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Kuntz A: Distribution of the Sympathetic Rami to the Brachial Plexus: Its Relation to Sympathectomy Affecting the Upper Extremity. Arch. Surg., 15, 871-877, 1927.

DISTRIBUTION OF THE SYMPATHETIC RAMI
TO THE BRACHIAL PLEXUS
ITS RELATION TO SYMPATHECTOMY AFFECTING THE
UPPER EXTREMITY*
ALBERT KUNTZ, Ph.D., M.D.
ST. LOUIS

Extirpation of the stellate ganglion or section of the gray rami which connect this ganglion with the brachial plexus has become a recognized surgical procedure, especially in diseases involving the blood vessels of the upper extremity. The aim of this procedure in diseases of the blood vessels is vasomotor denervation of the extremity. Extirpation of the stellate ganglion alone, or section of the gray rami which connect it with the brachial plexus, however, does not completely eliminate the sympathetic nerves of the upper limb in a large percentage of cases. The operation has failed to produce the desired results in certain cases, probably because of incomplete sympathetic denervation of the blood vessels which were involved.
During the progress of studies involving the gray rami associated with the brachial plexus and the distribution of sympathetic fibers in the upper extremity, my attention was called to the inconstant intra thoracic ramus that connects the first and second thoracic nerves as a possible pathway through which sympathetic fibers that leave the sympathetic trunk below the stellate ganglion might enter the first thoracic nerve and become incorporated in nerves arising from the brachial plexus. Accordingly, the present study of the lower cervical and upper thoracic portions of the sympathetic trunks and the communicating rami joining the spinal nerves which contribute to the innervation of the upper extremity was undertaken in order to obtain more exact knowledge regarding the sources of the sympathetic innervation of the upper limb and, if possible, to afford a rational basis for an operative procedure that will in all cases effectively deprive the blood vessels of this limb of their vasomotor nerves.
The chief sources of sympathetic fibers to the upper extremity are the middle cervical and stellate ganglions. These ganglions, as well as the upper thoracic sympathetic ganglions, are extremely variable. Not infrequently the middle cervical ganglion is absent; when it is present, it is generally located about the level of the body of the sixth cervical vertebra. It is usually connected through the gray rami with the fifth and sixth cervical nerves; in some instances, also with the fourth and seventh cervical nerves (Potts, 1925).1 In some instances the middle cervical ganglion lies close to the stellate ganglion. In such cases, the communicating rami arising from the cervical sympathetic trunk may join the fifth and sixth and possibly the fourth and seventh cervical nerves.
A discrete, inferior, cervical sympathetic ganglion occurs but rarely, if at all, in man. This ganglion commonly fuses with the first thoracic sympathetic ganglion to form a stellate ganglion. In some instances the second thoracic sympathetic ganglion is also incorporated in the stellate ganglion. This ganglion varies greatly in size and form. It commonly lies about the level of the neck of the first rib, but it may occupy a somewhat lower position. Gray rami arising from the stellate ganglion join the seventh and eighth cervical and the first thoracic nerves. Not infrequently, especially if the middle cervical ganglion is absent, a gray ramus from the stellate ganglion joins the sixth cervical nerve. At times the stellate ganglion sends a gray ramus to the second thoracic nerve. The first thoracic nerve also sends a white ramus into the stellate ganglion.
Although an intrathoracic ramus of the second thoracic nerve joins the first thoracic nerve in a large percentage of cases, the second thoracic nerve is not commonly regarded as contributory to the brachial plexus. In forty-eight cadavers examined during the present study, an intra thoracic ramus connecting the first and second thoracic nerves was present bilaterally in twenty-one and unilaterally in nine. In the twenty-one cadavers in which it was present bilaterally, this ramus was described as large in ten, of medium size in seven and as small in four. In the nine cadavers in which it was present on only one side, it was described as of medium size in five and as small in four.
According to statements in the textbooks regarding this inconstant ramus of the second thoracic nerve, it may join only the intercostal ramus of the first thoracic nerve or only the brachial plexus, or it may contribute fibers to both the first intercostal nerve and the brachial plexus. In the cadavers examined in the present study, this ramus joined the first intercostal nerve distal to its origin from the first thoracic nerve in only six cases, in all of which it was described as medium or small. In all the other cases it joined the first thoracic nerve proximal to the origin of the first intercostal nerve. If the ramus in question is small, all of its fibers may still be incorporated in the first intercostal nerve, although a contribution of fibers from the second thoracic nerve to the brachial plexus is not precluded. Not infrequently this ramus is actually larger than the first intercostal nerve. In such instances the second thoracic nerve clearly contributes fibers to the brachial plexus.
* From the St. Louis University School of Medicine.
1. Potts, T. K.: The Main Peripheral Connections of the Human Sympathetic Nervous System, J. Anat. 59:129, 1925.

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