a. 39
thoracic vertebrae 96 umbilical n. 66

Index
thoracodorsal n. 55 umbilical v. 38
thorax, v.s 36 upper limb
thyroarytenoid m. 10 arteries 32, 33
thyrocervical trunk 33 cutaneous n. 88
thyrohyoid l. 9 dermatomes 88
thyrohyoid m. 10, 13 nerves 54, 60–3
thyrohyoid membrane 8 veins 34, 36, 37
thyroid cartilage 8–9 utricle, nerve supply 83
thyroid gland 11
thyroid v. 120–1 vagus n. 13, 20, 74, 82–5
thyroidea ima 31 vas deferens 116–17
tibial a. 34–5, 68 veins
tibial (deep peroneal) n. 64, 66, 68 abdomen 36
tibial v. 36, 37 head and neck 34, 35, 120–1
tongue lower limb 36–7
nerve supply 2, 83, 86 thorax 36
vascular supply 2 upper limb 34, 36, 37
tonsil 3 venae cordis minimae 29
nerve supply 83 vertebrae 94–102
trachea 14–15 vertebral a. 32–3, 43, 94, 97
bifurcation 16 vertebral l. 100
cartilages 16 vertebral v. 35
nerve supply 14–15, 21 vestibular cord 11
vascular supply 14 vestibular n. 83
tracheostomy 14 vestibule, mouth 2–3
trapezius n. 86 vestibulocochlear n. 82, 83
trigeminal ganglion 78, 79 vestibulospinal tract 44–5
trigeminal n. 78, 79 vocal folds 9, 11, 85
trochlear n. 76–77, 125–7
trunk, dermatomes 90 xiphisternal n. 66
xiphoid, diaphragm m. 22
ulnar a. 32–3, 119
ulnar n. 54, 55, 62, 65 zygomatic n. 78–9, 81

143