Instructions to the user

The Sobotta learning experience

The Sobotta Anatomy Textbook complements the likewise newly structive images, making learning easier and more enjoyable. For
released Sobotta Dissection Atlas. This textbook contains all the learning on-the-go the Sobotta app is useful, with a training and
relevant contents regarding macroscopic anatomy and neuroana­ learning mode. The one-volume Sobotta Dissection Atlas was cre­
tomy, including the evolutionary foundation that is required for ated for study in the anatomical theatre using donated bodies. It
medical school and clinical practice. contains all the images necessary for working on the donated body,
Together with the three-volume Sobotta Atlas, all the contents are is easy to carry and has been designed in such a way that it doesn't
described in conjunction with a great number of attractive and in­ suffer from the conditions in the anatomical theatre.

Overview of the didactical elements

in the Sobotta Anatomy Textbook
Suggestions for use, important associations and clinical references Skills
are summarised in the highlighted text. The descriptions in detail:
The knowledge and medical capabilities that a physician is to
acquire during his studies, is increasingly defined as skills,
and purely factual knowledge is incorporated into these skills.
In the Sobotta Anatomy Textbook, the Skills boxes summarise
CASE STUDY the content of the respective section that needs to be learnt
during the dissection course for verification or for the prelimi-
nary medical examination. They provide a quick overview of
At the beginning of each chapter or subchapter, brief medical case competency-based study objectives, which help building a
studies with characteristic symptoms are described, introducing the contextualised knowledge useful in exams and applicable to
chapter, and highlighting the relevance of anatomical knowledge future professional practice.
needed in order to illustrate the close clinical relationship.

Clinical remarks
Student’s notes during patient examination
Important clinical references which clarify why the anatomical
Brief notes on the case provide an overview for patient contact knowledge is required in everyday clinical practice are sum-
marised in the Clinical remarks feature. The subjects dis-
during residency, a clinical elective or the internship year.
cussed herein complement the anatomical content in that, on
During your internship in A&E, you come across the following case. For the report you have to
the basis of the clinical relationships, the importance and the
write about the internship, you make the following notes: application of what has been learnt in the clinical section of
In particular ACS! the degree and later during medical practice can be under-
(What should you do if there is chest pain?!)
stood and explained.
Hx.: 73 year-old patient, acute chest pain since the morning,
radiating in left arm and throat area. Shortness of breath,
sweating, thoracic tightness; no complete recovery when resting
Smoker (problems with lung!), arterial hypertension (AHT)
CE: cold sweats, dyspnoea, HR 120/min, RR 100/60 mmHg NOTE
systolic with
p.m. over aortic valve, lungs free
The Note feature contains information that is particularly important
DD.: Tropic positive, myoglobin, CK, CK-MB and CRP ↑ for your understanding and for the examinations, and therefore
ECG: ST elevation in I, aVL and V1 – V6 (esp. STEMI!) worth remembering.
Tx: heart catheter with PTCA and Stent (RIVA)
Proc.: platelet aggregation inhibition!
Abbreviations
Singular: Plural:
A. = Arteria Aa. = Arteriae
Lig. = Ligamentum Ligg. = Ligamenta
Ln. = Nodus lymphoideus Lnn. = Nodi lymphoidei
M. = Musculus Mm. = Musculi
N. = Nervus Nn. = Nervi
Proc. = Processus Procc. = Processus
R. = Ramus Rr. = Rami
V. = Vena Vv. = Venae
Var. = Variation

Colour key

Concha nasalis inferior Os occipitale

Mandibula Os palatinum

Maxilla Os parietale

Os ethmoidale Os sphenoidale

Os frontale Os temporale

Os lacrimale Os zygomaticum

Os nasale Vomer

For newborns, the following cranial bones are shown in the same colour:

Os nasale, Os temporale, Mandibula

Maxilla, Os incisivum

Os occipitale, Os palatinum
Edited by
J. Waschke, T.M. Böckers, F. Paulsen

Sobotta
ANATOMY TEXTBOOK
This page intentionally left blank

     
Edited by
Jens Waschke, Tobias M. Böckers, Friedrich Paulsen

Sobotta
ANATOMY TEXTBOOK
English edition with Latin nomenclature

First edition
With the assistance of:
Prof. Dr. Wolfgang Arnold, Witten Dr. Martin Krüger, Leipzig
Prof. Dr. Ingo Bechmann, Leipzig Dr. Daniela Kugelmann, Munich
PD Dr. Anja Böckers, Ulm Prof. Dr. Martin Scaal, Cologne
Prof. Dr. Lars Bräuer, Erlangen Prof. Dr. Dr. Michael J. Schmeißer, Magdeburg
Prof. Dr. Faramarz Dehghani, Halle (Saale) Prof. Dr. Michael Scholz, Erlangen
Prof. Dr. Thomas Deller, Frankfurt PD Dr. Stephan Schwarzacher, Frankfurt
Prof. Dr. Martin Gericke, Halle (Saale) Prof. Dr. Volker Spindler, Basel
Prof. Dr. Bernhard Hirt, Tübingen Prof. Dr. Andreas Vlachos, Freiburg
Hackerbrücke 6, 80335 Munich, Germany
Reply to [email protected]

Original Publication:
Sobotta Anatomie – das Lehrbuch
© Elsevier GmbH, 2015.
All rights reserved.
ISBN 978-3-437-44080-9

This translation of Sobotta Anatomie – das Lehrbuch, 1st edition by Jens Waschke, Tobias M. Böckers and
Friedrich Paulsen was undertaken by Elsevier GmbH.

ISBN 978-0-7020-6760-0
eISBN 978-0-7206-7617-4

All rights reserved

1st edition 2019
© Elsevier GmbH, Munich, Germany

Important note for the user

Medical knowledge is constantly evolving as a result of research and clinical experience. The editors and authors of this
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­therapeutic indications, dosages and adverse reactions) is fully up-to-date. This does not however mean that the users of
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Preface
Anatomy is the study of the body’s structure. The anatomical dealt with as a stand-alone course and in traditional anatomy
structure forms the morphological basis for functions. The combi- textbooks is dealt with in different chapters. Usually, though,
nation of modern morphological methods with molecular biologi- students cannot clearly understand the extent of the contents to
cal, biochemical, biomechanical, bioinformatical and electrophysi- be learned, nor where the details can be found in the book. In
ological techniques have turned modern-day anatomy into func- this textbook, neuroanatomy is displayed comprehensively and
tional, clinically orientated, structural research. Without the in its own section. Buying a stand-alone book on neuroanatomy
knowledge of anatomy, no functions can be deduced and without is thereby no longer necessary.
the knowledge of structure and function, no pathological changes • In the chapter ‘Head’ we have placed special emphasis on topics
can be understood. of interest to students of dental medicine and have displayed it
• The question as to whether anything is still changing in anatomy in a clear and richly illustrated manner.
often comes up, because we supposedly already know every- • Practical case descriptions show the relevance of anatomical
thing. This applies in particular to macroscopic anatomy and knowledge to eventual clinical practice.
also to an anatomy textbook. So why do we need another anato- • The book intensively connects the macroscopic content with
my textbook? In compiling this textbook, several issues were im- functional and clinical aspects. This means that students are
portant to us: not just learning about unalterable anatomy, but are also learn-
• A textbook that works as closely as possible in conjunction with ing and transferring this knowledge within the context of their
an anatomy atlas will facilitate learning. In doing so, we're con- eventual profession as practical and clinically active doctors.
tinuing a tradition, since even the first issues of the Sobotta Atlas • Including suggestions on which skills are to be developed by
of Human Anatomy were accompanied by a manual. The fact studying the individual chapters, we consciously continue the
that the textbook and atlas are put together by the same publish- current approaches of the new National Competence Based
er, and that the editors of the atlas were also involved in the text- Catalogues of Learning Objectives for Undergraduate Medical
book, can only be an advantage. Within the field of neuroanato- Education (NKLM) and Dental Education (NKLZ).
my, we are very fortunate to have gathered numerous authors Despite the new concept of this textbook, there is one thing it can-
working as neuroanatomy researchers in the field of CNS, and not do: it cannot do the learning for the students. Everyone must
who have thereby provided highly up-to-date and relevant con- invest the time to learn. This textbook is designed to help facilitate
tent. learning through vivid representations of anatomical structures; we
• The book is limited to macroscopic anatomy and related devel- want to make you curious about your future career and present the
opment (embryology) and refers to histological aspects only in- contents in an exciting and interesting manner. It should be a wel-
sofar as they are necessary for understanding macroscopic anat- come companion throughout all of your studies in human medi-
omy. This issue was important to us, since all students already cine, dentistry and molecular medicine.
have a book on histology and do not learn histology from an We hope you enjoy the process.
anatomy textbook.
• Most students do buy a separate book for neuroanatomy. The Erlangen, Ulm, Munich, Summer of 2015
main reason for this is the fact that neuroanatomy is usually Friedrich Paulsen, Tobias M. Böckers and Jens Waschke

V
Acknowledgments
We would like to thank all our colleagues who contributed to the (Institute for Anatomy II, Friedrich-Alexander University of
book as authors for the intense dedication, critical advice and great Nuremberg), Prof. Dr. Norbert Kleinsasser (University Clinic for
amount of time they have invested in the project. Otolaryngology, Julius Maximilians University of Würzburg), Prof.
As well as the authors, we would like to thank everyone at Elsevier Dr. Stephan Knipping (Clinic for ENT Medicine, Head & Neck Sur-
who was involved in the planning process and release: we especial- gery, Städtisches Klinikum Dessau), Prof. Dr. Klaus Matzel (Colo-
ly would like to thank Dr. Andrea Beilmann and Dr. Katja Wei- proctology Department of Surgery, University of Erlangen), Prof.
mann, who, with their many years of technical expertise took care Dr. Felicitas Pröls (Institute for Anatomy II of the University of Co-
of the book project as part of the Sobotta team. With their personal logne) and Dr. Nicolas Schlegel (Clinic and Polyclinic for General,
dedication they helped to guide it to its successful completion – the Visceral, Vascular and Paediatric Surgery of the University Clinic
editors will miss the monthly telephone calls. of Würzburg). We are grateful to Dr. Gunther von Hagens (von Ha­
Our special thanks also to Martin Kortenhaus, who intensively ed- gens Plastination, Guben) for allowing us to use the photographic
ited all the chapters for the German edition, as well as our illustra- documentation of plastinated palates, which form the basis for the
tors, who revised several images and created many new ones: Dr. illustrations in the chapter on the head/oral cavity and chewing ap-
Katja Dalkowski, Sonja Klebe, Jörg Mair and Stephan Winkler. paratus, by Prof. Dr. Wolfgang Arnold. We are grateful to Dr. Ste-
We would like to thank Sibylle Hartl for all aspects of production, fanie Lescher and Prof. Dr. Joachim Berkefeldt (Neuroradiology,
Dr. Constance Spring and Dr Dorothea Hennessen for the overall University Clinic of the Goethe University, Frankfurt) for the pro-
coordination, as well as Alexandra Frntic and Elisa Imbery for the vision of neuroradiological images and helpful comments. We are
initial planning. grateful to Dr. Stephan Schwarzacher for his critical comments and
For the review and updating of chapter content we would very critical review of chapter 13.9 Autonomic Nervous System. We are
much like to thank Prof. Dr. Christopher Bohr (Department for grateful to Dr. med. Tamas Sebesteny (Johannes Gutenberg Univer-
Phoniatrics and Paediatric Audiology, University Clinic of Erlan- sity of Mainz, formerly: Goethe-University of Frankfurt) for creat-
gen), Prof. (em.) Dr. Dr. h.c. Bodo Christ (Institute for Anatomy of ing excellent neuroanatomical specimens.
the University of Freiburg), Prof. Dr. Christoph-Thomas Germer
(Clinic and Polyclinic for General, Visceral, Vascular and Paediat- Erlangen, Ulm, Munich, Summer of 2015
ric Surgery, University Clinic of Würzburg), Dr. Johannes Gottanka Friedrich Paulsen, Tobias M. Böckers and Jens Waschke

VI
List of editors and authors1
Editors
Prof. Dr. Jens Waschke Prof. Dr. Tobias M. Böckers Prof. Dr. Friedrich Paulsen
Ludwig Maximilians University of Munich University of Ulm Friedrich Alexander University
Institute of Anatomy – Department I Institute of Anatomy and Cell Biology Erlangen-Nuremberg
Pettenkoferstr. 11 Albert-Einstein-Allee 11 Institute of Anatomy II
80336 Munich 89081 Ulm Universitätsstr. 19
91054 Erlangen

Authors
Prof. Dr. Wolfgang Arnold Dr. Martin Gericke Dr. Dr. Michael J. Schmeißer
University of Witten/Herdecke Leipzig University University of Ulm
Faculty of Dental, Mouth and Jaw Medicine Institute of Anatomy Institute of Anatomy and Cell Biology
Alfred-Herrhausen-Str. 44 Liebigstr. 13 Albert-Einstein-Allee 11
58455 Witten 04103 Leipzig 89081 Ulm

PD Dr. Anja Böckers, MME Prof. Dr. Bernhard Hirt Prof. Dr. Michael Scholz, MME
University of Ulm Eberhard Karls University of Tübingen Friedrich Alexander University
Institute of Anatomy and Cell Biology Institute of Anatomy of Erlangen-Nuremberg
Albert-Einstein-Allee 11 Sector of Macroscopic Institute of Anatomy II
89081 Ulm and Clinical Anatomy Universitätsstr. 19
Elfriede-Aulhorn-Str. 8 91054 Erlangen
Prof. Dr. Lars Bräuer 72076 Tübingen
Friedrich Alexander University PD Dr. Stephan Schwarzacher
of Nuremberg Dr. Martin Krüger Goethe University
Institute of Anatomy II Leipzig University Dr. Senckenbergische Institute
Universitätsstr. 19 Institute of Anatomy of Anatomy I –
91054 Erlangen Liebigstr. 13 Clinical Neuroanatomy
04103 Leipzig Theodor-Stern-Kai 7
Prof. Dr. Faramarz Dehghani 60590 Frankfurt
Martin Luther University Dr. Daniela Kugelmann
of Halle-Wittenberg Ludwig Maximilians University of Munich Prof. Dr. Volker Spindler
Institute of Anatomy and Cell Biology Institute of Anatomy – Department I Ludwig Maximilians University of Munich
Große Steinstr. 52 Pettenkoferstr. 11 Institute of Anatomy – Department I
06108 Halle (Saale) 80336 Munich Pettenkoferstr. 11
80336 Munich
Prof. Dr. Thomas Deller Prof. Dr. Martin Scaal
Goethe University University of Cologne PD Dr. Andreas Vlachos
Dr. Senckenbergische Institute of Anatomy II Goethe University
Institute of Anatomy I Neuroanatomy and Macroscopic Anatomy Dr. Senckenbergische
Clinical Neuroanatomy Joseph-Stelzmann-Str. 9 Institute of Anatomy I –
Theodor-Stern-Kai 7 50931 Cologne Clinical Neuroanatomy
60590 Frankfurt Theodor-Stern-Kai 7
60590 Frankfurt

Contributors
Prof. Dr. Ingo Bechmann
Leipzig University
Institute of Anatomy
Liebigstr. 13
04103 Leipzig

1
All editors and authors are located in Germany.
VII
Picture credits
At the end of each caption for each image, a reference is given in L238 Sonja Klebe, Löhne.
square brackets to the relevant source for that image. L240 Horst Ruß, Munich.
All charts and images not identified in this manner have been tak- L266 Stefan Winkler, Munich.
en from the Sobotta Atlas of Human Anatomy, 23rd ed., Elsevier M375 Prof. Dr. Dr. Ulrich Welsch, Munich.
2010, and previous editions, © Elsevier GmbH, Munich. O541 Prof. Dr. Kurt Possinger, Medical Clinic and Outpa-
E347-09 Moore KL et al. The Developing Human. 9th ed. Saun- tients' Clinic II specialising in Haematology and On-
ders – Elsevier, 2011. cology, Charité Mitte Campus, Berlin.
E402 Drake RL et al. Gray's Anatomy for Students. 1st ed. O932 Annegret Hegge, Osnabrück.
Churchill Livingstone – Elsevier, 2005. R234 Bruch HP, Trentz O. Berchtold Chirurgie. 6th ed. Ur-
E460 Drake RL et al. Gray's Atlas of Anatomy. 1st ed. Chur- ban & Fischer – Elsevier, 2008.
chill Livingstone – Elsevier, 2008. R235 Böcker W et al. Pathologie. 4th ed. Urban & Fischer
E581 Moore KL, Persaud TVN. The Developing Human. 7th – Elsevier, 2008.
ed. Saunders – Elsevier, 2003. R236 Classen M, Diehl V, Kochsiek K. Innere Medizin.
E838 Sharma R, Mitchell B. Embryology. 1st ed. Churchill 6th ed. Urban & Fischer, 2009.
Livingstone – Elsevier, 2005. R247 Deller T, Sebesteny T. Fotoatlas Neuroanatomie. 1st ed.
E943 Kanski YY. Clinical Ophthalmology. A Systematic Ap- Urban & Fischer – Elsevier, 2007.
proach. 6th ed. Butterworth-Heinemann – Elsevier, R317 Trepel M. Neuroanatomie. 5th ed. Urban & Fischer –
2007. Elsevier, 2011.
G210 Standring S. Gray's Anatomy. 40th ed. Churchill Living- S010-1-16 Benninghoff A. Anatomie, Vol. 1. 16th ed. Urban &
stone – Elsevier, 2008. Fischer, 2002.
G394 Schoenwolf G et al. Larsen's Human Embryology. 4th S010-2-16 Benninghoff A. Anatomy, Vol. 2. 16th ed. Urban &
ed. Churchill Livingstone – Elsevier, 2008. Fischer – Elsevier, 2004.
J787 Colourbox.com. S010-17 Benninghoff A, Drenckhahn D. Anatomie. Vol. 1.
J787-023 Colourbox.com / Phovoir French Photolibrary. 17th ed. Urban & Fischer – Elsevier, 2008.
J787-029 Colourbox.com / Pressmaster. T719 Prof. Dr. Norbert Kleinsasser, ENT Clinic, University
K340 Andreas Rumpf, Ottobrunn. of Würzburg.
L106 Henriette Rintelen, Velbert T785 Prof. Dr. Wolfgang Arnold, University Witten/Her-
L126 Dr. Katja Dalkowski, Erlangen. decke.
L127 Jörg Mair, Munich. T786 Dr. Stefanie Lescher, Prof. Dr. Joachim Berkefeldt,
L141 Stefan Elsberger, Planegg. Neuroradiology, University Clinic of the Goethe
L157 Susanne Adler, Lübeck. ­University, Frankfurt.

VIII
Table of contents
I GENERAL ANATOMY AND EMBRYOLOGY
1 General anatomy . . . . . . . . . . . . . . . . . . . . 3 2.3.2 Blastocysts and implantation . . . . . . . . . . 50
Friedrich Paulsen, Faramarz Dehghani
2.4 Gastrulation . . . . . . . . . . . . . . . . . . . . . . . . 51
1.1 Subdivisions . . . . . . . . . . . . . . . . . . . . . . . . 5 2.4.1 Two-leaved germinal disc . . . . . . . . . . . . . 51
2.4.2 Creation of the germinal layers . . . . . . . . . 51
1.2 Architecture of the human body . . . . . . . 5
1.2.1 Organisation . . . . . . . . . . . . . . . . . . . . . . . . 5 2.5 Development of the ectoderm . . . . . . . . . 53
1.2.2 Body proportions . . . . . . . . . . . . . . . . . . . . 7 2.5.1 Induction of the neuroectoderm . . . . . . . . 53
1.2.3 Positional descriptions . . . . . . . . . . . . . . . 8 2.5.2 Neurulation . . . . . . . . . . . . . . . . . . . . . . . . . 54
1.2.4 General anatomical descriptions . . . . . . . 10 2.5.3 Neural crest . . . . . . . . . . . . . . . . . . . . . . . . 55
1.3 Skin and skin appendages . . . . . . . . . . . . 15 2.6 Development of the mesoderm . . . . . . . . 56
1.3.1 Skin types and skin layers . . . . . . . . . . . . . 16 2.6.1 Axial mesoderm . . . . . . . . . . . . . . . . . . . . . 56
1.3.2 Skin appendages . . . . . . . . . . . . . . . . . . . . 16 2.6.2 Paraxial mesoderm . . . . . . . . . . . . . . . . . . 56
2.6.3 Intermediate mesoderm . . . . . . . . . . . . . . 59
1.4 Musculoskeletal system . . . . . . . . . . . . . . 18
2.6.4 Lateral mesoderm . . . . . . . . . . . . . . . . . . . 60
1.4.1 Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
1.4.2 Bones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 2.7 Development of the entoderm . . . . . . . . . 61
1.4.3 Joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.8 Folding movements of the embryo . . . . . 61
1.4.4 General considerations on muscles . . . . . 29
2.8.1 Craniocaudal curvature . . . . . . . . . . . . . . . 62
1.5 Circulation systems . . . . . . . . . . . . . . . . . . 33 2.8.2 Lateral folding up . . . . . . . . . . . . . . . . . . . . 62
1.5.1 Body and pulmonary circulation . . . . . . . 33
2.9 Extra-embryonic tissue . . . . . . . . . . . . . . . 63
1.5.2 Portal vein circulation . . . . . . . . . . . . . . . . 37
2.9.1 Trophoblast . . . . . . . . . . . . . . . . . . . . . . . . . 63
1.5.3 Prenatal circulation . . . . . . . . . . . . . . . . . . 38
2.9.2 Chorionic cavity and yolk sac . . . . . . . . . . 63
1.5.4 Lymphatic circulation . . . . . . . . . . . . . . . . . 38
2.9.3 Amnion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
1.6 Mucous membranes, glands, 2.9.4 Allantois . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
serous cavities . . . . . . . . . . . . . . . . . . . . . . 41
2.10 Early development of the extremities . . . 65
1.6.1 Mucous membranes . . . . . . . . . . . . . . . . . 41
2.10.1 Formation of the extremity buds . . . . . . . 65
1.6.2 Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.10.2 Pattern formation in the
1.6.3 Serous cavities . . . . . . . . . . . . . . . . . . . . . . 41
extremities positions . . . . . . . . . . . . . . . . . 65
1.7 Nervous system . . . . . . . . . . . . . . . . . . . . . 42 2.10.3 Origin of the skeleton and
the muscles of the extremities . . . . . . . . . 66
2 General embryology . . . . . . . . . . . . . . . . . 45
2.11 Early development
Martin Scaal
of the head and throat area . . . . . . . . . . . 66
2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . 47 2.11.1 Pharyngeal arches . . . . . . . . . . . . . . . . . . . 66
2.11.2 Pharyngeal grooves
2.2 Fertilisation . . . . . . . . . . . . . . . . . . . . . . . . 47
and pharyngeal pouches . . . . . . . . . . . . . . 70
2.2.1 Translocation and capacitation . . . . . . . . . 47
2.11.3 Development of the tongue
2.2.2 Acrosome reaction
and thyroid gland . . . . . . . . . . . . . . . . . . . . 70
and fusion of the germ cells . . . . . . . . . . . 48
2.11.4 Facial development . . . . . . . . . . . . . . . . . . 71
2.2.3 Fusion of genetic material . . . . . . . . . . . . . 48
2.11.5 Development of the oral
2.3 Preimplantation development . . . . . . . . . 50 and nasal cavities . . . . . . . . . . . . . . . . . . . . 72
2.3.1 Cleavage and compaction . . . . . . . . . . . . . 50

II MUSCULO­SKELETAL SYSTEM
3 Torso . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 3.1.1 General structure . . . . . . . . . . . . . . . . . . . . 76
3.1.2 Thoracic wall . . . . . . . . . . . . . . . . . . . . . . . . 77
3.1 Ventral torso wall . . . . . . . . . . . . . . . . . . . 76
3.1.3 Diaphragm . . . . . . . . . . . . . . . . . . . . . . . . . 87
Martin Gericke, Martin Krüger (with
3.1.4 Abdominal wall . . . . . . . . . . . . . . . . . . . . . 90
contribution from Ingo Bechmann)

IX
Table of contents

3.2 Dorsal torso wall . . . . . . . . . . . . . . . . . . . . . 104 4.6.7 N. ulnaris . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

Friedrich Paulsen, Jens Waschke
4.6.8 N. cutanei brachii and
3.2.1 General structure . . . . . . . . . . . . . . . . . . . . 104
antebrachii medialis . . . . . . . . . . . . . . . . . . 184
3.2.2 Back muscles . . . . . . . . . . . . . . . . . . . . . . . 105
3.2.3 Vascular, lymphatic and nervous 4.7 Arteries of the upper extremity . . . . . . . . 184
systems of the dorsal torso wall . . . . . . . . 112 4.7.1 A. subclavia . . . . . . . . . . . . . . . . . . . . . . . . 185
4.7.2 A. axillaris . . . . . . . . . . . . . . . . . . . . . . . . . . 186
3.3 Spine, spinal cord and thorax . . . . . . . . . 104
4.7.3 A. brachialis . . . . . . . . . . . . . . . . . . . . . . . . 187
Bernhard Hirt, Friedrich Paulsen
4.7.4 A. radialis . . . . . . . . . . . . . . . . . . . . . . . . . . 188
3.3.1 Embryology . . . . . . . . . . . . . . . . . . . . . . . . 115
4.7.5 A. ulnaris . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
3.3.2 Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
3.3.3 Spinal cord site . . . . . . . . . . . . . . . . . . . . . . 129 4.8 Veins of the upper extremity . . . . . . . . . . 190
3.3.4 Thorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 4.8.1 Superficial veins . . . . . . . . . . . . . . . . . . . . . 190
4.8.2 Deep veins . . . . . . . . . . . . . . . . . . . . . . . . . 191
4 Upper extremity . . . . . . . . . . . . . . . . . . . . 139
4.9 Lymphatic vessels
Volker Spindler, Jens Waschke
of the upper extremity . . . . . . . . . . . . . . . 191
4.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 4.9.1 Epifascial and subfascial
lymph vessels . . . . . . . . . . . . . . . . . . . . . . . 191
4.2 Development of upper
4.9.2 Lymph nodes of the axilla . . . . . . . . . . . . . 191
and lower extremities . . . . . . . . . . . . . . . . 142
4.2.1 Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 4.10 Topographically important
4.2.2 Bones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 aspects of the arm . . . . . . . . . . . . . . . . . . . 192
4.2.3 Muscular system . . . . . . . . . . . . . . . . . . . . 143 4.10.1 Trigonum clavipectorale . . . . . . . . . . . . . . 192
4.2.4 Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 4.10.2 Axillary cavity . . . . . . . . . . . . . . . . . . . . . . . 192
4.2.5 Blood vessels . . . . . . . . . . . . . . . . . . . . . . . 145 4.10.3 Axillary spaces and triceps groove . . . . . 193
4.10.4 Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
4.3 Shoulder girdle . . . . . . . . . . . . . . . . . . . . . 145
4.10.5 Carpal tunnel and GUYON’s canal . . . . . . 194
4.3.1 Bones of the shoulder girdle . . . . . . . . . . . 145
4.3.2 Joints and ligament connections
5 Lower extremity . . . . . . . . . . . . . . . . . . . . 195
of the s­ houlder girdle . . . . . . . . . . . . . . . . . 146
Volker Spindler, Jens Waschke
4.3.3 Shoulder girdle mechanics . . . . . . . . . . . . 147
4.3.4 Shoulder girdle muscles . . . . . . . . . . . . . . 148 5.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
4.4 Upper arm . . . . . . . . . . . . . . . . . . . . . . . . . . 150 5.2 Pelvis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
4.4.1 Humerus . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 5.2.1 Structure and form . . . . . . . . . . . . . . . . . . . 198
4.4.2 Shoulder joint . . . . . . . . . . . . . . . . . . . . . . . 150 5.2.2 Bones of the pelvis . . . . . . . . . . . . . . . . . . . 199
4.4.3 Shoulder joint mechanics . . . . . . . . . . . . . 151 5.2.3 Pelvic joints and ligament attachments . . 201
4.4.4 Shoulder muscles . . . . . . . . . . . . . . . . . . . 152 5.2.4 Mechanics of the pelvic joints . . . . . . . . . . 201
4.5 Forearm and hand . . . . . . . . . . . . . . . . . . . 155 5.3 Thigh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
4.5.1 Bones of the forearm . . . . . . . . . . . . . . . . . 156 5.3.1 Thigh bone . . . . . . . . . . . . . . . . . . . . . . . . . 202
4.5.2 Elbow joint . . . . . . . . . . . . . . . . . . . . . . . . . 156 5.3.2 Hip joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
4.5.3 Joint connections between 5.3.3 Mechanics of the hip joint . . . . . . . . . . . . . 205
the forearm bones . . . . . . . . . . . . . . . . . . . 157 5.3.4 Muscles of the hip joint . . . . . . . . . . . . . . . 205
4.5.4 Elbow joint and distal 5.3.5 Fascia lata and Tractus iliotibialis . . . . . . . 209
radioulnar joint ­mechanics . . . . . . . . . . . . 157
5.4 Lower leg . . . . . . . . . . . . . . . . . . . . . . . . . . 209
4.5.5 Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
5.4.1 Bones of the leg . . . . . . . . . . . . . . . . . . . . . 209
4.5.6 Structure and bones of the hand . . . . . . . 159
5.4.2 Attachments between
4.5.7 Joints of the hand . . . . . . . . . . . . . . . . . . . 160
the Tibia and Fibula . . . . . . . . . . . . . . . . . . 211
4.5.8 Hand-joint mechanics . . . . . . . . . . . . . . . . 163
5.4.3 Knee joint . . . . . . . . . . . . . . . . . . . . . . . . . . 211
4.5.9 Muscles of the forearm and hand . . . . . . . 164
5.4.4 Mechanics of the knee joint . . . . . . . . . . . 214
4.5.10 Auxiliary structures of the
5.4.5 Muscles of the knee joint . . . . . . . . . . . . . . 216
musculature in the area of the hand . . . . . 169
5.5 Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
4.6 Nerves of the upper extremity . . . . . . . . . 174
5.5.1 Bones of the foot . . . . . . . . . . . . . . . . . . . . 219
4.6.1 Sensory innervation . . . . . . . . . . . . . . . . . 174
5.5.2 Joints of the foot . . . . . . . . . . . . . . . . . . . . 220
4.6.2 Structure of the Plexus brachialis . . . . . . . 175
5.5.3 Mechanics of the ankle joints . . . . . . . . . . 221
4.6.3 N. axillaris . . . . . . . . . . . . . . . . . . . . . . . . . . 178
5.5.4 The arch of the foot . . . . . . . . . . . . . . . . . . 223
4.6.4 N. radialis . . . . . . . . . . . . . . . . . . . . . . . . . . 178
5.5.5 Muscles of the lower leg and foot . . . . . . 225
4.6.5 N. musculocutaneus . . . . . . . . . . . . . . . . . 180
5.5.6 Support facilities of the musculature
4.6.6 N. medianus . . . . . . . . . . . . . . . . . . . . . . . . 181
in the region of the lower leg and foot . . . 229

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5.6 Nerves of the lower extremity . . . . . . . . . 231 5.9 Lymph vessels of the lower extremity . . 245
5.6.1 Plexus lumbosacralis . . . . . . . . . . . . . . . . . 233 5.9.1 Lymph vessels . . . . . . . . . . . . . . . . . . . . . . 245
5.6.2 N. ischiadicus . . . . . . . . . . . . . . . . . . . . . . . 236 5.9.2 Inguinal lymph nodes . . . . . . . . . . . . . . . . 245
5.9.3 Pelvic lymph nodes . . . . . . . . . . . . . . . . . . 245
5.7 Arteries of the lower extremity . . . . . . . . 238
5.7.1 A. iliaca externa . . . . . . . . . . . . . . . . . . . . . 239 5.10 Topographically important
5.7.2 A. femoralis . . . . . . . . . . . . . . . . . . . . . . . . 239 aspects of the leg . . . . . . . . . . . . . . . . . . . . 246
5.7.3 A. poplitea . . . . . . . . . . . . . . . . . . . . . . . . . . 241 5.10.1 Lacuna musculorum and
5.7.4 A. tibialis anterior . . . . . . . . . . . . . . . . . . . . 241 Lacuna vasorum . . . . . . . . . . . . . . . . . . . . . 246
5.7.5 A. tibialis posterior . . . . . . . . . . . . . . . . . . . 243 5.10.2 Femoral triangle and adductor canal . . . . 247
5.10.3 Gluteal region . . . . . . . . . . . . . . . . . . . . . . . 248
5.8 Veins of the lower extremity . . . . . . . . . . 243
5.10.4 Hollow of the knee . . . . . . . . . . . . . . . . . . . 249

III INTERNAL ORGANS

6 Chest viscera . . . . . . . . . . . . . . . . . . . . . . . 253 6.5.2 Mediastinum . . . . . . . . . . . . . . . . . . . . . . . . 288
Daniela Kugelmann, Jens Waschke 6.5.3 Pleural cavities . . . . . . . . . . . . . . . . . . . . . . 289
6.5.4 Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
6.1 Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
6.5.5 Development of the visceral cavities . . . . 291
6.1.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
6.1.2 Function . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 6.6 Vessels and nerves
6.1.3 Development of the heart of the thoracic cavity . . . . . . . . . . . . . . . . . 294
and blood vessels . . . . . . . . . . . . . . . . . . . 256 6.6.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
6.1.4 Prenatal and postnatal 6.6.2 Arteries of the thoracic cavity . . . . . . . . . . 294
blood circulation . . . . . . . . . . . . . . . . . . . . 260 6.6.3 Veins of the thoracic cavity . . . . . . . . . . . . 295
6.1.5 Location and projection . . . . . . . . . . . . . . . 262 6.6.4 Lymph vessels of the thoracic cavity . . . . 296
6.1.6 Atria and ventricles . . . . . . . . . . . . . . . . . . 264 6.6.5 Nerves of the thoracic cavity . . . . . . . . . . 297
6.1.7 Heart wall and pericardium . . . . . . . . . . . . 266
6.1.8 Cardiac skeleton and heart valves . . . . . . 267 7 Abdominal viscera . . . . . . . . . . . . . . . . . . . 299
6.1.9 Conduction system and innervation Jens Waschke
of the heart . . . . . . . . . . . . . . . . . . . . . . . . . 269
7.1 Stomach . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
6.1.10 Coronary blood vessel . . . . . . . . . . . . . . . . 271
7.1.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
6.1.11 Veins and lymphatic vessels
7.1.2 Functions of the stomach . . . . . . . . . . . . . 302
of the heart . . . . . . . . . . . . . . . . . . . . . . . . . 273
7.1.3 Development of stomach,
6.2 Trachea and lungs . . . . . . . . . . . . . . . . . . . 274 Bursa omentalis, Omentum minus
6.2.1 Overview and function . . . . . . . . . . . . . . . 274 and Omentum majus . . . . . . . . . . . . . . . . . 303
6.2.2 Development of trachea and lungs . . . . . 275 7.1.4 Projection of the stomach . . . . . . . . . . . . . 305
6.2.3 Topography and structure 7.1.5 Structure and sections of the stomach . . 305
of the trachea and main bronchi . . . . . . . . 276 7.1.6 Surface enlargement
6.2.4 Vessels and nerves of the stomach lining . . . . . . . . . . . . . . . . . 306
of the trachea and main bronchi . . . . . . . . 277 7.1.7 Topography . . . . . . . . . . . . . . . . . . . . . . . . . 306
6.2.5 Projection of the lungs . . . . . . . . . . . . . . . . 277 7.1.8 Arteries of the stomach . . . . . . . . . . . . . . . 307
6.2.6 Structure of the lungs . . . . . . . . . . . . . . . . 279 7.1.9 Veins of the stomach . . . . . . . . . . . . . . . . . 307
6.2.7 Vessels and nerves of the lungs . . . . . . . . 281 7.1.10 Lymph vessels of the stomach . . . . . . . . . 308
7.1.11 Innervation of the stomach . . . . . . . . . . . . 309
6.3 Oesophagus . . . . . . . . . . . . . . . . . . . . . . . . 282
6.3.1 Overview, function and development . . . 282 7.2 Intestines . . . . . . . . . . . . . . . . . . . . . . . . . . 309
6.3.2 Structure and projection . . . . . . . . . . . . . . 283 7.2.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
6.3.3 Classification . . . . . . . . . . . . . . . . . . . . . . . 283 7.2.2 Functions of the intestine . . . . . . . . . . . . . 310
6.3.4 Constrictions of the oesophagus . . . . . . . 284 7.2.3 Development . . . . . . . . . . . . . . . . . . . . . . . 310
6.3.5 Closing mechanisms . . . . . . . . . . . . . . . . . 284 7.2.4 Structure and projection
6.3.6 Vessels and nerves of the small ­intestine . . . . . . . . . . . . . . . . . 312
of the oesophagus . . . . . . . . . . . . . . . . . . . 285 7.2.5 Structure and projection
of the large intestine . . . . . . . . . . . . . . . . . 313
6.4 Thymus . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
7.2.6 Structural features
6.4.1 Overview, function and development . . . 287
of the small and large ­intestines . . . . . . . . 315
6.4.2 Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
7.2.7 Topography of small
6.4.3 Vessels and nerves of the thymus . . . . . . 288
and large intestines . . . . . . . . . . . . . . . . . . 316
6.5 Thoracic cavity . . . . . . . . . . . . . . . . . . . . . . 288 7.2.8 Intestinal arteries . . . . . . . . . . . . . . . . . . . . 318
6.5.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 288 7.2.9 Veins of the intestine . . . . . . . . . . . . . . . . . 320

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7.2.10 Lymph vessels of the intestine . . . . . . . . . 320 8.1 Kidneys . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352

7.2.11 Innervation of the intestine . . . . . . . . . . . . 320 8.1.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
8.1.2 Functions of the kidneys . . . . . . . . . . . . . . 352
7.3 Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
8.1.3 Development of the kidneys . . . . . . . . . . . 352
7.3.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
8.1.4 Projection and structure of the kidney . . . 354
7.3.2 Functions of the liver . . . . . . . . . . . . . . . . . 322
8.1.5 Fascial system of the kidney . . . . . . . . . . . 355
7.3.3 Development of the liver
8.1.6 Topography . . . . . . . . . . . . . . . . . . . . . . . . . 356
and gall bladder . . . . . . . . . . . . . . . . . . . . . 323
8.1.7 Vessels and nerves of the kidney . . . . . . . 357
7.3.4 Projection of the liver . . . . . . . . . . . . . . . . . 323
7.3.5 Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . 324 8.2 Adrenal gland . . . . . . . . . . . . . . . . . . . . . . . 358
7.3.6 Parts and segments of the liver . . . . . . . . 325 8.2.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
7.3.7 Fine structure of the liver . . . . . . . . . . . . . 326 8.2.2 Functions of the adrenal
7.3.8 Topography . . . . . . . . . . . . . . . . . . . . . . . . . 327 gland and development . . . . . . . . . . . . . . . 358
7.3.9 Arteries of the liver . . . . . . . . . . . . . . . . . . 327 8.2.3 Structure, projection and
7.3.10 Veins of the liver . . . . . . . . . . . . . . . . . . . . . 328 topography of the adrenal glands . . . . . . 359
7.3.11 Portocaval anastomoses . . . . . . . . . . . . . . 328 8.2.4 Vessels and nerves
7.3.12 Lymph vessels of the liver . . . . . . . . . . . . . 329 of the adrenal glands . . . . . . . . . . . . . . . . . 359
7.3.13 Innervation of the liver . . . . . . . . . . . . . . . 330
8.3 Efferent urinary tracts . . . . . . . . . . . . . . . . 359
7.4 Gall bladder and bile ducts . . . . . . . . . . . . 331 8.3.1 Overview and function . . . . . . . . . . . . . . . 359
7.4.1 Overview and function . . . . . . . . . . . . . . . 331 8.3.2 Development
7.4.2 Projection and topography of the efferent urinary tracts . . . . . . . . . . . 359
of the gall bladder . . . . . . . . . . . . . . . . . . . 331 8.3.3 Renal pelvis and ureter . . . . . . . . . . . . . . . 361
7.4.3 Construction of gall bladder and 8.3.4 Urinary bladder . . . . . . . . . . . . . . . . . . . . . 362
extrahepatic bile ducts . . . . . . . . . . . . . . . 331 8.3.5 Urethra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
7.4.4 Pathways of the gall bladder 8.3.6 Closure mechanisms
and bile ducts . . . . . . . . . . . . . . . . . . . . . . . 332 of the urinary bladder and the urethra . . . 363
7.4.5 CALOT’s triangle . . . . . . . . . . . . . . . . . . . . 333 8.3.7 Vessels and nerves
of the efferent urinary tracts . . . . . . . . . . . 363
7.5 Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
7.5.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 333 8.4 Rectum and anal canal . . . . . . . . . . . . . . . . 364
7.5.2 Functions of the pancreas . . . . . . . . . . . . . 334 Jens Waschke, Friedrich Paulsen
7.5.3 Development . . . . . . . . . . . . . . . . . . . . . . . 334 8.4.1 Overview and function . . . . . . . . . . . . . . . 364
7.5.4 Projection and structure 8.4.2 Classification, projection and
of the pancreas . . . . . . . . . . . . . . . . . . . . . . 334 structure of rectum and anal canal . . . . . . 364
7.5.5 Excretory duct system of the pancreas . . 335 8.4.3 Mesorectum . . . . . . . . . . . . . . . . . . . . . . . . 365
7.5.6 Topography . . . . . . . . . . . . . . . . . . . . . . . . . 335 8.4.4 Continence organ . . . . . . . . . . . . . . . . . . . . 366
7.5.7 Vessels and nerves of the pancreas . . . . . 337 8.4.5 Arteries of the rectum and anal canal . . . 369
8.4.6 Veins of the rectum and anal canal . . . . . 369
7.6 Spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
8.4.7 Lymphatic vessels
7.6.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
of the rectum and anal ­canal . . . . . . . . . . . 370
7.6.2 Functions of the spleen . . . . . . . . . . . . . . . 338
8.4.8 Innervation of the rectum
7.6.3 Development . . . . . . . . . . . . . . . . . . . . . . . 338
and anal canal . . . . . . . . . . . . . . . . . . . . . . . 370
7.6.4 Projection, construction
and topography of the spleen . . . . . . . . . . 339 8.5 Male genitalia . . . . . . . . . . . . . . . . . . . . . . . 371
7.6.5 Vessels and nerves of the spleen . . . . . . . 339 8.5.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 372
8.5.2 Function of the male genitalia . . . . . . . . . . 372
7.7 Peritoneal cavity . . . . . . . . . . . . . . . . . . . . 340
8.5.3 Development of the male genitalia . . . . . 372
7.7.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
8.5.4 Penis and scrotum . . . . . . . . . . . . . . . . . . . 375
7.7.2 Omentum majus and Omentum
8.5.5 Testis and epididymis . . . . . . . . . . . . . . . . 376
minus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
8.5.6 Vas deferens and spermatic cord . . . . . . . 377
7.7.3 Recessus of the peritoneal cavity . . . . . . . 342
8.5.7 Accessory sex glands . . . . . . . . . . . . . . . . 378
7.8 Vessels and nerves 8.5.8 Vessels and nerves of the external and
of the peritoneal cavity . . . . . . . . . . . . . . . 343 ­internal male genitalia . . . . . . . . . . . . . . . . 379
7.8.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
8.6 Female genitalia . . . . . . . . . . . . . . . . . . . . . 383
7.8.2 Arteries of the peritoneal cavity . . . . . . . . 343
8.6.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
7.8.3 Veins of the peritoneal cavity . . . . . . . . . . 345
8.6.2 Function of the female genitalia . . . . . . . . 385
7.8.4 Lymph vessels of the peritoneal cavity . . 345
8.6.3 Development of the external and
7.8.5 Nerves of the peritoneal cavity . . . . . . . . . 346
internal f­ emale genitalia . . . . . . . . . . . . . . 385
8.6.4 Vulva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386
8 Pelvic viscera . . . . . . . . . . . . . . . . . . . . . . . 349
8.6.5 Ovary and fallopian tubes . . . . . . . . . . . . . 387
Jens Waschke

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8.6.6 Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388 8.8.2 Arteries of the retroperitoneum

8.6.7 Vagina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389 and pelvic cavity . . . . . . . . . . . . . . . . . . . . 394
8.6.8 Vessels and nerves of the external 8.8.3 Veins of the retroperitoneum
and ­internal female genitalia . . . . . . . . . . 390 and pelvic cavity . . . . . . . . . . . . . . . . . . . . 397
8.8.4 Lymphatic vessels of the
8.7 Retroperitoneal space
retroperitoneum and pelvic cavity . . . . . . 398
and pelvic cavity . . . . . . . . . . . . . . . . . . . . 392
8.8.5 Nerves of the retroperitoneum and
8.7.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
pelvic cavity . . . . . . . . . . . . . . . . . . . . . . . . 400
8.7.2 Retroperitoneal space . . . . . . . . . . . . . . . . 392
8.7.3 Subperitoneal space . . . . . . . . . . . . . . . . . 392 8.9 Pelvic floor and perineal region . . . . . . . . 401
8.9.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
8.8 Vessels and nerves of the extraperitoneal
8.9.2 Pelvic floor . . . . . . . . . . . . . . . . . . . . . . . . . 401
space and pelvic cavity . . . . . . . . . . . . . . . 394
8.9.3 Perineal region . . . . . . . . . . . . . . . . . . . . . . 402
8.8.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 394

IV HEAD AND THROAT

9 Head . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409 9.5 Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477
Friedrich Paulsen
9.1 Skull . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
9.5.1 Embryology . . . . . . . . . . . . . . . . . . . . . . . . 478
Lars Bräuer
9.5.2 External ear . . . . . . . . . . . . . . . . . . . . . . . . . 478
9.1.1 Neurocranium and viscerocranium . . . . . 411
9.5.3 Middle ear . . . . . . . . . . . . . . . . . . . . . . . . . . 481
9.1.2 Skull development – Embryology . . . . . . . 411
9.5.4 Internal ear . . . . . . . . . . . . . . . . . . . . . . . . . 488
9.1.3 Calvaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
9.1.4 Base of the skull . . . . . . . . . . . . . . . . . . . . . 414 9.6 Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
9.1.5 Individual bones of Friedrich Paulsen
the viscerocranium . . . . . . . . . . . . . . . . . . 418 9.6.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 492
9.1.6 Individual bones of 9.6.2 Development . . . . . . . . . . . . . . . . . . . . . . . 492
the neurocranium . . . . . . . . . . . . . . . . . . . . 422 9.6.3 External nose . . . . . . . . . . . . . . . . . . . . . . . 493
9.6.4 Nasal cavities . . . . . . . . . . . . . . . . . . . . . . . 495
9.2 Soft tissue covering . . . . . . . . . . . . . . . . . . 424
9.6.5 Paranasal sinuses . . . . . . . . . . . . . . . . . . . . 499
Lars Bräuer, Friedrich Paulsen
9.6.6 Vascular, lymphatic and
9.2.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
nervous systems . . . . . . . . . . . . . . . . . . . . 500
9.2.2 Scalp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
9.2.3 Face and facial soft tissue . . . . . . . . . . . . . 428 9.7 Oral cavity, masticatory apparatus,
9.2.4 Superficial lateral facial region . . . . . . . . . 436 tongue, palate, floor of the mouth,
9.2.5 Deep lateral facial region . . . . . . . . . . . . . . 439 salivary glands . . . . . . . . . . . . . . . . . . . . . . 502
Wolfgang H. Arnold
9.3 Cranial nerves . . . . . . . . . . . . . . . . . . . . . . 443
9.7.1 Oral cavity . . . . . . . . . . . . . . . . . . . . . . . . . . 503
Lars Bräuer
9.7.2 Masticatory apparatus – teeth . . . . . . . . . 506
9.3.1 N. olfactorius [I] . . . . . . . . . . . . . . . . . . . . . 444
9.7.3 Masticatory apparatus –
9.3.2 N. opticus [II] . . . . . . . . . . . . . . . . . . . . . . . . 445
Masticatory muscles . . . . . . . . . . . . . . . . . 512
9.3.3 N. oculomotorius [III] . . . . . . . . . . . . . . . . . 445
9.7.4 Masticatory apparatus –
9.3.4 N. trochlearis [IV] . . . . . . . . . . . . . . . . . . . . 446
temporomandibular joint . . . . . . . . . . . . . 514
9.3.5 N. trigeminus [V] . . . . . . . . . . . . . . . . . . . . 447
9.7.5 Tongue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516
9.3.6 N. abducens [VI] . . . . . . . . . . . . . . . . . . . . . 449
9.7.6 Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520
9.3.7 N. facialis [VII] . . . . . . . . . . . . . . . . . . . . . . . 449
9.7.7 Floor of the mouth . . . . . . . . . . . . . . . . . . . 524
9.3.8 N. vestibulocochlearis [VIII] . . . . . . . . . . . 453
9.7.8 Lymphatic pathways of
9.3.9 N. glossopharyngeus [IX] . . . . . . . . . . . . . 454
the oral cavity . . . . . . . . . . . . . . . . . . . . . . . 526
9.3.10 N. vagus [X] . . . . . . . . . . . . . . . . . . . . . . . . 455
9.7.9 Salivary glands . . . . . . . . . . . . . . . . . . . . . . 526
9.3.11 N. accessorius [XI] . . . . . . . . . . . . . . . . . . . 457
9.3.12 N. hypoglossus [XII] . . . . . . . . . . . . . . . . . . 457
10 Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
9.4 Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
10.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 533
Michael Scholz
Michael Scholz
9.4.1 Embryology . . . . . . . . . . . . . . . . . . . . . . . . 460
10.1.1 Surface anatomy of the neck . . . . . . . . . . 533
9.4.2 Protective and auxiliary
10.1.2 Regions of the neck and neck triangles . . 534
structures of the eye . . . . . . . . . . . . . . . . . 461
9.4.3 Orbita . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465 10.2 Musculoskeletal system of the neck . . . . 534
9.4.4 Bulbus oculi . . . . . . . . . . . . . . . . . . . . . . . . 472 Michael Scholz
10.2.1 Passive sections . . . . . . . . . . . . . . . . . . . . . 534
10.2.2 Active sections – neck muscles . . . . . . . . 535

XIII
Table of contents

10.3 Cervical fascia and connective 10.6 Larynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562

tissue spaces . . . . . . . . . . . . . . . . . . . . . . . 541 Friedrich Paulsen
Michael Scholz 10.6.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 563
10.3.1 Neck fasciae . . . . . . . . . . . . . . . . . . . . . . . . 542 10.6.2 Development . . . . . . . . . . . . . . . . . . . . . . . 563
10.3.2 Connective tissue spaces of the neck . . . 543 10.6.3 Laryngeal skeleton . . . . . . . . . . . . . . . . . . . 564
10.6.4 Laryngeal levels . . . . . . . . . . . . . . . . . . . . . 571
10.4 Vascular, lymphatic and
10.6.5 Structure of the Plicae vocales
nervous systems of the neck . . . . . . . . . . 545
und Plicae vestibulares . . . . . . . . . . . . . . . 572
Michael Scholz
10.6.6 Vascular, lymphatic and
10.4.1 Arteries of the neck . . . . . . . . . . . . . . . . . . 545
nervous systems . . . . . . . . . . . . . . . . . . . . 573
10.4.2 Veins of the neck . . . . . . . . . . . . . . . . . . . . 548
10.4.3 Nerves of the neck . . . . . . . . . . . . . . . . . . . 550 10.7 Pharynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . 575
10.4.4 Lymph nodes of the neck . . . . . . . . . . . . . 557 Wolfgang H. Arnold
10.7.1 Development . . . . . . . . . . . . . . . . . . . . . . . 575
10.5 Thyroid and parathyroid glands . . . . . . . . 559
10.7.2 Levels of the pharynx . . . . . . . . . . . . . . . . 575
Michael Scholz
10.7.3 Pharyngeal wall . . . . . . . . . . . . . . . . . . . . . 576
10.5.1 Location and function . . . . . . . . . . . . . . . . 559
10.7.4 Pharyngeal musculature . . . . . . . . . . . . . . 576
10.5.2 Development . . . . . . . . . . . . . . . . . . . . . . . 559
10.7.5 Vascular, lymphatic and
10.5.3 Vascular, lymphatic and
nervous systems . . . . . . . . . . . . . . . . . . . . 577
nervous systems . . . . . . . . . . . . . . . . . . . . 561
10.7.6 Swallowing . . . . . . . . . . . . . . . . . . . . . . . . . 579
10.7.7 Lymphatic pharyngeal ring . . . . . . . . . . . . 579

V NEURO­ANATOMY
11 General neuroanatomy . . . . . . . . . . . . . . . 583 11.4.5 Cerebrospinal fluid . . . . . . . . . . . . . . . . . . . 610
11.4.6 Circumventricular organs . . . . . . . . . . . . . 611
11.1 Embryology . . . . . . . . . . . . . . . . . . . . . . . . 584
Tobias M. Böckers 11.5 Cerebral vessels . . . . . . . . . . . . . . . . . . . . . 612
11.1.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 584 Thomas Deller
11.1.2 Further brain development . . . . . . . . . . . . 586 11.5.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 612
11.1.3 Development of the spinal cord . . . . . . . . 591 11.5.2 A. carotis interna and its branches . . . . . . 617
11.1.4 Development of the peripheral nervous 11.5.3 Aa. vertebrales/A. basilaris
­system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 593 and their branches . . . . . . . . . . . . . . . . . . . 619
11.5.4 Central blood supply . . . . . . . . . . . . . . . . . 622
11.2 Structure of the nervous system . . . . . . . 593
11.5.5 Vascular supply of the spinal cord . . . . . . 623
Anja Böckers
11.5.6 Topography and supply
11.2.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 593
areas of the arteries . . . . . . . . . . . . . . . . . . 624
11.2.2 Structure of the CNS . . . . . . . . . . . . . . . . . 593
11.5.7 Clinical description
11.2.3 Morphology of the CNS . . . . . . . . . . . . . . . 594
of the vascular sections . . . . . . . . . . . . . . . 628
11.2.4 Distribution of grey matter
11.5.8 Venous sinuses of the brain . . . . . . . . . . . 628
in the CNS . . . . . . . . . . . . . . . . . . . . . . . . . . 599
11.5.9 Presentation of the vasculature . . . . . . . . 630
11.2.5 Distribution of white matter
in the CNS . . . . . . . . . . . . . . . . . . . . . . . . . . 599
12 Special neuroanatomy . . . . . . . . . . . . . . . 635
11.3 Meninges . . . . . . . . . . . . . . . . . . . . . . . . . . 603
12.1 Telencephalon . . . . . . . . . . . . . . . . . . . . . . 637
Michael J. Schmeißer
12.1.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 637
11.3.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 603
12.1.2 Embryology . . . . . . . . . . . . . . . . . . . . . . . . 637
11.3.2 Embryology . . . . . . . . . . . . . . . . . . . . . . . . 604
12.1.3 Classification of the telencephalon . . . . . 637
11.3.3 Pachymeninx – Dura mater . . . . . . . . . . . . 604
12.1.4 Fibre systems of the telencephalon . . . . . 638
11.3.4 Leptomeninx . . . . . . . . . . . . . . . . . . . . . . . . 604
12.1.5 Neocortex . . . . . . . . . . . . . . . . . . . . . . . . . . 638
11.3.5 Neurovascular pathways
12.1.6 Archicortex . . . . . . . . . . . . . . . . . . . . . . . . . 643
of the meninges . . . . . . . . . . . . . . . . . . . . . 606
12.1.7 Paleocortex . . . . . . . . . . . . . . . . . . . . . . . . . 650
11.4 Ventricular system and 12.1.8 Subcortical nuclei . . . . . . . . . . . . . . . . . . . 652
adjacent structures . . . . . . . . . . . . . . . . . . 607
12.2 Diencephalon . . . . . . . . . . . . . . . . . . . . . . . 656
Anja Böckers
Tobias M. Böckers
11.4.1 Overview and structure . . . . . . . . . . . . . . . 607
12.2.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 656
11.4.2 Embryology . . . . . . . . . . . . . . . . . . . . . . . . 608
12.2.2 Epithalamus . . . . . . . . . . . . . . . . . . . . . . . . 657
11.4.3 Inner cerebrospinal fluid space . . . . . . . . 609
12.2.3 Thalamus . . . . . . . . . . . . . . . . . . . . . . . . . . 658
11.4.4 External subarachnoid fluid spaces – ­
12.2.4 Hypothalamus . . . . . . . . . . . . . . . . . . . . . . 660
Spatium subarachnoideum . . . . . . . . . . . . 610
12.2.5 Subthalamus . . . . . . . . . . . . . . . . . . . . . . . . 664

XIV
 Table of contents

12.3 Brainstem . . . . . . . . . . . . . . . . . . . . . . . . . . 664 13.1.3 Peripheral section . . . . . . . . . . . . . . . . . . . 730

Michael J. Schmeißer, 13.1.4 Execution of voluntary movements . . . . . 731
Stephan Schwarzacher
13.2 Somatosensory system . . . . . . . . . . . . . . 732
12.3.1 Mesencephalon . . . . . . . . . . . . . . . . . . . . . 664
Anja Böckers
12.3.2 Pons and Medulla oblongata . . . . . . . . . . 668
13.2.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 732
12.3.3 Functional systems of the brainstem . . . . 672
13.2.2 Peripheral section . . . . . . . . . . . . . . . . . . . 732
12.3.4 Blood supply to the brainstem . . . . . . . . . 673
13.2.3 Central section . . . . . . . . . . . . . . . . . . . . . . 732
12.4 Cerebellum . . . . . . . . . . . . . . . . . . . . . . . . . 673
13.3 Visual system . . . . . . . . . . . . . . . . . . . . . . . 738
Michael J. Schmeißer
Michael J. Schmeißer
12.4.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 674
13.3.1 Optic tract . . . . . . . . . . . . . . . . . . . . . . . . . . 738
12.4.2 Embryology . . . . . . . . . . . . . . . . . . . . . . . . 674
13.3.2 Visual reflexes . . . . . . . . . . . . . . . . . . . . . . 740
12.4.3 Position and external appearance . . . . . . 674
13.3.3 Management of ocular motor function . . 741
12.4.4 Internal structure . . . . . . . . . . . . . . . . . . . . 676
12.4.5 Neurovascular pathways . . . . . . . . . . . . . . 677 13.4 Auditory system . . . . . . . . . . . . . . . . . . . . 742
12.4.6 Blood supply . . . . . . . . . . . . . . . . . . . . . . . . 678 Anja Böckers
13.4.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 743
12.5 Cranial nerves . . . . . . . . . . . . . . . . . . . . . . 679
13.4.2 Peripheral section . . . . . . . . . . . . . . . . . . . 743
Anja Böckers, Michael J. Schmeißer
13.4.3 Central section . . . . . . . . . . . . . . . . . . . . . . 744
12.5.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 679
12.5.2 Embryology . . . . . . . . . . . . . . . . . . . . . . . . 681 13.5 Vestibular system . . . . . . . . . . . . . . . . . . . 746
12.5.3 Arterial blood supply . . . . . . . . . . . . . . . . . 684 Anja Böckers
12.5.4 N. olfactorius (1st cranial nerve, N. I) . . . . 684 13.5.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 746
12.5.5 N. opticus (2nd cranial nerve, N. II) . . . . . 685 13.5.2 Peripheral section . . . . . . . . . . . . . . . . . . . 746
12.5.6 N. oculomotorius 13.5.3 Central section . . . . . . . . . . . . . . . . . . . . . . 746
(3rd cranial nerve, N. III) . . . . . . . . . . . . . . 685
13.6 Olfactory system . . . . . . . . . . . . . . . . . . . . 748
12.5.7 N. trochlearis (4th cranial nerve, N. IV) . . 687
Michael J. Schmeißer
12.5.8 N. trigeminus (5th cranial nerve, N. V) . . . 688
13.6.1 Regio olfactoria . . . . . . . . . . . . . . . . . . . . . 749
12.5.9 N. abducens (6th cranial nerve, N. VI) . . . 695
13.6.2 Pathway of the olfactory tract . . . . . . . . . . 749
12.5.10 N. facialis (7th cranial nerve, N. VII) . . . . . 696
13.6.3 Olfactory cortex . . . . . . . . . . . . . . . . . . . . . 750
12.5.11 N. vestibulocochlearis
(8th cranial nerve, N. VIII) . . . . . . . . . . . . . 699 13.7 Gustatory system . . . . . . . . . . . . . . . . . . . 750
12.5.12 N. glossopharyngeus Anja Böckers
(9th cranial nerve, N. IX) . . . . . . . . . . . . . . 701 13.7.1 Peripheral section . . . . . . . . . . . . . . . . . . . 750
12.5.13 N. vagus (10th cranial nerve, N. X) . . . . . . 704 13.7.2 Central section . . . . . . . . . . . . . . . . . . . . . . 751
12.5.14 N. accessorius
13.8 Nociceptive system . . . . . . . . . . . . . . . . . . 752
(11th cranial nerve, N. XI) . . . . . . . . . . . . . . 708
Anja Böckers
12.5.15 N. hypoglossus
13.8.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 752
(12th cranial nerve, N. XII) . . . . . . . . . . . . . 709
13.8.2 Pain conduction . . . . . . . . . . . . . . . . . . . . . 752
12.6 Spinal cord . . . . . . . . . . . . . . . . . . . . . . . . . 711 13.8.3 Pain processing . . . . . . . . . . . . . . . . . . . . . 754
Anja Böckers
13.9 Autonomic nervous system . . . . . . . . . . . 755
12.6.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 711
Thomas Deller
12.6.2 Segmental structure
13.9.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 755
of the Medulla spinalis . . . . . . . . . . . . . . . . 711
13.9.2 Visceromotor function . . . . . . . . . . . . . . . . 756
12.6.3 Surface and cross-sectional anatomy . . . 712
13.9.3 Viscerosensory function . . . . . . . . . . . . . . 762
12.6.4 Structure of the Substantia grisea . . . . . . 715
13.9.4 Autonomic reflex arcs
12.6.5 Structure of the Substantia alba . . . . . . . . 716
and control circuits . . . . . . . . . . . . . . . . . . 763
12.6.6 Blood supply . . . . . . . . . . . . . . . . . . . . . . . . 719
13.9.5 Central regulation
12.6.7 Motor functions of the spinal cord . . . . . . 720
of the autonomic nervous system . . . . . . 764
13.9.6 Summary and outlook . . . . . . . . . . . . . . . . 768
13 Functional systems . . . . . . . . . . . . . . . . . . 723
13.10 Limbic system . . . . . . . . . . . . . . . . . . . . . . 768
13.1 Somatic nervous system . . . . . . . . . . . . . 725
Thomas Deller
Tobias M. Böckers
13.10.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 768
13.1.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . 725
13.10.2 Components of the limbic system . . . . . . 769
13.1.2 Central section . . . . . . . . . . . . . . . . . . . . . . 725
13.10.3 Neuronal circuits of the limbic system . . 769

XV
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 GENERAL
ANATOMY AND
EMBRYOLOGY
1 General anatomy
2 General embryology
1 General anatomy
Friedrich Paulsen, Faramarz Dehghani

1.1 Subdivisions . . . . . . . . . . . . . . 5 1.5 Circulation systems . . . . . . . . 33

1.5.1 Body and pulmonary
1.2 Architecture of circulation . . . . . . . . . . . . . . . . 33
the human body . . . . . . . . . . . 5
1.5.2 Portal vein circulation . . . . . . 37
1.2.1 Organisation . . . . . . . . . . . . . . 5
1.5.3 Prenatal circulation . . . . . . . . . 38
1.2.2 Body proportions . . . . . . . . . . 7
1.5.4 Lymphatic circulation . . . . . . . 38
1.2.3 Positional descriptions . . . . . . 8
1.2.4 General anatomical 1.6 Mucous membranes,
descriptions . . . . . . . . . . . . . . . 10 glands, serous cavities . . . . . . 41
1.6.1 Mucous membranes . . . . . . . 41
1.3 Skin and skin appendages . . . 15
1.6.2 Glands . . . . . . . . . . . . . . . . . . . 41
1.3.1 Skin types and skin layers . . . 16
1.6.3 Serous cavities . . . . . . . . . . . . 41
1.3.2 Skin appendages . . . . . . . . . . 16
1.7 Nervous system . . . . . . . . . . . 42
1.4 Musculoskeletal system . . . . 18
1.4.1 Cartilage . . . . . . . . . . . . . . . . . 18
1.4.2 Bones . . . . . . . . . . . . . . . . . . . . 18
1.4.3 Joints . . . . . . . . . . . . . . . . . . . . 23
1.4.4 General considerations
on muscles . . . . . . . . . . . . . . . 29
 CLINICAL CASE

Gonarthrosis
procedure, the anterior region of the knee joint (Regio genus anterior)
Medical history is opened by using a vertical incision of the skin and joint capsule.
A 63-year-old patient has complained about increasing pain and The direct view into the joint cavity confirms the diagnosis. The
restricted mobility of his left knee joint for several years. He had menisci are largely degenerated, the joint cartilage has almost
formerly practised a lot of sports. As a result, his menisci were completely disappeared, particularly on the medial side, and the
lesioned twice. Painkillers no longer helped him, but caused underlying (subchondral) bone can already be seen. Also on the
increasingly stomach problems. lateral side, two large lesions of the cartilage are visible. As the
posterior surface of the patella looks macroscopically intact, the
surgeons forego the replacement of the patellar cartilage. They
Initial examination perform a bicondylar surface replacement. In doing so, in contrast to
the earlier frequently used total endoprosthesis of the knee joint,
In the clinical examination it becomes apparent, among other things, only the destroyed sliding surfaces of the joint are replaced, to
that the left knee is slightly swollen and pressure on the medial joint sacrifice as little bone substance as possible. In addition, in the case
space is painful. On mobilisation of the knee some friction noise of a bicondylar surface replacement, the replaced parts are not or
(crepitus) can be felt and heard. The mobility is restricted. The knee only partially coupled to enable a more physiologic joint mobility.
can only be flexed up to approx. 80° and also cannot be fully stretched.

Further development
Further diagnostic
Postoperatively the patient is already mobile on the 1st day. He
The radiological examination shows a significantly narrowed joint receives special injections to prevent a thrombosis. A few days after
space, the bony tissue immediately below the cartilage is of higher the operation, the doctors detect that the lower leg is swollen. In this
density and there are small bone cysts. By appositional growth on case, a lymphatic congestion (lymphoedema) had developed, which
the lateral side of the bone osteophytes (bony spurs) have been resolved within a few days by applying a lymphatic drainage. Twelve
formed. The examination by the orthopaedist leads to the diagnosis days after surgery, the suture staples were removed and the patient
of an advanced arthritis. was discharged for the subsequent rehabilitative treatment. The
subsequent rehabilitation is focused on an intense physical therapy
for strengthening the muscles. The mobility was gradually increased
Treatment and the coordination trained. Eight weeks later, the patient comes to
the clinic for a follow-up examination. He has no more pain and can
Because of the relatively advanced pathology, the severely painful flex his knee now up to 95°. The scar is well healed, and he tells that
knee and its already restricted mobility, the orthopaedist advises the he wants to attend dancing lessons in the near future.
patient to undergo joint surface replacement. During the surgical

You may assist at your first operation as a trainee. The chief physician for orthopaedics
is known for questioning his students on the patients, so you should prepare for the
questions.

Question time in the surgery room!

Hx: 63-year-old patient (m), with increasing pain and restricted

range of motion in his left knee for years; used to do a lot of sport
→ condition following a meniscus lesion. Improvement under pain
medication ∅
CAVE: Stomach problems!
CE: Swelling left knee; range of motion: Flexion 80° , ∅ Fully
consistent extension possible, crepitations, pain on pressure
medial Joint space
DD.: MRI/x-ray: joint gap narrowed, degenerated medial
joint cartilage, densification of subchondral bone,
bone cysts,osteophytes → advanced gonarthrosis
Tx: bicondylar replacement of joint surfaces
 1.2 Architecture of the human body

Skills Knowledge of human anatomy is fundamental for any practising

doctor. The macroscopic anatomy plays a central role in the daily
After working through this chapter, you should be able to:
practical work on the patient. Apart from the (external) inspection
• classify the different parts of the human body and to define
general anatomical terms of the body and the palpation (examination by touch) knowledge
• categorise postnatal morphological changes, such as body of the internal structures of the body plays a central role, e. g. for
proportions, body dimensions and sexual dimorphisms the evaluation of x-rays, CT and MRI scans, ultrasound and
• describe the structure of the skin and its appendages. ­endoscopic findings, or in the context of operations, to be able to
• understand the main features of the musculoskeletal system identify the relevant structures or to differentiate between ‘sick’
• describe the various circulation systems and ‘healthy’. A standardised anatomical nomen­clature used for
• define the structure of mucous membranes, glands and
the description is based on the Latin and Greek language. It
­serous cavities
• categorise the nervous system clearly ­consists of approx. 6 000 anatomical terms that are d ­ erived of about
600 linguistic (word) roots and have been summarised in the
­Terminologia Anatomica, an internationally valid nomenclature.
Anatomy is derived of the Greek word anatemnein (cut open, dis- In the teaching of anatomy, the dissection of a dead corpse has had
sect) and signifies the art of dissecting. It is a branch of morpholo- a central role since ancient times. In modern times the dissection
gy and deals with the structure of the healthy body (or in the class is indispensable for medical students, because studying the
broader sense of organisms) and is often referred to in conjunction anatomy of the real body can neither be replaced by anatomical
with pathology and forensic medicine. However, pathology ex- models nor by images in an atlas. By dissections you get an idea of
plores the emergence of structural changes in the body in the con- the shape, position and spatial relationships of the structures. The
text of diseases, and forensic medicine (legal medicine) is con- range of knowledge gained this way is supplemented by findings on
cerned with the theory of development, diagnosis and assessment the microscopic level of cells (cytology), tissues (histology) and or-
of legally relevant factors acting on the human body and deals with gans (microscopic anatomy).
unexplained cases of death and injuries of victims.

1.2 Architecture of the human body

1.1 Subdivisions
Anatomy is organised in various subdivisions: 1.2.1 Organisation
• Macroscopic anatomy: describes the structures visible with the
naked eye Topographical organisation
• Microscopic anatomy: describes the structures that can be visu- The human body is bilaterally symmetrical (› Fig. 1.1). It is divided
alised by means of a light microscope or electron microscope topographically into:
• Molecular anatomy: is linked to molecular biology, but pursues • Head (Caput); represents the highest point of the upright body
a morphological approach • Neck (Collum)
• Systematic anatomy: groups the structures of the body into • Trunk (Truncus)
functionally related organ systems (e. g. the circulatory system) • Chest (Thorax)
• Topographical anatomy: describes the topographic relationship • Abdomen
of individual structures according to their position to neigh- • Pelvis
bouring structures • Limbs (Membra)
• Functional anatomy: describes the connections between struc- • Upper limb (Membrum superius)
ture and function • Shoulder girdle
• Descriptive anatomy: pure description of the body architecture – Clavicle (Clavicula)
• Embryology: describes all processes associated with the human – Shoulder blade (Scapula)
development and therefore addresses the development of indi- – Free upper limb
vidual organisms (ontogenesis) (recent findings from early em- – Upper arm (Brachium)
bryonic development show that interferences in this very sensi- – Forearm (Antebrachium)
tive [vulnerable] phase not only promote the emergence of well- – Hand (Manus)
known malformations, but are also responsible for numerous • Lower limb (Membrum inferius)
metabolic disorders in adulthood due to epigenetic modifica- – Pelvic girdle
tions) – Hip bone (Os coxae)
• Comparative anatomy: studies the body architecture of differ- – Sacrum (Os sacrum)
ent animal species and compares it to that of humans; it allows – Free lower limb
an insight into the evolutionary history (phylogeny), which ad- – Thigh (Femur)
dresses the development of organs and organ functions in the – Lower leg (Crus)
course of evolution – Foot (Pes)
• Anatomy of living organisms: uses anatomical knowledge on
living organisms, e. g. when palpating bony points through the Functional organisation
skin, feeling pulses, etc.; it serves as an intensive preparation for Dividing the body according to functions the following systems
the future work with patients can be distinguished:
• Clinical anatomy: connects the normal anatomy with diseases • Locomotor system (skeletal and muscular system)
commonly encountered in the clinical practice; the clinical cor- • Respiratory system
relations originate in many different fields of medicine • Circulatory system

5
1 General anatomy

Caput

Collum

Brachium
Thorax

Membrum Ante- Abdomen Truncus

superius brachium

Manus Pelvis

Femur

Membrum
inferius Crus

a Pes b

Caput

Collum

Brachium
Truncus,
Dorsum
Membrum
Ante-
superius
brachium

Manus

Femur

Membrum
inferius
Crus

c Pes d

Fig. 1.1 Blueprint of the human body. a Man from the front. b Woman from the front. c Man from behind. d Woman from behind. [K340]

6
 1.2 Architecture of the human body

• Metabolic system • Mammary gland (mamma)

• Reproductive system • Distribution pattern of the subcutaneous fat (more consistent,
• Communication system smoother outlines)
• Central control system • Pubic hair pattern up to the Mons pubis
• Symmetrical (even) hairline
Bilateral symmetry and metamerism • Smaller body size
The body is bilaterally symmetric (bilateral symmetry). Both • Horizontally oval pelvis
halves of the body are laterally reversed and mirror each other on The secondary sexual characteristics of men are:
the right and the left side. The internal organs are an exception. • Pubic hair pattern up to the navel
Metamerism refers to the repetition or a series of similar elements • Beard growth
(e. g. the ribs), which are arranged along an axis (vertebral column) • Hair growth on the anterior thoracic and abdominal wall (varies
(segmental or metameric organisation). Their origin lies in the greatly) as well as on the back and limbs
development of somites (primary segments), which represent • Reduced hairline (receding hairline, partial baldness)
­segmental units. The temporary occurrence of branchial arches • Larger body size
(pharyngeal arches) is also known as branchiometry. • Narrower pelvis
Constitution refers to every person's physical and mental charac-
teristics that are very individual in their interdependencies. Ac-
1.2.2 Body proportions cording to Kretschmer, a distinction is made between 3 constitu-
tional types:
Age, sex, weight, body size and offspring (ethnic factors) affect the • Leptosome: slim, slender body type, fragile limbs with light-­
form and architecture of the body. The limbs, organs and regions of weighted bones and thin muscles
the body are connected to each other in a certain proportional • Pyknic: medium-sized, broad body type, having a tendency to
manner at any age and grow at different speeds. These directly pro- become fat, rounded chest (below wider than above) and face,
portional relationships are most notable in infants and toddlers short neck; sedate, cosy, kind-hearted, sociable, serene tempera-
and also play the most important role in these age groups. ment
• Athletic: muscular body type, broad shoulders and broad upper
Developmental stages chest; in general serene temperament, outspoken, active
In paediatrics, the postnatal period is divided into developmental This classification is rejected by psychology today.
stages:
• Neonatal period (the first 2 weeks of life) Body weight
• Infancy (up to the end of 1st year of life) For determining the normal weight and also the overweight and
• Early childhood (up to the end of the 5th year of life) underweight of adults the body mass index (BMI, or Quetelet in-
• School age (up to the beginning of puberty) dex) is used today. It is the quotient of body weight (in kg) and the
• Puberty (maturation age, with variable duration) square of the body size (in m). However, the age, gender and con-
• Adolescence (completion of the development and length growth stitution must be taken into account in the evaluation. A BMI
of the skeletal system) ­below 16 stands for severe underweight, 16–20 for underweight,
Since the middle of the 19th century there has been a general ac- 20–25 for normal weight, 30–40 for strong obesity and values over
celeration of development compared to previous generations, e. g. 40 for extreme obesity.
with respect to the growth or physical maturation processes. Im-
provements of life, sanitary and nutritional conditions as well as NOTE
changes in the social environment are viewed as responsible for Obesity (with a BMI above 30) per se is not an eating disorder:
this. ­it is a disease, which can be caused by an eating disorder but not
exclusively.
External appearance
For the individual periods of life there are typical physical features,
which shape the external appearance of an individual. Morphological Skeletal age
differences are most marked as gender differences (sexual dimor- In order to determine the skeletal age of infants and toddlers an
phism, especially after sexual maturity). The skeletal system, the x-ray image of the left hand is used. For assessing the skeletal age of
skeletal muscles, the distribution of the subcutaneous fatty tissue, school children the size and shape of the ossification centres in the
the hair growth pattern and the body proportions contribute the knee joint region are evaluated. After completion of the growth
largest part. during puberty the closure of the epiphyseal gaps is assessed.
The genetically determined primary genitalia (testes or ovaries)
which are responsible for the formation of gonads, are described as
primary sexual characteristics. The secondary sexual character-
istics, which develop during puberty, are mainly responsible for
the external appearance. Their development is influenced by go-
nadotropins (hormones of the pituitary gland), which are respon­
sible for the production of gender-specific gonadal hormones.
The secondary sexual characteristics of women are:

7
1 General anatomy

0 1 2 3 4 5 0 1 2 3 4 5
cm cm
120 % 120 %
Girls Height of the father cm 97
Boys Height of the father cm
97
0–5 years Height of the mother cm 90 120 0–5 years Height of the mother cm 120
75 90

50 75
110 Lying 110 Lying
25 50
Length Length
10
110 25 110
3 10
100 100 3

100 100

90 95
90

kg 90 kg

% %
80 24
97 97
23
22 80
90 90
22
21
75 21
70 20 75
20
19
50 70 50 19
18
25 18
60 17
25 17
16 10
10 60 16
15 3 15
3 14
50 14
13
13
12 50 12
11
11
kg 10
kg 10
9
9
8
8
7
7
6
6
5 Weight 5
5 Weight 5
4
4
3
3
0 1 2 3 4 5
0 1 2 3 4 5
a Age in years b Age in years

Fig. 1.2 Percentile growth curves. a Girls 0–5 years. b Boys 0–5 years. [L157]

1.2.3 Positional descriptions

Clinical remarks Topographically, the body can be divided into regions (› Fig. 1.4).
These regions are extremely useful to determine the exact position
For the assessment of a normal (standard) or deviating growth of the organs, to describe changes visible on the surface of the body
(variation) the measured body size, weight and cranial circum-
ference of children are set in relation to their age and evaluat-
or to document the process of surgical procedures (for regions of
ed by using percentile curves or tables (› Fig. 1.2). the head › Fig. 9.11).

Body size
The body size or height is the length from the crown of the head to
the soles of the feet. It is also referred to as the body length. The rel-
ative changes in the length of the body are shown in › Fig. 1.3
compared with each other. Therefore, the head of an embryo at the
end of the second month of pregnancy corresponds to the height of
the rest of the body. The head of a newborn measures just a quarter,
the head of a 6-year-old child a sixth and the head of an adult an
eighth of the body length. The navel shifts from the lower abdomen
(in an embryo) up to the waist during body growth.
Newborn Infant Schoolchild Adolescent Adult

Fig. 1.3 Change of body proportions during growth. [L238]

8
 1.2 Architecture of the human body

Regio cervicalis anterior

Regio sternocleidomastoidea Regio cervicalis lateralis
Trigonum clavipectorale
Regio deltoidea
Regio presternalis
Regio axillaris Regio pectoralis
Regio mammaria Regio inframammaria
Regio brachii anterior Regio epigastrica
Regio cubitalis anterior, Regio hypochondriaca
Fossa cubitalis Regio umbilicalis

Regio antebrachii anterior Regio abdominalis lateralis

Regio inguinalis
Palma [Vola]
Regio pubica
[Hypogastrium]
Regio urogenitalis
Trigonum femoris

Regio femoris anterior

Regio genus anterior

Regio cruris posterior

Regio parietalis
Regio cruris anterior
Regio occipitalis

Regio cervicalis posterior

a Dorsum pedis
Regio deltoidea
Regio vertebralis
Regio scapularis
Regio axillaris
Regio brachii posterior
Regio infrascapularis
Regio cubitalis posterior

Regio lumbalis
Regio antebrachii posterior
Regio sacralis
Regio analis
Dorsum manus

Regio glutealis

Regio femoris posterior

Regio genus posterior,

Fossa poplitea

Regio surae

Regio cruris posterior

Regio cruris anterior

Dorsum pedis

b Calx [Regio calcanea] Planta

Fig. 1.4 Regions of the body. a Front view. b Rear view. [K340]

9
1 General anatomy

1.2.4 General anatomical descriptions the exception of the median plane. In radiographic imaging tech-
niques (computed tomography, CT and magnetic resonance imag-
In medicine the positional and directional terms are transferred to ing, MRI) the three cardinal anatomical planes are defined as layers
a three-dimensional coordinate system with 3 axes and planes per- with their own nomenclature.
pendicular to each other. This corresponds to a person standing
upright, with the head facing forward, the arms hanging at the Axes
sides, the palms facing forward and the feet next to each other Longitudinal, transverse and sagittal axes are the main axes of the
­(anatomical position). body (› Table 1.2).

Planes Directional and positional terms for parts of the body

The cardinal planes of the body are the frontal, the transverse, the Positional and directional terms are used for the description of po-
sagittal, and the median planes (› Table 1.1, › Fig. 1.5). These sition, location and course of individual structures. Sometimes
cardinal planes can be shifted arbitrarily to all parallel levels with these terms are also an integral part of anatomical names. Position-

Table 1.1 Cardinal planes.

Plane Corresponding radiological Description

sectional planes
Frontal plane (coronal plane) (› Fig. 1.5) Coronal plane • Movement plane visible in the front view of humans
• Any plane that divides the body into front and back, and runs parallel to the
forehead
• Movements in this plane take place from left to right or from top to bottom
Transverse plane (axial plane, horizontal Axial layer • Any plane perpendicular to the longitudinal axis
plane, transaxial plane) (› Fig. 1.5) • Therefore each horizontal plane when standing upright
Sagittal plane Sagittal layer • Any plane crossing the body from front to back
(› Fig. 1.5) • Runs parallel to the midsagittal plane
Median (or midsagittal) plane Sagittal layer • Sagittal plane passing from front to back through the centre of the body and
(› Fig. 1.5) dividing it into two equal halves

Table 1.2 Cardinal axes.

Axis Description
Longitudinal axis (vertical axis) Longitudinal axis passing through the body from top to bottom (or vice versa)
(› Fig. 1.5)
Transverse axis (horizontal axis) Crossing the body from the left to the right half (or vice versa)
(› Fig. 1.5)
Sagittal axis (ventrodorsal axis) Penetrates the body in the direction of the arrow from front to back (or vice versa)
(› Fig. 1.5)

3 1
7

2
4
5
2

3
6
6

1 Sagittal plane
2 Longitudinal axis
3 Sagittal axis
4 Median sagittal plane
5 Transversal plane
6 Transverse axis 2
7 Frontal plane a 3 b c

Fig. 1.5 Planes and axes. a Sagittal plane (Planum sagittale), through which sagittal and longitudinal axes pass. b Transverse plane = horizon-
tal plane (Planum transversale), through which transverse and sagittal axes pass. c Frontal plane = coronal plane (Planum frontale), through
which longitudinal and transverse axes pass. [L127]

10
 1.2 Architecture of the human body

Table 1.3 Directional and positional terms for the body parts. al terms are independent of the actual position of the body. The po-
sitional descriptions always refer to the anatomical position. The
Term Meaning
key terms are summarised in › Table 1.3 and partially represented
Cranial or superior Towards the head in › Fig. 1.5. In › Fig. 1.6and › Table 1.4 the orientation lines
Caudal or inferior Towards the tail bone (sacrum) on the body are also summarised.
Anterior or ventral Towards the front or abdomen
Terms of movement
Posterior or dorsal Towards the back
In order to describe changes of position and location of individual
Lateral Towards the side, away from the midline
parts of the body in relation to the biomechanical movements oc-
Medial Centred, in the middle or towards the midline curring in their joints, defined terms are used (› Table 1.5, › Fig.
Median or medianus Within the median plane 1.7). These terms are not always clearly differentiated, as the joints
Intermediate Lying in between allow different degrees of freedom or range of motion, so that their
movements depend on the type of joint involved, and thus combi-
Central Towards the interior of the body
nations are possible. The movement terms differ according to the
Peripheral Towards the surface of the body specific body region.
Profunda Lying deep inside
Superficial Lying close to or on the surface Range of motion
External Outside
The range or freedom of motion in a joint is the maximum excur-
sion from its neutral position: when standing upright, the arms
Internal Inside
hanging loosely down at the sides of the body, the thumbs facing
Apical Directed or related to the tip forward, the elbow and knee joints not completely extended but
Basal Directed towards the base minimally flexed (› Fig. 1.8). This neutral (‘zero’) position cor­
Dexter Right responds to the anatomical position with the exception that the
Sinister Left
thumbs are pointing forward. The freedom of motion can be limit-
ed by bony and soft tissue structures (joint inhibition):
Proximal Towards the trunk or torso
• Bone-guided inhibition: If two bones touch in a certain joint
Distal Towards the end of the limbs position, the movement may not be continued, e. g. the exten-
Ulnar Towards the ulna sion in the elbow joint when the Olecranon clicks into the Fossa
Radial Towards the radius olecrani.
Tibial Towards the tibia
• Ligament-guided inhibition: In this case the joint movement
comes to a standstill by a tense or stretched ligament, e. g. the
Fibular Towards the fibula
retroversion in the hip joint induced by extension of the Lig.
Volar or palmar Towards the palm of hand ­iliofemorale.
Plantar Towards the sole of the foot • Soft tissue or mass-guided inhibition: If soft tissues oppose
Dorsal (Extremities) towards the back (dorsum) of hand or foot each other in a certain joint position, the movement may not be
continued, e. g. when the bending in the elbow joint is restricted
Frontal Towards the front
by overdeveloped muscles of the arm and forearm.
Rostral Towards the mouth or tip of nose (literally: towards the
• Muscle-guided inhibition: The arrangement of muscles can be
beak; used only for head-related terms)
the limiting factor, e. g. in a maximum flexed position of the
wrist it is not possible to close the fist (› Chap. 1.4.4, active and
passive insufficiency).

Table 1.4 Orientation lines on the body.

Line Legend
Linea mediana anterior Front midline that divides the body in 2 symmetrical halves
Linea sternalis Parallel to the Linea mediana anterior at the lateral margin of the breastbone (sternum)
Linea parasternalis Parallel to the Linea mediana anterior, just between Linea sternalis and Linea medioclavicularis
Linea medioclavicularis Parallel to the Linea mediana anterior, right through the centre of the clavicle
Linea axillaris anterior Parallel to the Linea mediana anterior, just through the anterior border of the axilla
Linea axillaris posterior Parallel to the Linea mediana posterior, just through the posterior border of the axilla
Linea scapularis Parallel to the Linea mediana posterior, just through the lower angle (Angulus inferior) of the shoulder blade (scapula)
Linea paravertebralis Parallel to the Linea mediana posterior at the lateral margin of the spine
Linea mediana posterior Posterior midline that divides the body in 2 symmetrical halves

11
1 General anatomy

Linea mediana Linea mediana

anterior posterior

Linea axillaris
Linea
anterior
Cranial paravertebralis
Linea medio-
clavicularis Linea scapularis
Proximal
Linea Linea axillaris
parasternalis posterior
Lateral
Linea
sternalis
Distal Medial
Caudal

Proximal

Distal

Main line of
the lower limb

a b

Main line of the hand

Main line of Proximal
the lower limb
Distal Radial
Proximal
Main line of
the upper limb Ulnar
Distal
Radial/lateral

Ulnar/medial
Fibular/lateral
Tibial/medial
Main line of the foot

Medial
Lateral
c

Fig. 1.6 Orientation lines, directional and positional terms. [L127]

12
 1.2 Architecture of the human body

Table 1.5 Anatomical terms of movement.

Region Term Movement

Extremities Extension Elongation

Flexion Bending
Abduction Pulling away from the body
Adduction Pulling towards the body
Elevation Raising of the arm/shoulder above the horizontal plane
Depression Lowering the arm/shoulder from above the horizontal plane
Inner rotation Inward rotation
Outer rotation Outward rotation
Pronation Rotation movement of hand/foot with hand turned inwards or sole of foot turned outwards
Supination Rotation movement of hand/foot with palm of hand turned outwards or sole of foot turned inwards
Radial abduction Swivelling hand/fingers towards the radius
Ulnar abduction Swivelling hand/fingers towards the ulna
Palmar flexion/Volar flexion Bending palm of hand towards back of arm
Plantar flexion Bending sole of the foot towards back of leg
Dorsiflexion Extending hand/foot towards the back of arm/leg
Opposition Comparison of thumb vs. little finger
Reposition Repositioning of the thumb next to the index finger
Inversion Lifting the inner side of the foot using the talocalcaneonavicular joint
Eversion Lifting the outside of the foot using the talocalcaneonavicular joint

Spine Rotation Rotation of the spine in the longitudinal axis

Lateral flexion Lateral tilt
Inclination (flexion) Forward tilt
Reclination (extension) Backward tilt

Pelvis Flexion (anterior/ventral rotation) Pelvic tilt towards the front

Extension (dorsal rotation) Pelvic lying towards the back

Temporomandibular Abduction Opening the jaw

joint Adduction Closing the jaw
Protrusion/protraction Pushing the lower jaw forward
Retrusion/retraction Pulling the lower jaw back
Occlusion Interlocking the upper and lower jaw teeth
Mediotrusion Ventral-medial translation of the lower jaw on one side
Laterotrusion Dorsal-lateral translation of the lower jaw on one side

13
1 General anatomy

Opposition/reposition Abduction/adduction Opposition Dorsal extension/palmar-

a of the thumb b of the thumb c (thumb-small finger sample) d flexion of the hand

e f g h
Adduction of the fingers Abduction of the fingers Circumduction Abduction/adduction
of the shoulder joint of the arm and leg

i j k l
Lateral flexion Flexion/extension Internal rotation External rotation
of the trunk of the knee joint of the shoulder joint of the shoulder joint

Inversion Eversion
o p
of the foot of the foot

m n

Anteversion/retroversion Flexion/extension Pronation Supination

of the arm of the elbow joint of the hand of the hand

q r

Fig. 1.7 Definitions of movements. [L126]

14
 1.2 Architecture of the human body

5°
Extension/flexion 0°
5°–0°–140°
a
140°

5°
Extension/flexion 0°
0°–20°–140°
b 20°
140°

a b
5°
Extension/flexion 0°
Fig. 1.8 Neutral position. a Front view. b Lateral view. 0°–20°–20°
c 20°
140°
NOTE
In order to describe the range of motion of a joint and to make the Fig. 1.9 Documentation of the range of motion of joints.
measurements comprehensible for follow-up examiners, one uses a Normal range of motion of the knee joint. b Extension of the knee is
the neutral-zero method (› Fig. 1.8). not possible. c Complete stiffening of the knee.

Clinical remarks • Protection (as a mechanical, thermal, chemical or immunologi-

The neutral-zero method is a standardised orthopaedic evalu- cal barrier)
ation and documentation system for describing the mobility of • Registration of pressure, touch, vibration, pain, temperature
joints. Starting from the neutral or ‘zero’ position (› Fig. 1.8) • Energy storage
the achievable range of motion around a specific axis is mea- • Heat insulation
sured and defined as degrees of angle. First the range of mo-
tion leading away from the body is determined, followed by
the range of motion leading back towards the body (› Fig. NOTE
1.9). Thus, the mobility can be clearly defined and document- Condition and appearance of the skin and skin appendages signifi-
ed in findings and medical documents. All restrictions of the cantly influence the social acceptance and the subjective impres-
mobility are determined and assessed by comparison with sion of a person. For the medical professionals they provide infor-
standard values. They can serve as a basis for expert opinions. mation about age, life style, health, general condition and mood of
For example, the normal range of motion of the knee joint is 5° a person.
extension and 140° flexion. The straight extended or minimal-
ly flexed knee is the neutral or ‘zero’ position of the joint.
­However, the neutral or ‘zero’ position of the foot is at right an-
gles to the lower leg. From this position, a maximum of 20° ex-
Clinical remarks
tension and 40° flexion is possible. Therefore the normal For a grading of burns by the body surface affected, the Neuner
range of motion in the knee joint is defined as 5°–0°–140° rule is applied, which allows a prognostic estimation of the
(extending the knee, passing the ‘zero’ position and bending burnt skin surface:
the knee, › Fig. 1.9a); for the foot it is defined as 20°–0°–40° • Adults:
(dorsal extension, passing the ‘zero’ position, and plantar – Arms and head 9 % respectively
flexion). – Chest/abdomen, back and legs 18 % respectively
Restrictions of joint mobility can be reproduced exactly by the – Palm of hands including fingers and genital region 1 %
neutral ‘zero’ method. If, for example, there is a flexion con- respectively
tracture in the knee joint of 0°–20°–140° (› Fig. 1.9b), the • Children up to 5 years:
knee cannot be extended or pass the ‘zero’ position, it re- – Arms 9.5 %
mains in a 20° flexed position at the maximum range of exten- – Chest/abdomen, back 16 % respectively
sion, but can be further bent up to 140°. In the case of a com- – Legs 17 %
plete knee stiffening of 0°–20°–20° (› Fig. 1.9c) neither – Head 12 % (age-dependent)
­extension nor bending of the knee is possible, and the ‘zero’ If more than 20 % of the skin surface is burnt, it is a severe
position is not achieved. burn. From 40 % on the probability is extremely high that the
patient dies. From 5 % in children and 10 % in adults there is
a risk of shock. Inpatient treatment in a hospital is nearly al-
ways indicated, and should be reserved for specialised cen-
tres for patients with burns, in order to treat the patient in the
1.3 Skin and skin appendages best way possible.

The skin covering the body has with 1.5–2 m2 the largest extension
or surface area of all organs of the body. It has a total weight be-
tween 3 and 4 kg (and together with the subcutaneous fat up to 16
kg). The thickness of the skin varies between 1 and 2 mm depend-
ing on the body region. It has the following functions:

15
1 General anatomy

1.3.1 Skin types and skin layers • Stratum papillare: papillae of collagenous and elastic connective
tissue link (indent) the dermis with the epidermis. In each papil-
Meshed and ridged skin la a capillary of the Plexus superficialis runs to the tip.
A distinction is made due to the morphological structure between • Stratum reticulare: tense collagenous and elastic connective
meshed and ridged skin. Meshed skin has glands and hairs and ­tissue
makes up the largest part of the body surface area. It has a variable The dermis is well vascularised and innervated. It houses various
thickness in different regions of the body. Ridged skin forms the specialised receptors:
surface relief of the palms and soles and is – being genetically • MERKEL cells for pressure sensation
­determined – an individual characteristic of each person (finger- • MEISSNER tactile corpuscles for touch (especially Stratum
print). This enables an individual identification. ­papillare)
• RUFFINI corpuscles for stretching sensation (especially Stratum
Skin layers reticulare)
The skin (Cutis) consists of epidermis, dermis and subcutis • VATER-PACINI corpuscles for vibration sensation
(› Fig. 1.10). • Free nerve endings for mechanical, thermal and/or pain percep-
tion
Epidermis Furthermore there are nerves, lymphatic vessels, immune cells,
The epidermis (Epithelium) is the surface of the skin and has melanotropin-producing cells (UV protection), sweat glands, hair
characteristic layers: follicles, sebaceous glands and smooth muscle cells in the dermis.
• Stratum corneum Epidermis and dermis are linked via the papillae of the Stratum
• Stratum lucidum (only ridged skin) papillare. Below this follows the Stratum reticulare of the dermis.
• Stratum granulosum The latter is mainly responsible for the elasticity of the skin.
• Stratum spinosum
• Stratum basale
It is a multi-layer (or stratified) squamous epithelium without
Clinical remarks
blood vessels, containing numerous sensory receptors in the form The epidermis and the Stratum papillare of the dermis (der-
of free nerve endings (mechanical, temperature and/or pain per- mo-epidermal transition zone) are interlocked by various pro-
ception) and MERKEL cells (pressure sensation). In addition, there teins and other structures. If one or more of these proteins or
are melanocytes and dendritic cells (immune cells, LANGERHANS adhesive structures is missing (e. g. genetically) or undergoes
destruction (e. g. mechanically), bubbles (Bullae) may occur,
cells).
and in rare cases there may be a large-scale detachment of the
epidermis. There are also conditions such as the bullous pem-
Dermis phigoid, in which antibodies are formed against components
The layer below the epidermisis the dermis (or Corium), is a layer of the adhesive structures (auto-antibodies). In the case of
of connective tissue with a superficial capillary plexus (Plexus su- pemphigus the antibodies disturb the adhesion of the cells
perficialis) on the border between the epidermis and dermis and a within the epidermis.
deep vascular plexus (Plexus profundus) on the border between
dermis and underlying subcutis. These vascular plexuses not only
play a role in the blood circulation, but also in the heat regulation. Subcutis
The dermis has two layers: Below the dermis lies the subcutis, consisting of loose connective
tissue and adipose tissue (subcutaneous fat tissue).

E
Clinical remarks
C D
The main orientation of the collagen fibres in the Stratum re-
ticulare of the dermis determines the so-called cleavage lines
of the skin, which play an important role for correct incisions
SD in surgery. If incisions are opposing these cleavage lines, this
leads to increased scarring and the formation of non-physio-
logical wrinkles in later life.
SC
rc

1.3.2 Skin appendages
Fo
The skin appendages (or organs) include, apart from hair and nails,
Fm
numerous large and small sweat glands, sebaceous glands and the
mammary glands (lacteal glands, Mammae).
M

Fig. 1.10 Layers of the skin (integument). C = Cutis, E = Epidermis, Hair

­D = Dermis, SC = Subcutis, Fo = Surface fascia, Fm = Muscle fascia, Hair (Pili) are viewed as remnants which once served as heat insu-
M = Muscle, rc = Retinaculum cutis, SD = Eccrine sweat glands; lation. In the evolutionary development this function became ob-
H&E staining, magnification x22. [S010–2–16] solete and has receded. Today, hair contributes substantially to the

16
 1.2 Architecture of the human body

external appearance of a person and plays a major role in social ac- forms, such as scalp hair, eyelashes, eyebrows, pubic hair, axil-
ceptance and aesthetic perceptions. Furthermore hair serves as a lary hair and beard hair, which usually differ considerably in the
protective shield against UV light and heat, as well as conveying various ethnic groups. Terminal hair is classified as short (eye-
tactile sensations. lashes, eyebrows) and long hairs (all other). Its structure de-
Hair is the product of keratinisation, which begins in matrix cells pends on genetic factors and gender.
at the bottom of invaginations in the epidermis (› Fig. 1.11). The
cells derived of the matrix cells differentiate to become horny cells Hair follicles
which form the hair shaft. Hairs begin to develop in depressions (invaginations) of the colum­
n­ar epithelium, which extend to the dermis or the subcutis. These
Basic types hair follicles are nourished by blood vessels and consist of a hair
Postnatally, a distinction is made between two basic types of hair: bulb and a hair papilla. Here the hair growth begins. Each hair fol­
• Vellus hair (fluffy hair): are soft and short hairs, with hair folli- licle is associated with a sebaceous gland (pilo-sebaceous gland
cles (see below) in the epidermis. The thin and nearly colourless unit) and a smooth muscle (M. arrector pili). The latter can
vellus hairs have no medulla (see below) and correspond to the straighten the hair by indenting the epidermis (goose bumps). In
foetal lanugo hair. It covers the largest part of the body in chil- the hair, a distinction is made between (› Fig. 1.11):
dren and women. • Hair shaft: completely keratinised with an epithelial hair root
• Terminal hair (long hair): is strong and long, with hair follicles sheath
extending into the subcutis. The thick and coloured (pigmented) • Hair bulb: the distended epithelial part where the hair begins to
terminal hairs have shafts with medulla, and occur in various grow, and which contains matrix cells capable of cell division
• Hair papilla: a cell-rich connective tissue extension of the der-
mis, indenting from below into the hair bulb
Air-filled space in the medulla
Hair cuticle • Hair funnel: opening of the hair follicle to the skin surface; the
duct of the associated sebaceous gland ends here
Hair shaft
Cortex • Epithelial root sheath: divided into the inner and the outer root
sheath
Medulla – Inner root sheath: with the following layers from inside to
Epidermis outside
Hair funnel
– Cuticle (of sheath)
– HUXLEY's layer
Dermis
– HENLE's layer
– Outer root sheath: consists of several layers of bright, non-ke-
ratinised cells that only become horny in the area of the hair
Hair root M. arrector
funnel and pass here to the epidermis of the skin
pili Genetic factors and the pigment content (melanin) of the hair are
responsible for a person's characteristic hair colour. Once the pro-
Connective tissue Sebaceous gland
Torus duction of melanin ceases, the hair appears grey or white.
root sheath

Keratogenous zone Nails

Sheath cuticle
On the upper side of the fingers and toes, there are approximately
HUXLEY’s layer
0.5 mm thick nails. Each nail (Unguis) is a convex, translucent
HENLE’s layer keratin plate (body of nail), which protects the finger tips and sup-
Hair bulb
ports the grasping function (› Fig. 1.12). The nail structures are:
Internal root sheath
External root sheath
• Body of nail (Corpus unguis)
Matrix • Nail wall (Vallum unguis): on both sides of the body of nail
• Nail fold: skin fold, which rises above the nail wall
Melanocytes • Cuticle of nail (Eponychium, Cuticula): epithelium of the nail
Hair papilla wall, lying dorsally on the body of nail.
Fig. 1.11 Structure of a hair follicle. [L141]

Matrix unguis
Corpus unguis Eponychium
Hyponychium Vallum unguis
Margo liber Aponeurosis dorsalis
Margo liber Nail bed
Articulatio interphalangea distalis
Phalanx distalis
Vallum unguis Corpus unguis
Epidermis Capsula articularis
Lunula Nail wall Dermis
Subcutis
a Eponychium b M. flexor digitorum profundus, Tendo

Fig. 1.12 Structure of a nail (distal phalanx, Phalanx distalis). a View from above. b Sagittal section.

17
1 General anatomy

• Hyponychium: epithelium, covered by the body of nail 1.4 Musculoskeletal system

• Nail matrix (Matrix unguis): epithelium proximal of the
­hyponychium, from which the body of nail emerges The musculoskeletal system consists of passive (bone, cartilage, lig-
• Nail bed: connective tissue below the nail matrix, which is aments and joints) and active (muscles and tendons) elements.
­firmly fused with the periosteum of the distal phalanx
• Lunule of nail: crescent-shaped whitish part of the Matrix un-
guis, from which the body of nail emerges; the Lunula is visible 1.4.1 Cartilage
through the nail
Cartilage like bone belongs to the supportive tissues of the body. It
is only briefly mentioned here for further understanding. Cartilage
Clinical remarks consists of cartilaginous cells (chondrocytes) and the extracellular
Some people have white spots under their nails. This signi- matrix (ECM), with proteoglycans and collagen fibrils as key com-
fies, that the nail is insufficiently fixed on the nail bed. Chang- ponents. Cartilage has a high elasticity on pressure. This is based
es in light reflection at these points cause the nail to appear on its solid consistency, which helps to only slightly change its
milky-white (similar to the lunule). Possible reasons for this form under pressure and to return it back to its old form when the
are impacts against the nail, medication or various diseases.
pressure subsides. Due to the composition, a distinction is made
A lack of biotin (vitamin H) is a common causefor brittle nails,
because biotin is required for the production of keratin, the between three different types of cartilage:
main component of the body of nail. • Hyaline cartilage: This most common type of cartilage (joint
Numerous systemic diseases are associated with nail disor- cartilage, respiratory tract, nose tip, nasal septum, larynx, tra-
ders. Psoriasis, for example, causes the formation of pitted chea, bronchi, ribs, epiphyses, primordial bones before ossifica-
nails, oil-drop signs, crumbly nails or nail dystrophy. tion) consists of cartilaginous cell (chondrocyte) clusters and
Onychomycoses (fungal colonisation/mycosis of the nails) are ECM. The collagen fibres are not visible in histological sections
a common cause for consulting a dermatologist (skin specialist).
(they are masked).
The treatment is often lengthy.
• Elastic cartilage: structured similar to hyaline cartilage, it con-
tains additionally a larger quantity of elastic fibres in the ECM and
has smaller chondrocytes. It occurs in the auricle, in the external
Skin glands acoustic meatus, in the pharyngo-tympanic tube, the epiglottis, as
Sweat glands the small laryngeal cartilage and in the smallest bronchi.
Sweat glands (Glandulae sudoriferae) occur as small and large • Fibrous cartilage: In this type of cartilage the cells are separate,
sweat glands. and the collagen fibres are not masked, so they are visible in
• Small sweat glands are distributed over the entire body surface. ­histological sections (hence the name). Fibrous cartilage occurs
The density varies from 50/cm2 (on the back) to 300/cm2 (in the in the intervertebral discs, the pubic symphysis, articulardiscs,
palms). The excretory ducts open onto cutaneous ridges or menisci, in chondrotendinous insertions, sliding tendons, and in
raised points of the epidermis. Functionally, they provide a regu- the temporomandibular joint.
lation of the body's temperature: With increased secretion of
sweat, this hypotonic fluid evaporates and heat is removed from
the body (evaporative cooling). Generally, in 12 hours approxi- 1.4.2 Bones
mately 250 ml of sweat is secreted. If the ambient temperature is
elevated, this amount may increase many times over. Bacteria The bones (Ossa) form the bony skeleton of the body. The adult
that colonise the skin physiologically, change the composition of skeleton is made up of nearly 200 single bones, which are connect-
the sweat and add a characteristic odour. ed by joints.
• Large sweat glands (scent glands) only occur regionally, e. g. in Bone is not a dead, but a living tissue that is very well supplied with
the armpit, around the nipples, in the eyelids, in the external blood. In 10 % of bones there is a constant remodelling of bone
acoustic meatus, in the perigenital and perianal regions. They even after completed growth. If osteogenesis and osteoclasis take
only become fully functional in puberty and influence – by place at different sites, this will change the form (shape) of the bone
­bacterial modification of the secretion – the individual body (modelling); if both processes take place at the same site, the form
odour of a person. does not change (remodelling). With a constant loading of bones,
osteogenesis and osteoclasis will be balanced. Only when one pro-
Sebaceous glands cess outweighs the other, does the bony structure begin to change:
Sebaceous glands mostly occur in association with hair (pilo-seba- if osteogenesis predominates, this leads to a greater density of
ceous gland unit, see above). However, there are also regions of the bones (osteosclerosis); if more bone is degenerated (by osteoclasis)
body, where sebaceous glands occur independently of hair, e. g. in than newly formed, one speaks of osteolysis or osteoporosis. These
the eyelids (MEIBOMIAN glands), in the external acoustic meatus, processes can be localised or generalised.
on the nipples, lips and in the genital region. Sebaceous glands pro- Bone consists of organic substances (mainly type I collagen, and
duce an oily discharge, which greases hair and skin, or for example bone cells [osteocytes, osteoblasts, osteoclasts]) and inorganic ma-
covers the tear film and protects it from evaporation. trix (containing salts such as calcium phosphate, magnesium phos-
phate and calcium carbonate as well as calcium, potassium and so-
Mammary gland dium compounds with chlorine and fluorine). 99 % of the body's
The mammary gland is described in › Chap. 3.1.2 together with calcium reserves are bound in the bone. This is equivalent to
the chest or thoracic wall. 1–1.5 kg calcium in the human body. Only 1 % is not bound in

18
 1.4 Musculoskeletal system

bone, but is found elsewhere, e. g. in the blood or muscles. Organic Classification of bones
substances and inorganic matrices form a composite, its mechani- The bones are divided into different types, based on their structure
cal properties depend on the ratio of the individual components. and their appearance (› Table 1.6, › Fig. 1.13).
Osteogenesis (bone formation) and osteoclasis (bone resorption) are
influenced by various factors such as mechanical load, hormones, Table 1.6 Classification of bones.
growth factors, matrix molecules and cytokines.
Functions of bone are: Description Example Explanation
• Support (the entire skeletal system) Long bones Femur, Humerus • Have a shaft (Corpus) and ends
• Protection (skull and vertebral canal) (Ossa longa) (Extremitates)
• Calcium reservoir (the entire skeletal system) • The medullary cavity (Cavitas
• Blood formation (the entire skeletal system, age-dependent) medullaris) is in the shaft
Flat bones Os parietale, Scapula Consist of 2 compact lamellae

Clinical remarks (Ossa plana) with integrated cancellous bone

in between

In the case of inactivity or immobilisation (e. g. by a plaster Short bones Carpal bones, tarsal Have no medullary cavity, but a
cast), lack of gravity (astronauts), and diseases such as osteo- (Ossa brevia) bone core of cancellous bone
porosis or spreading of malignant tumour cells in bone (bone Irregular bones Vertebrae Bones that do not fit into the
metastases) the bone mass is reduced, and the stability of the (Ossa irregularia) above categories
bone is at risk. The goal of treatment is to balance this dis-
Air-filled bones Maxilla, Os ethmoid- Bones with one or more air-filled
equilibrium in favour of a regeneration (osteogenesis) or pres-
(Ossa pneumatica) ale spaces and lined with mucosa
ervation of bone mass by means of an early initiated therapy
with exercises or drugs. The functional early mobilisation after Sesamoid bones Patella, Os pisiforme Bones embedded in tendons
injury and operations through physical therapy is therefore of (Ossa sesamoidea)
very great importance. Accessory bones Os trigonum Accessory bones that do not
(Ossa accessoria) occur regularly

Functional adaptation
Os frontale
Orbita
Construction principle/architecture
Os zygomaticum
Maxilla The shape of bones is genetically determined; in contrast their
Vertebra cervicalis VII Mandibula structure depends considerably on the type and amount of me-
chanical stresses acting upon them. In this respect, bones are
Costa I Clavicula formed according to an economic construction principle: with a
Scapula minimum of material, a maximum of strength is achieved (mini-
Sternum mum-maximum principle). The tube (of long bones) is the optimal
Humerus
architectural element for a body that is subject to bending: being
Vertebra hollow inside and flexible in all directions (high peripheral ten-
lumbalis III
sions, inside = 0 = neutral fibre = no tension). The light weight
construction is particularly evident when one considers the weight
Radius Os coxae relations: the bones account for only 10 % of body weight, the mus-
Ulna Os sacrum
cles over 40 %.
Ossa carpi Bones have an outer layer of compact or cortical bone (Substantia
Ossa metacarpalia
compacta or corticalis) consisting of osteons and lamellae, and an
inner light weight construction due to trabeculae (Substantia
Ossa digitorum Os
[Phalanges] ischii spongiosa, cancellous or spongy bone trabeculae) with inter-
Os Femur
posed spaces, filled with bone marrow or medulla (› Fig. 1.14).
coccygis The plate-like structure of flat bones allows the distinction between
an outer and an inner cortical layer with spongy bone in between.
Patella On the flat cranial bones, the outer layer of the Substantia compac-
ta is referred to as Lamina externa and the inner layer as Lamina
interna. The Substantia spongiosa is referred to as diploe. The hol-
Fibula
low spaces of pneumatised (air-filled) bones are lined with mucous
Tibia
membrane. This construction, which is only found in the cranial
region, is a useful means of minimising the weight.

Ossa tarsi
Ossa metatarsalia
Ossa digitorum
[Phalanges]

Fig. 1.13 Skeleton. Ventral view. [E460]

19
1 General anatomy

Osteon with In unloaded areas of the bone (so-called neutral fibres), no cancel-
special lamellae lous or spongy bone exists, e. g. in the long bones.
HAVERS canal VOLKMANN canal
with blood vessel with blood vessel
Clinical remarks
Interstitial lamella
Individual lamella
of the external
The femoral neck angle (angle between the neck and shaft of
general lamellae the femur; also CCD angle = Centrum-Collum-Diaphyseal an-
gle; › Chap. 5.3.1) of adults measures normally approximately
126° in the frontal plane. If the angle is below 120°, one
Peri-
osteum
speaks of a coxa vara. In this case more tension trabeculae are
formed in the bone to counteract the high load by tensile
stresses in the femoral neck. However, these adaptive processes
Osteon are possible only up to a certain extent. If the load on the fem-
with oral neck in coxa vara exceeds the adaptive capacities of the
special bone, a femoral neck fracture can occur. In the case of coxa
lamellae
vara a fracture can be caused by considerably lower forces
than in the case of a normal femoral neck angle (coxa norma).

VOLKMANN canal Trabeculae of

with blood vessel spongy bone
Architecture of a long bone
Fig. 1.14 Structure of a bone with compact and spongy bone. Regardless of their absolute length long bones are divided into a
shaft (diaphysis) with normally 2 ends (epiphysis proximalis and
Adaptation epiphysis distalis) (› Fig. 1.16). These epiphyses are covered by
The compact bone is reinforced in areas exposed to higher com- articular cartilage on their ends; between epiphysis and diaphysis
pressive loads by external forces (quantitative adaptation). Thus, lies the cartilaginous growth zone (epiphyseal gap) during the time
for example, the cortical bone of the femur is reinforced on the me- of length growth. After completion of the bone growth, you can still
dial side of the thigh (thickened cortical bone, Linea aspera), be- see the former growth zone in sections through the bone (Linea
cause it is exposed to a large bending stress here in the frontal epiphysialis). The metaphysis is directly linked to the growth zone
plane (› Fig. 1.15a). The spongy bone trabeculae are aligned ac- or Linea epiphysialis. It represents the zone of the bone formation
cording to the compressive and tensile forces acting on the bone in (osteogenesis) emerging in the course of growth. Other bony pro-
this area, e. g. pressure trabeculae = pressure trajectories, tension trusions or prominences are referred to as apophyses. They are
trabeculae = tension trajectories (qualitative adaptation) (› Fig. formed by the insertions of tendons and ligaments and have their
1.15b). Pressure trabeculae run like compression trajectories, and own ossification centres during development. Areas where the bone
tension trabeculae like stretching trajectories. surface is not smooth but rough, are referred to as roughness or tu-

Vector of the partial

body weight

Joint resultant

Tension trabeculae
Vector of the partial
body weight
Muscular strength

WARD’s triangle
(neutral fibre) Compression
trabeculae
Joint resultant

Centre of gravity
of the partial body weight Linea aspera
a Pivotal point of the hip joint b

Fig. 1.15 Functional adaptation of bones exemplified by the femur. a Vectors of forces in the medial and lateral cortical tissues of the femoral
head and neck. b Course of the corresponding trajectories.

20
 1.4 Musculoskeletal system

Linea epiphysialis marrow within a short time. The diagnosis of diseases, e. g. of

Epiphysis proximalis the haematopoietic system (leukaemia) can then be con-
Metaphysis proximalis
firmed with a bone marrow biopsy of the spongy bone (punch
Apophysis biopsy) of the iliac crest or of the sternum (sternal biopsy–
Metaphysis proximalis conducted only rarely today).
Substantia spongiosa

Apophysis

Bone development (osteogenesis)

The development of bones begins with cartilaginous or fibrous pre-
Substantia compacta
cursor cells (condensed mesenchyme, blastema). The processes of
desmal (fibrous, direct) and endochondral (cartilaginous, indi-
Diaphysis
rect) bone formation (osteogenesis), the structure of immature
(woven bone, fibrous bone, primary bone) and mature bones
Cavitas medullaris
(lamellar bone, secondary bone) as well as the processes in the
Periosteum growth zones of bones are dealt with in detail in histology textbooks.
Bone formation (osteogenesis) does not, however, take place in all
parts of the skeleton at the same time. It starts as early as in the 2nd
embryonic month at the clavicle (Clavicula) and ends around the
20th year of life with the closure of the epiphyseal gaps of certain
long bones. During this development, due to an endochondral
­ossification in the epiphyses and apophyses secondary ossification
Metaphysis distalis Foramen nutritium centres occur. They are usually formed in a limited period of time
and in a typical sequence for each skeletal element. The skeletal age
Epiphysis distalis can be determined by comparing at which time the ossification
centres emerge and the ossification pattern of the bones (› Fig.
Cartilago articularis 1.17). A distinction is made between primary ossification centres,
which emerge during the foetal period in the area of the diaphyses
Fig. 1.16 Structure of a long bone (Os longum) exemplified by the
femur. Dorsal view. (diaphyseal ossification) and secondary ossification centres,
which develop partly in the 2nd half of the foetal period and partly
in the first years of life within the cartilaginous epiphyses and
berosity (Tuberositas). Furthermore there are osseous combs or apophyses (epiphyseal and apophyseal ossification). With the
ridges (Cristae), lips (Labiae) or rough lines (Lineae). All these dif- closure of the epiphyseal gaps (synostosis, see below) the length
ferent types of roughness serve as a connection with muscles and growth is completed. Thereafter, isolated ossification centres are no
ligaments. Depending on its use the thickness of bone and the ratio longer visible in X-ray images.
of compact and spongy bone will be adapted (see above). The med-
ullary cavity (Cavitas medullaris) is filled with bone marrow that
also extends between the spongy bone trabeculae.
Clinical remarks
In orthopaedics the determination of the skeletal age and of a
potential ‘growth reserve’ plays an important role for the treat-
Clinical remarks ment planning and the outcome of orthopaedic disorders and
If the load on a bone exceeds its strength, a fracture may oc- malformations in childhood.
cur. This results in 2 or more bone fragments, which can be
shifted (dislocation). Apart from pain, the typical clinical signs
of a fracture include abnormal mobility, grinding sounds with Periosteum and endosteum
movement (crepitation), axial misalignment, and an initial
With the exception of joint surfaces or direct insertions of tendons,
stupor (lack of muscular activity). The diagnosis is confirmed
by an x-ray image. For the healing of a fracture it should be all other parts of bones are covered with periosteum. The perioste-
ideally immobilised without any stress or movement. This in- um consists of an outer fibrous layer (Stratum fibrosum) and an in-
volves a fixation of the fragments until the bone can be com- ner nourishing regenerative layer (Stratum osteogenicum). The col-
pletely fused, and for the recovery of long bones it is neces- lagen fibres of the Stratum fibrosum run in a longitudinal direction.
sary to restore the medullary cavity, e. g. by a plaster cast, The off-branching collagen fibres are SHARPEY fibres which course
screws, or plates. If the fracture gap is small (< 5 mm) and not through the vascularised and densely innervated Stratum osteo-
irritated, a primary fracture healing is possible without forma-
genicum to the compact bone, and firmly anchor the periosteum to
tion of callus. However, this succeeds almost only after surgi-
cal osteosynthesis with screws and plates, when the fracture the bone. The periosteum is very well innervated and supplied with
ends have been optimally adapted. The secondary fracture blood. Inside, the spongy bone (cancellous bone trabeculae) is
healing occurs after the formation of callus which is then grad- ­covered by a single epithelial layer, the endosteum. The blood sup-
ually ossified and becomes functional. ply of the bone and the bone marrow is provided by larger vessels,
In the adult organism there is red marrow (Medulla ossium ru- which penetrate the bone via osseous channels (Vasa nutritia).
bra) in the epiphyses and yellow bone marrow (Medulla ossium They are visible as holes in the bones of a skeleton.
flava) in the diaphyses. Red marrow fulfils the task of blood
formation (haematopoiesis); yellow bone marrow consists
mainly of adipose and connective tissues. Under abnormal NOTE
(pathological) conditions (e. g. massive blood loss), the yel- Due to the good innervation of the periosteum, impacts against
low bone marrow in the diaphyses can be replaced by red bones are always extremely painful (kick against the shin). The regen-
eration of a bone fracture begins in the periosteum and endosteum.

21
1 General anatomy

7th EW
13th–15th LY
18th–19th LY
15th–18th LY 3rd–4th EM
15th–16th LY 18th–20th LY
1st LY 13th–15th LY
4th–5th EM
18th–21st LY
10th–12th LY 13th–15th LY 7th–8th LY
2nd–5th LM
5th LY 18th LY 5th–8th LM 6th–7th EM
2nd–3rd LY 18th–19th LY 3rd–5th LY
2nd–4th LY 16th–18th LY
17th–20th LY
20th–25th LY 8th EW 13th–15th LY
10th–13th LY
4th–6th LY
15th–18th LY 19th–20th LY

7th–8th EW 16th–20th LY

EW = Embryonic week
8th EW
EM = Embryonic month
LM = Month of life
LY = Year of life

5th LY
13th–16th LY 12th LY 16th–24th LY
8th–13th LY
1st LY 8th–12th LY 3rd–4th LY
9th EM

5th–7th LY 13th–17th LY
14th–18th LY
10th EM
10th–12th LY 17th–18th LY
5th–6th LY
17th–19th LY
12th–14th LY
7th EW
8th EW
7th EW

7th–8th EW

20th–24th LY
21st–25th LY 7th–8th LY
1st–2nd LY 5th–7th LY 6th LM 17th–18th LY
10th–12th LY
17th–18th LY

2nd–4th LY 2nd–4th LY
9th EW
9th EW
2nd–3rd LY

1st–3rd LY
3rd–4th LY
9th EW
9th EW
2nd–3rd LY 15th–21st LY
3rd–4th LY
11th–12th EW
1st–2nd LY
2nd–3rd LY 5th EM
3rd–5th LY
7th–8th EW
a b 8th EM
9th EW

Os scaphoideum 3rd–6th LM Os pisiforme 8th–12th LY Talus 7th EM Os cuneiforme mediale 2nd–3rd LY

Os lunatum 3rd–6th LY Os triquetrum 1st–4th LY Calcaneus 5th–6th EM Os cuneiforme intermedium 3rd–4th LY
Os trapezium 3rd–8th LY Os hamatum 2nd–5th LM Os naviculare 4th LY Os cuneiforme laterale 12th LM
Os trapezoideum 3rd–7th LY Os capitatum 2nd–4th LM Os cuboideum 10th EM

Fig. 1.17 Appearance of ossification centres for the skeleton. a Upper limb. b Lower limb. [L126]

22
 1.4 Musculoskeletal system

Blood supply • Collagen tissue fibres – e. g. Membrana interossea radioulnaris

For the continuous remodelling processes in bone, haematopoiesis • Elastic tissue fibres – e. g. Ligg. flava between adjacent vertebral
in the bone marrow and calcium homoeostasis, a good blood arches
­supply is needed. For this reason, there are afferent and efferent Syndesmoses include the Membrana interossea cruris, and the
blood vessels (Vasa nutritia), which enter and leave the bone via Syndesmosis tibiofibularis as well as the cranial sutures and fonta-
corresponding passageways (Foramina nutritia). The compact nelles. The cranial sutures are bridged by connective tissue, that
bone of the long bones has a specific vascular system, consisting of has developed from embryonic tissue and that shortly after birth,
HAVERS and VOLKMANN canals. has covered even larger areas between the developing cranial bones
in the form of fontanelles (› Chap. 9.1.3). According to the form
of sutures, a distinction is made between:
1.4.3 Joints • Sutura serrata (serrate suture): a toothed connection, very solid
(e. g. Sutura lambdoidea)
Joints are flexible connections (junctures) between cartilaginous • Sutura squamosa (squamous suture): a scale-like bevelled bone
and/or bony skeletal elements. They allow movements and a trans- surface (e. g. Squama ossis temporalis or Os parietale)
fer of forces without reaching critical values of load in the bones, • Sutura plana (plane suture): with almost even, smooth and par-
which could lead to a fracture. allel bone edges (e. g. Sutura palatina mediana)
• Schindylesis (‘tongue and groove’ suture): a bony crest sunken
Joint connections (junctures) into a slit-like deepening (e. g. the vomer in the Os sphenoidale)
The adjacent bones of the skeletal system can be connected contin- • Gomphosis (pouring in): as the dental root ‘plugged’ in the
uously or articulate intermittently, and therefore two types of joints ­alveolar bone
exist:
• ‘false’ joints (synarthroses, as continuous connections) Synchondrosis [cartilaginous articulation or juncture, Junctura
• ‘true’ joints (diarthroses, as discontinuous connections) cartilaginea]
‘False’ joints are immobile articulations characterised by filling tis- The adjacent bones of a synchondrosis are connected by hyaline car-
sue between the skeletal elements; there is no joint space; they are tilage. These junctures include the costal cartilage between ribs and
referred to as symphysis, junctures, syndesmosis or synchondrosis. sternum, the epiphyses (growth zones) and also the Synchondrosis
In contrast, true joints have a joint space between the articulating sphenooccipitalis of the skull. A symphysis (fused) like the Sym-
skeletal elements. physis pubica represents a special form. Fibrous cartilage occurs here
as well as in the intervertebral discs (Disci intervertebrales).
False joints
Synarthroses (› Table 1.7, › Fig. 1.18) differ according to the Synostosis [osseous juncture or union, Junctura ossea]
type of filling tissue which can consist of connective tissue, carti- Two bones are secondarily fused by bony tissue, e. g. the Os sa-
lage or bone. Normally synarthroses allow only a low-grade to crum and hip bones.
moderate mobility (connective or cartilaginous tissue) or no move-
ment at all (bony tissue) between the skeletal elements. The free-
dom of movement also depends on the type and amount of the
Clinical remarks
­filling tissue, which in turn develops in the sense of a functional If two bones of an existing joint become fused, e. g. after a
adaptation depending on the mechanical stresses to which the sy- joint infection or due to immobilisation, this is defined as
narthrosis is exposed. In this way syndesmoses are loaded by ­ankylosis.
­traction; in synchondroses, depending on the type of loading, hya-
line cartilage (compressive stress) or fibrous cartilage (shear stress)
may occur. One example is the pubic symphysis (› Fig. 1.19). It is True joints
reinforced above and below by 2 ligaments (Ligg. pubica superius Characteristic features of diarthroses are (› Fig. 1.20):
and inferius), which absorb traction forces; the hyaline cartilage in • articulating skeletal elements
the gap of the pubic symphysis absorbs compressive forces and the • a joint space
fibrous cartilage absorbs shear stresses. • joint surfaces (Facies articulares) covered with cartilage
• a joint cavity (Cavitas articularis)
Syndesmosis [ligamentous juncture, Junctura fibrosa] • a surrounding joint capsule (Capsula articularis)
The adjacent bones of ligamentous articulations or junctures are • ligaments reinforcing the joint capsule
connected by: • and muscles that move and stabilise the joint

Table 1.7 Synarthroses.

Synarthrosis Synonym Filling tissue Description Examples

Ligamentous articulation Syndesmosis, Junctura fibrosa Connective tissue (collagen, 2 bones are connected by • Membrana interossea cruris, Syndesmo-
(› Fig. 1.18a) elastic fibres) ­connective tissue sis tibiofibularis, (cranial) fontanelles
• Special form: gomphosis (attachment of
a tooth in the alveolar part of the jaws)
Cartilaginous articulation Synchondrosis, Junctura carti- Cartilage (hyaline cartilage, 2 bones are connected by Epiphyseal gaps, rib cartilage, Symphysis
(› Fig. 1.18b) laginea fibrous cartilage) ­cartilage pubica
Osseous union Synostosis, Junctura ossea Bones 2 bones are secondarily fused Os sacrum, Os coxae, ossified epiphyseal
(› Fig. 1.18c) by bony tissue gaps after completed growth, individual
cranial sutures

23
1 General anatomy

Large fontanelle
(Fonticulus anterior)
Course of collagen fibres in bone
Tibia
Gomphose

Skull Fibula
Bones
bone Membrana
interossea

Small fontanelle
a (Fonticulus posterior)

Epiphysis

Epiphyseal plate Pubic symphysis

(Symphysis pubica)
Sternum
(sternum)
Costal cartilage
(Cartilagines Ribs
Diaphysis (Costae)
costal)

Epiphyseal plate
Hip bone (Os coxae)
Epiphysis
b

Metopic suture

Coronal suture

Parietal bone

Fig. 1.18 Synarthrosis. a Ligamentous articulation [syndesmosis]. b Cartilaginous articulation [synchondrosis]. c Osseous union [synostosis].
[L126]

Lig. pubicum superius

Joint development
Symphysis gap Fibrous cartilage The primordial limbs (› Chap. 4.2) consist of a mesenchymal
blastema, which originates from the parietal mesoderm of the body
wall (somatopleura). Within the mesenchyme, cell consolidations
(precartilage blastema) occur, from which preformed cartilaginous
skeletal elements develop. At the future locations of joints, an in-
tensive cell consolidation takes place. Thereby joints can develop in
Hyaline cartilage
two ways:
• Carve out (carve out joints): In this most common type, split-
Lig. pubicum inferius ting within a preformed skeletal element occurs, e. g. hip joint,
knee joint.
Fig. 1.19 Functional adaptation via connective and supporting t­ issues
exemplified by the pubic symphysis (symphysis pubica). [L126] • Apposition (apposition joints): In this case two preformed
skeletal elements grow towards each other. In the area of their
These structures form a functional unit. Joints, which have very first contact initially a bursa develops which is later transformed
limited mobility due to a tense joint capsule are called amphiar- into a joint cavity. In addition, there are articular discs (see
throses or fixed joints (e. g. Articulatio sacroiliaca, numerous car- ­below), e. g. in the temporomandibular joint, the sternoclavicular
pal joints of hand and foot). joint or the posterior joint of pelvic girdle (sacroiliac joint).

24
 1.4 Musculoskeletal system

• Number of movement axes (according to the body axes) or de-

grees of freedom:
Hyaline joint – uni-axial
cartilage
– biaxial
Subchondral – multiaxial
Membrana Bones • Number of articulating skeletal elements:
Capsula
fibrosa – Simple joints (Articulationes simplices): 2 bones articulate
Joint space
articularis Membrana with each other (e. g. hip joint)
synovialis
Cavitas – Composite joints (Articulationes compositae): several bones
articularis
Plicae articulate with each other (e. g. elbow joint, knee joint)
synoviales • Form and shape of the joint surfaces (› Fig. 1.21):
Periosteum
– Cylindrical or roll-like joints (Articulatio cylindrica):
– Hinge joint (Ginglymus): uni-axial joint, which allows flex-
ion and extension (e. g. Articulatio talocruralis, › Fig. 1.21a)
Fig. 1.20 Synovial or ‘true’ joint (Junctura synovialis, articulation, – Pivot joint (Articulatio conoidea): uni-axial joint, which
diarthrosis). The muscles moving the joint and the ligaments enhanc- allows rotational movements (e. g. Articulatio radioulnaris
ing the joint capsule are not shown here. proximalis, › Fig. 1.21b); the pivot rotates as a joint head in a
concave joint cavity
In the development of carve out joints the following processes occur: – Wheel-like or trochoid joint (Articulatio trochoidea):
• Within the blastema and under the influence of hox genes cell uni-axial joint, which allows rotational movements (e. g. Ar-
consolidations are organised, from which precartilage is differ- ticulatio atlantoaxialis mediana, › Fig. 1.21c); the concave
entiated (precursor of the later joint cartilage) with a cell-poor joint cavity turns around a fixed pivot
homogeneous intermediate zone (inter-zone, becoming the lat- – Condyloid or ellipsoid joint (Articulatio ovoidea, Articulatio
er joint space). ellipsoidea): biaxial joint which allows flexion, extension, ab-
• Due to the synchronised developmental processes, the charac- duction, adduction and slight rotatory movements (e. g. prox-
teristic shape of the precartilaginous preformed skeletal ele- imal wrist, › Fig. 1.21d)
ments can be seen as early as the 6th embryonic week. – Saddle joint (Articulatio sellaris): biaxial joint, which allows
• In the 8th embryonic week a cracking (joint space or line) and flexion, extension, abduction, adduction and slight rotatory
the formation of the joint cavity occur in the inter-zone. The pe- movements (e. g. carpometacarpal joint of the thumb, › Fig.
ripheral areas of the inter-zone differentiate into the joint cap- 1.21e)
sule, and the inner layer of the capsule starts producing the sy- – Ball-and-socket joint (Articulatio spheroidea): joint with 3
novial fluid. The precartilage immediately adjacent to the joint axes, which allows flexion and extension, abduction and ad-
space differentiates further into the hyaline joint cartilage. duction, internal and external rotation as well as rotatory
• The processes are completed in the middle of the 3rd embryonic movements (e. g. shoulder joint, › Fig. 1.21f )
month. Since then any further increase in size is achieved by in- – Plane or flat joint (Articulatio plana): joint which allows sim-
terstitial and appositional growth. However, the nutrition of the ple gliding movements in different directions (e. g. vertebral
cartilage by diffusion from the differentiated perichondrium and joints, › Fig. 1.21g)
from the synovia of the joint cavity will soon become insufficient, A special form are condylar joints (Articulationes bicondylares).
therefore in the 13th embryonic week blood vessels emerge in the They have similar curved surfaces like ellipsoid and cylindrical
hyaline cartilage. Only areas close to the perichondrium and the joints. Their main characteristics are biconvex bony prominences
joint space remain avascular. The regular growth of joint bodies (condyles), which articulate with concave joint surfaces. These bi-
therefore also depends greatly on the blood supply. However, this axial joints allow rotational, shifting (translational) and rolling
blood supply is not linked to the genetically determined begin- movements (e. g. temporomandibular joint, Articulatio femorotib-
ning of the endochondral osteogenesis. ialis).
Intra-articular structures such as menisci, ligaments, joint lips and
articular discs (see below) all originate from the blastema of the NOTE
­inter-zone. In contrast to diarthroses, in synarthroses the gap for- Uni-axial joints have one axis of movement, and the orientation of
mation in the inter-zone is omitted. Here, the filling tissue of the this axis is responsible for the type of movement. They have there-
corresponding synarthrosis (connective tissue or cartilage) differ- fore only one degree of freedom. The movement in biaxial joints oc-
entiates from the cells of the inter-zone. curs around two axes perpendicular to each other, which intersect
in the centre of the joint. The mobility of the joint bodies (articulat-
ing bones) in biaxial joints is therefore greater than in uni-axial and
Clinical remarks lesser than in three-axial joints.

In the case of disruptions or disturbances of joint develop-

ment, fusions of skeletal elements can occur (synostoses, Structure of joints
C
­ oalition), which appear most commonly in the hand and foot A characteristic feature of diarthroses is a synovial joint space
skeleton. (Cavitas articularis). With the help of the lubricating synovial flu-
id the articulating bones can move against each other.

Types of joint General structure

Joints (Juncturae synoviales, articulation, diarthroses) typically have Despite the different types of joints some basic structural character-
a significant range of motion and can be classified according to: istics can be distinguished:

25
1 General anatomy

a b

c d

e f g

Fig. 1.21 Types of joints (Juncturis synovialis). a Hinge joint. b Conoid pivot joint. c Trochoid pivot joint. d Condyloid joint. e Saddle joint.
f Ball-and-socket joint. g Plane joint. [L127]

• Caput articulare (joint head) this reason, joint cartilage can be divided into different zones
• Fossa articularis (joint socket) (› Fig. 1.22a):
• Coating of hyaline cartilage (on joint head and joint socket) • The superficial zone of tangential fibres (zone I) is directly adja-
cent to the joint space. The chondrocytes are spindle-shaped,
NOTE and the orientation of the collagen fibres is parallel to the sur-
Exceptions to the rule of a hyaline cartilage covering can be found face. Due to the composition of the extracellular matrix, the re-
in the temporomandibular joint and the sternoclavicular joint. They tention of water in this zone is particularly high.
are covered by fibrous cartilage. • In the transition zone (zone II) the collagen fibrils run obliquely
to the surface of the cartilage and cross the collagen fibrils of the
Joint cartilage opposite direction at right angles. The chondrocytes are ar-
The articulating bone ends (joint surfaces, Facies articulares) of sy- ranged in so-called isogenic groups (clusters of several cells).
novial joints are covered with hyaline cartilage of varying thick- • The radiate zone (zone III) is the widest layer, here the collagen
ness according to their exposure to biomechanical stresses (or fibrils converge radially to the underlying layers. The chondro-
loads). For example, the patella has a particularly thick joint carti- cytes are arranged in small columnar groups. The caudal border
lage (up to 7 mm), in the sacroiliac joint the cartilage on the joint forms a limiting line (‘tide mark’) between the non-mineralised
surface of the sacrum is much thicker (4 mm) than on the joint cartilage and the underlying mineralised cartilage.
surface of the ilium (1 mm); the thickness of the joint cartilage in • The zone of mineralised cartilage (zone IV) consists of calcified
the hip joint is 2–4 mm, and in the finger joints only 1–2 mm. cartilage, which is the connection to the underlying subchondral
Healthy joint cartilage appears whitish and is devoid of a perichon- bone and transfers the biomechanical forces onto the bone.
drium and blood vessels. So it has to be supplied via diffusion and Functionally, the joint cartilage serves as a smooth surface which
convection by blood vessels in the synovia of the joint space and reduces the friction between the articulating bones. This enables an
the subchondral bone. Joint cartilage is structured according to its equal distribution of pressure onto the subchondral bone. The vari-
exposure to biomechanical stresses: the collagen fibrils in the joint ous zones of joint cartilage adapt and balance the different elastici-
cartilage (specific type II collagen) run in a corresponding direc- ty modules of the tissues and prevent an overloading of the struc-
tion; the cartilaginous cells (chondrocytes), which form the colla- tures. When exposed to compressive forces, the cartilage conveys
gen fibrils as well as the basic substance (glycosaminoglycans and water towards the joint space and reabsorbs it when the pressure
proteoglycans, particularly the water-binding aggrecan), have a subsides (convection). The joint surfaces can reversibly deform to a
distinct morphology in different areas of the joint cartilage. For certain degree.

26
 1.4 Musculoskeletal system

Chondrocyte

Proteoglycans Tangential fibre zone

Collagen fibrils Transition zone

Hyaline joint Chondrocytes Radiate zone
cartilage
Subchondral bone Tide mark

Membrana
Mineralisation zone
fibrosa Joint space
Capsula
articularis Membrana
synovialis
Cavitas articularis Blood vessels Subchondral bone

Plicae b
synoviales

Blood vessels in the Type A synoviocytes

Periosteum bone marrow
a
Subsynoviales Type B synoviocytes
Connective tissue

c
Fat cells

Fig. 1.22 General structure of a joint. a General structure. b Joint cartilage. c Joint capsule. [L126]

Clinical remarks – The innermost synovial layer or Tunica intima (consists of

2 cell populations):
Degenerative changes of a joint are described as degenerative – Type A synoviocytes, have many vacuoles and are capable of
osteoarthritis (‘wear’ of joint, German term: ‘Arthrose’). This phagocytosis, take up waste products of the cartilage cell me-
condition is the most common cause for consulting a physi-
tabolism, lie superficial to the joint cavity
cian. In Germany alone, approximately 5–6 million people suf-
fer from a degenerative osteoarthritis. Around the world, it is – Type B synoviocytes, are fibroblast-like, rich in endoplasmic
the most common joint disease (arthropathy). As a general reticulum and produce the lubricating synovial fluid, lie below
rule, each joint can be affected, but arthropathies of the knee the type-a synovialocytes.
and hip joints are especially common. Possible causes are an – Subsynovial tissue, containing fibroblasts, fat cells (adipo-
overload (e. g. by the body weight) as well as congenital and cytes), macrophages, mastocytes, pain receptors and mecha-
traumatic changes (e. g. misalignments and deformities of noreceptors, as well as large quantities of blood vessels and
joints or bones). However, degenerative arthritis can also
lymphatic vessels)
­result from other diseases (e. g. joint inflammation) (second-
ary osteoarthritis). The surface area of the synovia is enlarged by synovial folds and
Morphologically the joint cavity narrows which is associated villi, and can easily follow joint movements.
with:
• Formation of superficial fibrils and unmasking (becoming
visible) of collagen fibrils (stage 1)
Clinical remarks
• Cartilage fissures and clusters of chondrocytes (stage 2) Immunological diseases such as rheumatoid arthritis primari-
• Subchondral sclerosis (stage 3) ly affect the joint capsule. They trigger the production of harm-
• Exposure of bones and resorption cavities (stage 4) ful substances that are secreted into the synovial fluid and can
X-ray or radiological signs of osteoarthritis are: damage the joint cartilage.
• Joint space narrowing (first radiological sign)
• Subchondral sclerosis
• Osteophytes (bony appositions)
• Pseudocysts (subchondral ‘debris’ cysts) Synovia
The highly viscous synovia or synovial fluid (‘lubricant’ of the
joint) is a clear, slightly yellowish fluid consisting of proteohyaluro-
Joint capsule nate and a transudate of blood, that is similar to the blood serum.
The joint cavity of synovial joints is completely surrounded by a Normally, there is only a small amount of synovia in a joint (e. g. in
joint capsule (Capsula articularis) (› Fig. 1.22b) that seals the the knee joint only 3–6 ml).
joint cavity airtight. The joint capsule consists of the following The synovial fluid produced by type B synoviocytes in the Tunica
structures: intima has a pH value of 7.3–7.7 and consists of hyaluronic acid
• Membrana fibrosa: this outer fibrous layer contains mainly type (2–3 mg/ml), proteins (10–30 mg/ml), glucose (0.5–0.7 mg/ml),
I collagen and only a few elastic fibres; in many joints it is water and desquamated cells.
­reinforced additionally by ligaments; it continues peripherally Its functions are:
into the periosteum of the bone. • Nutrition of the joint cartilage and of parts of the intra-articular
• Membrana synovialis: the inner lining of the joint capsule and structures
thus the layer directly adjacent to the joint space, is the cell-rich • Lubrication (friction-free gliding of the joint surfaces)
synovial membrane which is further divided into: • Shock absorption (by an even distribution of the compressive
forces)

27
1 General anatomy

Clinical remarks can be complete discs (Disci, like a full moon) or partial discs
(­ Menisci, crescent-shaped moon).
Injury or inflammation of joints can lead to an increased pro-
• Disci articulares consist of dense connective tissue and fibrous
duction of synovial fluid by irritation of the Membrana synovi-
alis. The result is a joint effusion, which may be so extensive cartilage. They fill the joint cavity completely and are often at-
that the entire joint is tender, congested, painful and swollen, tached to the joint capsule (e. g. Discus articularis of the tem-
and the joint contours have disappeared. Depending on the poromandibular joint).
cause, a reactive effusion with normal synovia or effusions • Menisci articulares also consist of dense connective tissue and
with coloured fluid may be present, e. g. after bleeding fibrous tissue. They look crescent-like seen from above, and
(haemarthrosis). wedge-shaped in profile, and they cover the margins or the pe-
riphery of the joint surfaces (medial meniscus, and lateral me-
niscus of the knee joint).
Joint loading
The joint cartilage is loaded under physiological conditions by axial NOTE
pressure, as the transfer of forces from a joint surface to the other is In contrast to menisci the articular discs completely cover the joint
perpendicular to the cartilage surface. Forces that act on the joint surface.
are:
• Partial body weight (e. g. with unilateral loaded hip joint, the Joint lips (Labra articularia)
weight of the torso, neck, head and upper limbs) These structures are composed of connective tissue and fibrous car-
• Muscular and ligamentous forces (e. g. with unilateral loaded tilage, and they serve to enlarge the sockets of joints. In the human
hip joint exerted by the iliotibial tract and the muscles acting on body, joint lips (Labra) are found in the shoulder joint (Labrum
it, as the M. tensor fasciae latae, M. gluteus maximus, M. vastus glenoidale) and in the hip joint (Labrum acetabuli). They are
lateralis) ­anchored in the bony ring (Limbus) of the respective joint socket.
The partial body weight is reduced by the action of antagonistic
muscles and ligaments. The result is the actual load of the joint Bursae
(› Fig. 1.15), which is referred to as the joint resultant (R) and A bursa (Bursa synovialis) is, in principle, structured like a joint
can be represented as the sum of vectors of gravitational (partial capsule. You can imagine it as a fluid-filled cushion. It is surround-
body weight), muscular and ligamentous forces. It passes in accor- ed by a layer of connective tissue (Membrana fibrosa) and inside
dance with the laws of balance through the respective fulcrum of there is a synovial membrane (Membrana synovialis), which pro-
the joint (› Fig. 1.15). With movements in the joint, size, direc- duces the fluid in the lumen of the bursa. The composition of the
tion and position of the joint resultant will change. fluid is almost identical with the synovial fluid in joints. The elastic
The actual pressure on the cartilage (intra-articular pressure and bursae allow the sliding of tendons and muscles on bones and ten-
surface contact) depends not only on the joint resultant (joint load) dons. They can communicate with the joint cavity (e. g. Bursa sub-
but also on the size of the surface exposed to the force. The smaller scapularis in the shoulder joint) or occur as independent bursa
the surface is, the greater the pressure is: the small area of a stiletto (e. g. Bursa prepatellaris).
heel will leave pits in a new wooden floor, whereas the larger area
of the flat sole does not.
Clinical remarks
Clinical remarks If overload, irritation or trauma cause a bursitis (inflammation
of a bursa), the bursa can become extremely enlarged, result-
In a Coxa valga (enlarged femoral neck angle), the pressure on ing in compression of adjacent structures (e. g. nerves) or re-
the joint increases and the surface exposed to it decreases. striction of movements. If the bursa communicates with a joint
This may cause an osteoarthritis. cavity, the inflammation can also affect the joint.

Auxiliary or accessory structures Ligaments

In several joints there are auxiliary or accessory intra-articular Ligaments (Ligamenta) consist of tight collagenous tissue. The
structures that are essential for the biomechanical function and the ­fibres are usually arranged in parallel. Ligaments can be flat or
range of motion of joints: string-like and form a connection of mobile skeletal elements. In
• Interposed discs addition to the tight ligaments of the locomotor system (e. g. the
– Disci articulares Lig. cruciatum anterius or anterior cruciate ligament in the knee
– Menisci articulares joint) there are thin, delicate connections between structures with-
• Joint lips (Labra articularia) in body cavities (e. g. the Lig. hepatoduodenale, a ligament be-
In addition, bursae (Bursae synoviales) occur, which form elastic tween liver and duodenum). The ligaments of the locomotor sys-
pads or cushions and enable the sliding of tendons and muscles tem occur as intra-articular ligaments (e. g. Lig. cruciatum ante­
against bone, as well as ligaments (Ligamenta) which reinforce the rius) within joints or as extra-articular ligaments outside the
capsule, guide or inhibit movements. joints (e. g. the Lig. collaterale fibulare, the lateral or outer collater-
al ligament of the knee joint). If ligaments are integrated into the
Intra-articular discs joint capsule, one speaks of intracapsular ligaments as opposed to
They can compensate for uneven areas (incongruence) of the artic- extracapsular ligaments, which are separated from the joint capsule
ulating joint surfaces and are exposed to compressive forces. They by loose connective tissue.

28
 1.4 Musculoskeletal system

Extracapsular ligaments are divided according to their function in: NOTE

Muscle origin and muscle attachment are arbitrarily determined.
• Reinforcing ligaments of the joint capsule, e. g. the Lig. pu- They must not be confused with the Punctum fixum and the Punc-
bofemorale at the hip joint tum mobile.
• Guiding ligaments, for the guidance of joint movements, e. g.
the Lig. anulare radii at the elbow joint
• Inhibiting or restricting ligaments, which limit joint move- It is not necessarily always the case that the Punctum fixum and
ments, e. g. the Lig. iliofemorale at the hip joint muscular origin match, because Punctum fixum and Punctum
Ligaments usually do not have just one, but several functions (of ­mobile can also change depending on the movement. Muscles on
the three mentioned above). the back of the thigh (ischiocrural muscles) can, for example, on
contraction cause either knee joint flexion (Punctum fixum and
muscle origin match) or in the case of a distal Punctum fixum­
1.4.4 General considerations on muscles ­support a backward tilt of the pelvis in the hip joint.

There are three different types of muscular tissue: Types of muscle

• Striated skeletal muscles There are several ways to grade muscles:
• Cardiac muscle • Arrangement of muscle fibres:
• Smooth muscles – parallel course of muscle fibres (to pulling direction of the
The striated skeletal muscles represent the active locomotor sys- tendon); extensive movements are possible with little force
tem. The skeletal muscles comprise approximately 300 muscles in- – pinnate, i.e. an oblique course of muscle fibres in a certain acute
cluding their tendons and muscle-specific connective tissue. Skele- angle (pinnate angle) to long, wide tendons, high muscle
tal muscles exist, apart from the axial system, in the tongue, pharynx, strength
larynx, in parts of the oesophagus and in the anal region. Each • Number of heads: 1, 2 or more heads
skeletal muscle consists of a varying number of muscle fibres, which • Differences according to joint involvement: depending on
are their smallest distinct structural units. whether a muscle is involved in movements in 1 or 2 joints or
Skeletal muscles actively move the bones of joints. Additional has no relationship to a joint, a distinction can be made between:
functions of muscles can be: – single joint muscles
• Stabilisation of joints (postural securing) – double joint muscles
• Tension banding (reduction of bending stress of long bones) – mimicry muscles (no joint involvement)
• Energy storage when stretched (attenuation in the joint with dy- • Shape: according to their form muscles are divided into (› Fig.
namic activity) 1.23):
– single-headed, parallel fibre muscles (M. fusiformis)
– two-headed parallel fibre muscles (M. biceps)
Clinical remarks
After strong, unusual loads (mostly in sports) the muscle tis-
sue can become disrupted. This is called a tear of muscle fi-
bres or in the case of a severe damage as muscle rupture (de-
pending on the extent of muscle damage). The muscles of the
thigh or lower leg are most often affected. It is differentiated
from muscle strain in which no macroscopic structural chang-
es with destruction of muscle cells and bleeding can be recog­
nised.
Muscle ache is a pain that occurs after physical exertion, espe-
cially after high stress of certain muscle parts. It is usually only
first detectable hours after the respective activity. It used to be
attributed to an acidification of the respective muscle by lactic
acid (lactate) but this has been refuted. This is caused by
a b c d
small microtears in the muscle fibrils with a subsequent in-
flammatory reaction.

Structure of skeletal muscle

Skeletal muscle can be differentiated into:
• Belly of a muscle (venter musculi): shaped differently
• Tendon (tendo musculi): transmits the muscle tension directly
or indirectly to the skeletal or connective tissue elements:
– Origin (Origo): original tendon, close to torso (proximal) e f g
­attachment point
– Attachment (Insertio): attachment tendon, far from torso Fig. 1.23 Types of muscles. a Single-headed muscle with parallel
fibres. b Two-headed muscle with parallel fibres. c Two-bellied mus-
(distal) attachment point cle with parallel fibres. d Multi-headed flat muscle. e Multi-bellied
– Fixation point: attachment site on an immovable skeletal muscle with tendinous intersections. f Unipennate muscle. g Multi-
­element pennate muscle.
– Mobile point: attachment site on a movable skeletal e­ lement

29
1 General anatomy

– two-lobed, parallel fibre muscles (M. biventer) Tendon attachment zones

– multilobed, flat muscles (M. planus) Tendon attachment zones are present to adapt the different elas-
– multilobed muscles divided by intermediate tendon (M. inter- ticity modules of connective tissue, cartilage and bone to each oth-
sectus) er, to avoid detachment or tearing of the tendons in the attachment
– semipennate muscles (M. semipennatus) area. You can imagine this as a spring embedded in the insertion
– multipennate muscles (M. pennatus) area. According to the structure and the position, a distinction is
made between 2 types of tendon attachment zones (› Fig. 1.24):
Tendon • Chondral apophyseal attachment zones: They occur in all
Tendons are constructed of dense parallel fibrous connective tissue muscles, which insert in areas of previous cartilaginous apophy-
and have special facilities at the muscle-tendon transition, as well as ses and also in some other muscles (e. g. the tendons of the mas-
in the area of the attachment zones to the skeleton. They are extreme- ticatory muscles on the skull skeleton). It is characteristic that
ly tear-resistant, elastic and can be plastically deformed. At the same fibrous cartilage is embedded at the insertion site, of which the
time, however, they can only be slightly stretched (5–10 %). They layer directly covering the bone is mineralised. In the area of in-
have the function to transfer the force created in the contraction of a sertion the periosteum is missing and the collagen fibres pene-
muscle to the skeletal elements. The transfer of the force takes place trate into the bone.
mainly at the muscle-tendon transition. The shape of the tendons dif- • Periosteal diaphyseal attachment zones: They are typical for
fers from muscle to muscle. Some tendons are so short that they can- the diaphyses of the long bones. The collagen fibres of the planar
not be seen macroscopically (fleshy attachment), while others are ex- tendons radiate into the periosteum and anchor the tendon into
tremely thin and flat, so that they are referred to as aponeuroses. the cortical bone. In this way, the force is transmitted over a very
large area. In some cases the collagen fibres penetrate directly
Types into the bone. At this point, the periosteum is missing. Periosteal
From a structural and functional point of view, a distinction is diaphyseal attachments are characterised by roughness (tuberos-
made between tension tendons and sliding tendons: ities) to the bone.
• Tension tendons are located in the main direction of the muscle
and are exclusively used in tensile stress. They have the typical
tendon structure.
Clinical remarks
• Sliding or pressure tendons change their course direction by Overloading of chondreal apophyseal tendon attachment
pulling around a bone or a connective tissue structure. The zones can lead to degenerative changes with pain in the area
bone/connective tissue structure is used as a pivot point (hypo- of the attachment zone (e. g. tennis elbow). In periosteal di-
mochlion). On the side facing the bone/connective tissue struc- aphyseal tendon attachment zones, increased bone formation
with pain sometimes occurs (e. g. in the area of the Achilles
ture, strain is placed on the tendon under pressure and slides at
tendon insertion at the heel bone as calcaneal spur or in the
this point. Fibrous tissue at the deflection point is stored in the insertion area of the quadriceps femoris muscle to the patella
tendon. as patellar tip syndrome).

Muscle-tendon transition
The myotendinous zone is the connection between the muscle
­fibre and the collagen fibres of the origin and attachment areas. It is Auxiliary equipment for muscles and tendons
characterised by an extensive surface enlargement (factor 10) of All muscles and tendons need additional structures to varying de-
the cytoplasmic membrane at the muscle fibre end. In the area of grees, to
surface enlargement the basal membrane of the muscle fibre is sur- • adapt to the environment
rounded by a microfibre network (thin collagen fibres). The fibrils • to protect against mechanical damage
of the network interlace internally with microfibres of the tendon • to prevent friction losses and to reduce
and create a fixed anchorage. • power loss.

Bones Mineralized fibrous cartilage

Mineralised fibrous cartilage

Fibrous cartilage Surrounded by cartilage

cells of proteoglycans

Tendon (parallel fibrous)

Muscle

Collagen fibres Tendon (parallel fibrous)

Muscle Elastic fibres

(attenuation of tensile strength)

Periosteum
a b c Bones

Fig. 1.24 Structure of tendinous insertions or attachment zones. a Chondroapophyseal attachment zone. b Schematic drawing of a chon-
droapophyseal attachment zone with chondrocytes, proteoglycans and collagen fibres. c Periosteal-diaphyseal attachment zone. [L126]

30
 1.4 Musculoskeletal system

Additional structures are: Stratum fibrosum

• Fascia (connective tissue sheath) Stratum synoviale,
Vagina
• Retinacula (connective tissue retaining ligaments) Pars parietalis
synovialis
Vagina
• Tendon sheaths Stratum synoviale, tendinis
tendinis
Pars tendinea
• Bursa
• Sesamoid bones
(Cavitas synovialis)
Mesotendineum
Fascia
The fascias, which are also known as muscular facias are sheaths Tendo
made of collagen connective tissue which surround individual Epiten-
dineum
muscles, several muscles (muscle groups) and tendons like a sheath
or a stocking. Fascias can be considered as an outer layer of the
musculature. The fascias allow the muscle to contract almost invis-
ibly without the surrounding tissue also contracting.
A distinction is made between:
Phalanx media
• Single fascia: enveloping a muscle
• Group fascias: encasement of several muscles of a muscle group
(but each individual muscle of the muscle group has its own in- Fig. 1.25 Structure of a tendon sheath.
dividual fascia)
• Body fascia: originate from the general body fascia (superficial sheaths are comparable in their design to joint capsules (› Fig.
fascia) and cover the underlying muscles (which are already in- 1.25). The inner tendon sheath sheet (Stratum synoviale, Pars
serted into individual and group fascias) tendinea) is fused with the tendon, the outer tendon sheath sheet
(Stratum synoviale, Pars parietale) with the fibrous layer of the
NOTE tendon sheath. In the gliding space (Cavitas synovialis) a fluid
Group fascias form the interosseous membrane or the intermuscu- comparable to synovial fluid is emitted. Small blood vessels guar-
lar septum (also a fascia) osteofibrous channels, especially in the antee the nourishment of the tendon via small ligaments of the me-
area of the lower leg of the lower extremities, together with the sotendon (Vincula brevia and longa) into the tendon.
periosteum of the adjacent bones in which single muscle groups
lie. They are referred to as fascial compartments. Each muscle
group is supplied by independent blood and lymph vessels. Clinical remarks
The importance of fascias for the body is greater than generally as-
sumed. Consequently fascias led a shadowy scientific existence. Overuse can lead to painful tenosynovitis (inflammation of
Only in the last few years have they increasingly become the goal of the tendon sheath) that is particularly common on hands and
scientific focus. Because they are innervated, pain can also be feet. A tenosynovitis stenosans (stenosing tenosynovitis) is
transmitted through them. Paramedically, there are now trends to- characteristic of overuse of hand flexor muscles. It is especial-
wards ‘fascial fitness’. ly common in activities with a stereotypic movement, e. g.
tradespeople, athletes, piano players or frequent long-term
work on a computer keyboard (is sometimes recognised as an
Clinical remarks occupational disease). The overload leads to minor injuries in
the tendon, which the body attempts to repair with an inflam-
Injuries of the blood vessels for individual muscular compart- matory reaction. The associated swelling of the tendon con-
ments in the context of major trauma (e. g. traffic accident) stricts the tendon sheath (Tenosynovitis stenosans) and leads
may cause a collection of effluent blood in the respective mus- to the formation of tendon nodules, which for every finger flex-
cle compartment (osteofibrous canal) and compression of the ion has to pass through small circular ligaments (ring liga-
(muscle) tissue. This is referred to as compartment syndrome ments, Ligg. annularia, affixing the tendon sheaths on the
(compartment = muscle group). If the osteofibrous canal is not bone) and can be trapped there. This secondarily gives rise to
relieved (opened) as soon as possible, the muscle tissue can the phenomenon of ‘trigger finger’.
be irreversibly damaged.

Bursa
Retinacula The pressure elastic bursae facilitate the sliding of tendons and
Retinacula are connective tissue retaining ligaments for tissue lay- muscles over bones and tendons (› Chap. 1.4.3).
ers or organs. In the extremities they ensure e. g. on the hand or
foot joints that the tendons do not become detached from the Sesamoid bone
bones in muscle contraction. You can look at it as a belt that keeps Sesamoid bones (Ossa sesamoidea) are bones which are stored in
them in their typical position. tendons and functionally protect the tendon
• against too much friction or
Tendon sheaths • extend the lever arm and thus save muscle strength.
A tendon sheath (Vagina tendinis) encloses a tendon everywhere They emerge in the sense of a functional fit of tissue in the area of
where it runs directly on the bone or is deflected (hypomochlion). pressure tendons. Examples are the kneecap (Patella) or the pisi-
It protects the tendon and enables improved gliding. Tendon form bone (Os pisiforme) of the wrist.

31
1 General anatomy

FS ≈ FM Levator scapulae muscle

Rhomboid minor muscle Clavicula

Rhomboid major muscle Scapula

α Humerus
FM FT (vertical)
FT (transverse) α
Vertebra
Fig. 1.26 Muscle work. Transfer
of muscle force on tendon force
FT (transverse) = FM · sin α depending on the orientation of
FT (vertical) = FM · cos α muscle fibres in relation to the
tendons.

General muscle mechanisms Muscle cross-section

Muscle activation and coordination A distinction is made on the muscle between an
The central nervous system coordinates movements by sending • Anatomical cross-section (is perpendicular to the main line in
pulses along the peripheral nerves to muscles. As a rule, several the thickest part of the muscle) and a
muscles will be addressed at the same time, which support a cer- • Physiological cross-section (is identical with the cross-sectional
tain movement in the same direction (synergists) or their counter- area of all muscle fibres and therefore a measure of the absolute
acting (antagonists). An activation of the synergists is paired with contraction force of all muscle fibres).
inhibition of antagonists. Physiologically the nerve impulses con- Anatomical and physiological cross-sections only rarely match
stantly reach the muscles and ensure that some of the muscle fibres (only in the case of parallel fibrous and spindle-shaped muscles).
are in the contraction state. Consequently, tension is built up,
which is designated as basic tone (resting tone). Lever arm and muscle activity
The visible contraction of a muscle commences only when an ini- For understanding the muscle work it is also necessary to include
tial resistance against the tone of the antagonists is overcome. Ini- the distance of the insertion point of the tendon from the joint piv-
tially only the tension condition increases in the muscle, without ot point in the considerations. In simple terms the necessary power
shortening of the muscle fibres (isometric contraction). Only then can be estimated with lever principles and the extent of the move-
does a shortening of the muscle fibres (isotonic contraction) occur ment can be determined. As with a lever,
at the same level of tension that leads to visible movement. • Load arm (body section to be moved),
• Force arm (muscles acting on the joint with their tendons) and
Muscle work • Pivot point (at the joint)
Lifting force/lifting height can be defined on the skeleton. The amount of force a muscle can
The work of a muscle depends on transfer to a joint depends on the length of the respective lever
• its power development (lifting force) and (vertical distance of the vector force of the muscle to the rotational
• the extent of its reduction (lifting height) axis of the joint = force arm) (› Fig. 1.27). The length of the lever
and can be calculated using the simple formula: work = force (F) × varies depending on the joint position and is known as virtual le-
distance. The force is referred to as a lifting force, the path as a lift- ver arm. The torque of a muscle is calculated according to the sim-
ing height. ple formula: Torque = Force (F) × virtual lever arm.
• Lifting force: It depends on the physiological cross-section (to-
tal cross-section) and from the pennate angle (the angle through
which the muscle fibres insert in the tendon, see above).
• Lifting height: It depends on the length of the muscle fibres and (Origin)
on the pennate angle. Fascia
There is a direct proportional relationship between muscle force Caput
and physiological cross-section of the muscle (lifting force of a
muscle relative to the cross-section of all muscle fibres positioned Line of action of the muscle
perpendicular to the direction of fibres): if the tendon of the mus-
cle runs parallel to its tension direction (e. g. M. levator scapulae, Venter
› Fig. 1.26), the complete momentum generated (absolute muscle
Tendo Virtual lever
force) is transferred to the tendon. Thereby, the muscle force (FM ) of the muscle
and the tendon force (FT) are nearly identical. If the muscle fibres (Insertion)
are at an angle to the tension direction of the tendon (e. g. Mm. Rotation axis
rhomboidei major and minor, › Fig. 1.26), only a part of their con- of the joint
traction force is transferred to the tendon. Thereby the vertical ten-
don force (FT [vertical]) compared to the muscle force (FM) is re-
duced by the factor cos α and the transverse tendon force
(FT [transversal]) is reduced by the factor sin α. Fig. 1.27 Basic structure of a skeletal muscle.

32
 1.5 Circulation systems

One-armed
lever Humerus
Scapula
M. biceps Caput longum
brachii Caput breve

Two-armed
lever Caput laterale
M. triceps
Caput longum
brachii
Caput mediale

M. brachialis

Radius Ulna Fig. 1.28 Lever arm and muscle

action. [L126]

For skeletal components to be moved around a rotational axis of a • Prenatal (or fetal) circulation
joint, a muscle must, as described, use an anatomical (= existing) • Lymphatic circulation
lever arm to generate torque. The length of the lever arm depends
on the distance between the muscle attachment and the centre of
rotation of the joint. Thus, e.g. the M. brachioradialis has a long 1.5.1 Body and pulmonary circulation
and the M. brachialis a short anatomical lever arm, when the arm
is moved towards the torso (› Fig. 1.28). If a muscle engages a Blood
single arm lever, the skeletal element is moved in the tension di­ Blood is the most important means of transport for gases, active
rection of the muscle (e. g. M. brachioradialis, M. biceps brachii, substances, nutrients, waste materials and warmth. It is a liquid tis-
M. brachialis, › Fig. 1.28). In the case of two-arm l­ evers, the sue. In the adult, the blood volume is between 4 and 6 l. Approxi-
­muscular attachment point is moved in the tension d ­ irection of the mately 44 % are solid components (cells). The most frequent type
muscle and the main part of the skeletal element is shifted in the of cell is the erythrocyte (red blood cells), used for gas transport
opposite direction (e. g. M. triceps brachii, › Fig. 1.28, see › Fig. (O2 and CO2). In second place are the thrombocytes, which act
1.27). within the framework of blood coagulation (platelets). Leukocytes
(white blood cells) describe a heterogeneous group of 5 different
Work and performance types of nucleated cells in the blood, which undertake all functions
The product achieved from lifting height and lifting force is the within the framework of the immune system (3 groups of granulo-
mechanical work of a muscle and is measured in joules. The work cytes, monocytes and lymphocytes). They use the blood only as a
a muscle performs per unit time is measured in watts. means of transport and are all capable of actively leaving the vas-
cular system and thus leave the blood through amoeboid move-
Active and passive insufficiency ment to actively arrive at their deployment site in the surrounding
If a muscle is already fully reduced but the joint function has not tissue.
yet reached the final position that would be possible via the maxi-
mum contraction of the muscle, one speaks of active insufficiency. Blood vessel system
Therefore, e. g. the knee joint cannot be bent above 125° (in neutral Blood is transported in a tube system made of blood vessels. The
zero position in the hip joint). Only when there is additional flex- motor for the continuous blood flow is the heart which is divided
ion in the hip joint can 140° be achieved. into a left and a right ventricle. The left ventricle serves the body
Passive insufficiency is when a muscle is prevented from achieving circulation, which supplies the individual organs with blood and
an active joint position due to its limited stretching (the muscle the right ventricle drives the pulmonary circulation for deposition
could shorten further but this is prevented by its antagonists). of CO2 and the intake of O2 (› Fig. 1.29).
Therefore, e. g. in a flexed wrist the fist cannot be closed.
Circulation
The heart is a muscular hollow organ. For each heart contraction
1.5 Circulation systems approximately 70 ml of blood are pumped from the heart ventricles
into each artery. For the left ventricle this is the main artery (aorta)
Warmth, gases, nutrients, metabolic end products, hormones, and for the right ventricle the pulmonary trunk from which the left
among other things, and immune cells must be distributed in the and right pulmonary arteries emerge. The permanent branching of
body. To ensure this, the body has different circulation systems: the main vessels creates increasingly smaller arteries and finally,
• Body circulation ­arterioles accomplish the transition into a capillary network, in
• Pulmonary circulation which material and gas exchange takes place. The return transport
• Portal vein circulation of the blood from the capillary network is carried out via venules

33
1 General anatomy

Pulmonary circulation the right atrium into the right ventricle) and the circulation cycle
(“small circulation”) starts again. Arterioles, capillary system and venules are jointly
­referred to as terminal vessels. Together they form the main
cross-sectional area of the vascular system. In the region of the ter-
Lymphatic trunks minal vessels in which the exchange of substances and fluid volume
dicharging into
venous angle shifts occur, more fluid leaves the vessel bed than is reabsorbed so
that only approximately 98 % of the fluid volume sent by the heart
into the body and pulmonary circulations is returned to the venous
system. The missing 2 % is drained via the lymph circulation and
thus takes a short cut just before the heart back into the venous
Head, upper arm of the bloodstream and thus back into the blood circulation.
extremities

High-pressure and low-pressure systems

According to the blood pressure, the circulation system is differen-
Truncus tiated into the high-pressure system (left heart chamber and arter-
pulmonalis
ies) and low-pressure system (capillaries, veins, right heart, lung
Vv. cavae circulation and left atrium). In the high-pressure system the blood
Aorta
pressure (RR = after RIVA-ROCCI) under physiological conditions
Ductus
thoracicus is between 60 and 130 mmHg (millimeters of mercury) and in the
Vv. hepaticae low-pressure system the blood pressure at the heart level is be-
tween 9 and 12 mmHg.
Liver
Vasa publica and Vasa privata
V. portae
Some organs, e. g. the lungs or liver, have 2 independently func-
tioning vessel systems:
Vessels of • Vasa publica: these vessels have a function for the whole body
stomach, circulation (in the lungs they are responsible for gas exchange –
intestines,
pancreas,
Aa. and Vv. pulmonales).
spleen • Vasa privata: these vessels are responsible for the specific organ
The lymphatic blood flow (in the lungs they serve the blood supply to the lung
system of the tissue – bronchial arteries).
intestine In the case of other organs (e. g. renal arteries) the arteries have a
(chyle vessels)
dual function and operate simultaneously as Vasa publica and Vasa
privata.
Renal vessels
Heart
The heart is the muscular pump for blood circulation. It conducts
rhythmically coordinated muscle contractions. The muscles consist
of specialised heart muscle cells. The muscle contractions create
pressure in the chambers of the heart, which is guided in one direc-
tion (from the atria into the ventricles and from the ventricles into
the arteries) by the opening and closing of cardiac valves between
Pelvic vessels
the atria and the chambers of the heart and between the chambers
of the heart and the connected arteries (aorta, pulmonary trunk).
Lymph nodes
The heart contraction is called systole; the relaxation phase is
called diastole.
Lymph vessels
Heart wall
Lower The heart wall consists of three layers:
extremi- • Endocardium: endothelium (coated inner layer) and connective
ties
tissue
Body circulation • Myocardium: Cardiac muscle and connective tissue
(“large circulation”) • Epicardium: Connective tissue and mesothelium (specialised
outer layer)
Fig. 1.29 Systemic and pulmonary circulation. The heart is located in a heart sac (pericardium). There is a capil-
lary gap between the epicardium and the pericardium (serous cavi-
and then continuously larger veins, which transport the blood ty, › Chap. 1.6.3).
from the body circulation via the upper (Vena cava superior) and
lower vena cava (Vena cava inferior) into the right atrium and from Heart valve
the pulmonary circulation via the pulmonary veins into the left Each heart ventricle has 2 openings (ostia) in which the heart
atrium. Finally, the blood from the atria goes back into the respec- valves (› Table 1.8) are located – one to the corresponding atrium
tive ventricle (from the left atrium into the left ventricle and from and the other to the corresponding artery. The valves between the

34
 1.5 Circulation systems

atria and ventricles are referred to as atrioventricular valves. They Structure

are named according to their structure as sail valves (on the left mi- In this respect, arteries and veins principally have the same struc-
tral valve, consisting of 2 sails on the right the tricuspid valve, ture. The wall of the larger vessels consists from the inside to the
consisting of 3 sails). The valves to the arteries (aorta, pulmonary outside of three layers:
trunk) are pocket flaps (on the left the aortic valve with 3 pockets • Tunica intima (intima, inner layer): this flat endothelial cell lay-
and on the right the pulmonary valve with 3 pockets). All 4 ostia er is separated from the internal elastic membrane by a basal
for the valves are located on a common level (valve level), in which membrane. The former is substantially stronger in arteries than
the connective tissue of the heart skeleton is also located, which in veins.
serves as a fixation point for the cardiac muscle. • Tunica media (media, middle layer): a layer of coats of smooth
The heart valves open and close depending on the prevalent pres- muscle cells, which in the case of arteries are of the elastic type
sure gradient (› Table 1.9). In the case of closure of the heart (see below) containing strong networks of elastic fibres. The
valves the free edges of the sail and pocket flaps are close to each smooth muscle cells regulate the vessel cross-section by contrac-
other. In contrast to the pocket flaps, the sail flaps have a holding tion and thus the resistance to flow. This is joined on the outside
apparatus of papillary muscles (Mm. papillares), which are at- to an external elastic membrane.
tached via tendon cords (Chordae tendineae) to the free under- • Tunica adventitia (Adventitia, Tunica externa, outer layer): it
side of the sails and prevent penetration. In contrast, the pocket contains collagenic connective tissue, which incorporates and
flaps work as non-return valves. anchors the blood vessel in the surroundings. Nerves, and in the
case of vessels with a large diameter, blood vessels run here for
Arteries and veins the blood supply of the vessel (Vasa vasorum).
The blood vessel system occurs macroscopically as a tubular net-
work of arteries and veins, which is distributed throughout the NOTE
body (› Fig. 1.30). The naming of the blood vessels depends on Arteries typically have roughly the same circumference as veins.
the direction of the blood flow in relation to the heart. Arteries Their wall is, however, significantly thicker and the lumen is conse-
transport blood from the heart to the periphery of the body or the quently smaller.
lungs (› Fig. 1.30a) and veins transport blood from the peri­phery
of the body or the lungs back to the heart (› Fig. 1.30b). The wall of arterioles, capillaries and venules shows an alternative
structure. Here we refer to textbooks on histology and to textbooks
on physiology with respect to the pressure conditions in the
­individual vessels, vessel number, vessel diameter, vessel motility
Table 1.8 Heart valves. (vasomotor), vascular resistance and cross-sectional area.
Some vessels have special facilities within the vascular system (e. g.
Valve type Name Number of Position the liver sinusoids). Here, too, we refer to textbooks on histology.
cusps or In some regions of the body or organs, the capillary bed can be cir-
leaflets
cumvented. Here, arteries and veins are directly linked with each
Atrioventricular Mitral valve (Valva 2 Between left atrium other (arteriovenous anastomoses). These play a large role e. g. in
valves atrioventricularis and left ventricle the skin for thermal regulation.
sinistra)
Tricuspid valve 3 Between right atrium Arteries
(Valva atrioven- and right ventricle Due to their histological structure a distinction is made between:
tricularis dextra)
• Arteries of the elastic type: in these arteries (e. g. aorta, arteries
Semilunar Aortic valve (Valva 3 Between left ventricle near the heart) the elastic wall structure is used to store a part of
valves aortae) and aorta the energy occurring during systole in the form of passive wall
Pulmonary valve 3 Between right ventri- distension for a short time and then release it again when re-
(Valva trunci pul- cle and Truncus pul- turning to the starting position (windkessel function). This en-
monalis) monalis
sures that the discontinuous blood flow initially resulting due to
the heart contraction is converted into a more continuous blood
Table 1.9 Cardiac action. flow.
• Arteries of the muscular type (most arteries, e. g. brachial ar-
Cardiac Phase Heart valves, Semilunar valves
tery, femoral artery).
action AV-valves
• Contractile arteries: these specialised arteries have an irregular-
Systole Contraction phase of the Closed Closed ly grouped longitudinal muscle layer. The intima bulges into the
ventricular myocardium
vessel lumen and on contraction is able to reduce or stop the
Ejection phase of the ven- Closed Open blood flow to the downstream areas. They occur, e. g. in the gen-
tricular myocardium ital organs (e. g. cavernous body of the penis).
Diastole Relaxation phase of the Closed Closed There is a gradual transition between the arteries of the elastic and
ventricular myocardium those of the muscular type. The arteries of the muscular type be-
Filling phase (relaxed ven- Open Closed come increasingly smaller in the body periphery, form an increas-
tricular myocardium) ing number of branches and eventually reach the capillary bed via

35
1 General anatomy

Temporal pulse
Facial nerve pulse
A. carotis interna A. carotis communis
A. carotis externa A. subclavia
Carotid pulse Arcus aortae
Truncus brachiocephalicus Pars ascendens aortae [Aorta ascendens]
A. axillaris Cor
A. brachialis Pars descendens aortae [Aorta descendens],
Brachial pulse Pars thoracica aortae [Aorta thoracica]
A. profunda brachii Truncus coeliacus
Cubital pulse A. mesenterica superior
A. ulnaris A. renalis
A. interossea communis Pars descendens aortae [Aorta descendens],
Pars abdominalis aortae [Aorta abdominalis]
A. radialis
A. testicularis*
Radial pulse
A. mesenterica inferior
Ulnar pulse
A. iliaca communis
Aortic bifurcation
A. iliaca externa
A. femoralis A. iliaca interna
A. profunda femoris Femoral pulse

A. poplitea
Popliteal pulse

A. tibialis posterior
A. tibialis anterior

A. fibularis
Posterior tibial pulse
A. dorsalis pedis Dorsalis pedis pulse

V. jugularis externa
V. jugularis anterior
V. jugularis interna V. brachiocephalica sinistra
V. brachiocephalica dextra V. subclavia
V. azygos V. cava superior
V. axillaris V. thoracica interna
Cor Vv. hepaticae
V. cephalica V. portae hepatis
V. basilica V. renalis
Vv. brachiales
V. testicularis sinistra*
V. mediana cubiti
V. splenica
V. testicularis dextra*
V. mesenterica inferior
V. iliaca communis
V. mesenterica superior
V. iliaca interna
V. cava inferior
V. iliaca externa

V. femoralis
V. femoralis
V. profunda femoris
V. saphena magna V. poplitea

V. saphena parva

V. tibialis anterior
Fig. 1.30 Arteries and veins of
V. tibialis posterior
the systemic circulation. a Arter-
ies; * in women: A. ovarica.
b Veins; deep veins are shown
on the left arm and the left side
of the head, superficial veins on
b the right arm and the right side
of the head.

36
 1.5 Circulation systems

arterioles (smallest arteries). The wall structure of the arterioles NOTE

The venous return flow to the heart is guaranteed by:
makes a significant contribution to the maintenance of blood pres- • Venous valves (responsible for the directional return flow)
sure. They constitute in their entirety approximately half of the pe- • The arterial pulse running through the arteries, which compresses
ripheral resistance. the walls of the accompanying veins (arteriovenous coupling)
• Contraction of the surrounding muscles (muscle pump), which al-
NOTE so leads to compression of the walls of the veins
In many parts of the body, large and medium-sized arteries run • Suction effect of the heart (only near the heart)
near the body surface. Here, the delayed heart contraction can be • Pressure differences in the chest (during inhalation and exhala-
palpated as a pulse (› Fig. 1.30a) by gently pressing the artery tion)
against a harder underlying structure (e. g. bone). The palpable
pulse most distal and thus farthest from the heart is the pulse of
the dorsalis pedis artery on the arch of the foot. Palpation of the Clinical remarks
pulse provides numerous indications, e. g. on the frequency of the
heartbeat, on possible circulation differences in the upper and low- Defects of the venous valves in the connecting veins between
er extremities or, more generally, on the state of the blood circula- the superficial and the deep venous system of the lower extrem-
tion in a body section. ities lead to the formation of varicose veins (varices), which can
be distinguished on the leg from the outside as greatly expand-
ed and tortuously running vessels under the skin.

Veins
Veins transport blood from the periphery of the body and the
lungs back to the heart. Their wall is easily expandable and pro- Some veins have a specialised structure:
vides a reservoir function. The veins of the systemic circulation • Capacitance veins: These are venous sections with very thin
transport deoxygenated blood and those of the lung circulation media, while at the same time having a large cross-section. They
transport ­oxygenated blood. Most veins are concomitant to arter- can store large volumes of blood, are usually downstream of con-
ies, i.e. they run parallel to corresponding arteries (accompanying tractile arteries and play a role for cavernous bodies (e. g. in the
veins). Overall, the course of veins is much more versatile than nasal mucosa/nasal conchae or the efferent tear ducts).
that of arteries and can show great individual variation. However, • Jugular veins: Just like contractile arteries they have (see above)
the large vein stems occur regularly in all people. Veins together irregularly grouped longitudinal muscle bundles in the media.
with capillaries and venules belong to the low pressure system of They are often downstream of capacitance veins but also occur
the blood circulation (see above). Since in an upright position most independently (e. g. in the adrenal medulla). In the case of mus-
veins have to transport the blood to the heart against gravity, the cle contraction the blood flow is reduced or stopped, so that the
larger veins of the extremities and the lower neck region have ve- blood in the upstream vessel sections is staunched.
nous valves (› Fig. 1.31), which support the venous return flow.
They ensure that the blood flow is only possible in the direction of
the heart. Venous valves are opposing bag-shaped projections of 1.5.2 Portal vein circulation
the intima (intima duplicators). They open in the case of blood
flow towards the heart and when the blood flow returns due to the The portal vein circulation (› Fig. 1.32) holds a special position
pressure conditions, blood flows into the pockets and closes them. within the systemic circulation. It is used to supply nutrients to the
Most of the body sections have a superficial venous system in the liver for further metabolism by the shortest routes via the gastroin-
subcutaneous fat tissue and a deep venous system, running mostly testinal tract. For this purpose, the blood of the unpaired abdomi-
parallel to the arteries. Both venous systems are interconnected via nal organs (stomach, gut, pancreas, spleen) is not directly fed to the
short veins but the venous blood only flows in a superficial to deep body through veins, but is taken from the capillary system to an
direction, as venous valves stipulate the flow direction in the con- interim switched venous system, draining the blood into the portal
necting veins. vein, which leads directly into the liver. After this blood has flowed
through the liver (and the nutrients have been metabolised), it en-
ters the inferior vena cava and thus back into the body circulation.

Clinical remarks
In the context of various diseases (e. g. alcohol abuse), cirrho-
sis of the liver can develop. The normal blood flow from the
Sinus valvulae Sinus valvulae
portal vein into the liver is disrupted and blood backs up into
the portal vein and the veins upstream of the portal vein. The
portal vein pressure is increased. The body tries to compen-
Valvulae venosae sate for the increased pressure via bypass circuits. In doing
so, the blood is drained via portacaval anastomoses (connec-
tion routes between portal vein and the superior and inferior
vena cavae) past the liver. However, the veins in the anasto-
motic region are inadequate for the increased blood flow and
are widened in a varicose manner. These varicose veins (ex-
tended, tortuously running veins) can arise:

Fig. 1.31 Venous valves.

37
1 General anatomy

V. azygos V. hemiazygos

(Plexus venosus submucosus)

V. phrenica inferior

V. hepatica
(R. oesophagealis)

V. gastrica sinistra

V. portae hepatis
V. splenica [lienalis]

V. renalis sinistra
V. mesenterica
V. lumbalis ascendens
superior
V. mesenterica inferior
V. paraumbilicalis

V. cava inferior
V. colica sinistra
V. epigastrica
superficialis
V. iliaca communis
V. sigmoidea

V. epigastrica inferior V. rectalis superior

V. iliaca interna

Vv. rectales inferiores Fig. 1.32 Portal vein circula-

tion.

• at the transition from the stomach to the esophagus (sub- Table 1.10 Structures of the prenatal circulation.
mucosal esophageal varices can be easily damaged during
food intake and lead to life-threatening bleeding). Shunt Prenatal Postnatal
• In the veins around the navel (paraumbilical veins), whereby Between right and left Foramen ovale Fossa ovalis in the atrial
the image of a so-called caput medusae (Medusa’s head- atrium septum
from Greek mythology) emerges.
Between pulmonary trunk Ductus arteriosus Lig. arteriosum
• In the anal canal.
and aortic arch (BOTALLI)
Between portal vein and Ductus venosus Lig. venosum
inferior vena cava (ARANTII)

1.5.3 Prenatal circulation
Clinical remarks
The prenatal circulation is different from the circulation after birth If the foramen ovale closes only partially or not at all a left-to-
(› Fig. 1.33). Before birth, nutrients and oxygen are taken up via right shunt is formed after birth when the blood flows in the
the umbilical cord through the placenta and metabolic products reverse direction. These shunts are among the most common
are delivered in a reverse way. The lungs of the unborn child are congenital heart defects.
not yet ventilated and there is still no gas exchange. The pulmonary
circulation is therefore almost entirely disconnected from the body;
the blood is routed past the lungs via short circuits (› Table 1.10).
The majority of the blood flows through a connecting opening in
the atrial septum (Foramen ovale) directly from the right into the 1.5.4 Lymphatic circulation
left atrium and therefore circumvents the lungs. A further part is
taken from the pulmonary trunk, which joins the right ventricle, The lymphatic circulation is in addition to the systemic circulation
via a connecting shunt (Ductus arteriosus) into the aortic arch and a system of tubes (lymph vessels) that transports lymph. It begins
also circumvents the lungs. Since the liver is not yet fully matured, blind with lymph vessels in the interstices, which absorb approxi-
the blood is transported for the most part via another short circuit mately 2 % of the fluid emitted by the capillary system of the blood
(Ductus venosus) from the umbilical vein directly into the inferior circulation, and lead through the lymph vessel system and the
vena cava. Immediately after birth the foramen ovale closes and the ­venous arm of the blood circulation again before entering the
ductus arteriosus (BOTALLI) and the ductus venosus (ARANTII) ­superior vena cava. Lymph nodes are integrated into the lymphatic
obliterate. Now the blood flows through the pulmonary circulation circulation, which have to be traversed by the draining lymphatic
and through the liver. fluid (lymph). They are used for immune defence.

38
 1.5 Circulation systems

Lig. arteriosum*

Arcus aortae

Fossa ovalis Ductus arteriosus**

V. cava superior Truncus pulmonalis

Atrium sinistrum
Foramen ovale
Pulmo sinister
Pulmo dexter
Atrium dextrum
Ventriculus dexter Ventriculus sinister
V. cava inferior Hepar
V. cava inferior
Lig. venosum****
Ductus venosus***
Pars abdominalis aortae
[Aorta abdominalis]
V. umbilicalis
V. cava inferior V. portae hepatis
Fig. 1.33 Prenatal cardiovas-
Lig. teres hepatis
Placenta cular system;
Vesica biliaris [fellea] * Ligament BOTALLI,
Funiculus umbilicalis
** Ductus arteriosus BOTALLI,
Aa. umbilicales *** Ductus venosus ARANTII,
**** Ligament ARANTII.

Lymph vessel system The major part of the lymph is drained by the Ductus thoracicus
The lymph vessel system is a system comparable to the blood vessel into the left venous angle (between the Vv. jugularis interna sinistra
system from vessels that are coupled together (see below). and subclavia sinistra, › Fig. 1.34). In contrast, the lymph of the
right upper quadrant of the body drains via the Ductus lymphati-
Functions cus dexter into the right venous angle (between the Vv. jugularis
Functions of the lymph vessel system are: interna dextra and subclavia dextra) (› Fig. 1.34).
• Liquid transport: transport of a part of the liquid overflowed To enable a directional lymph flow to the feeder centres above the
from the capillaries into the interstices (including substances heart into the venous vascular system, lymph collectors and lymph
dissolved in it ) as lymph back into the venous arm of the sys- vessels have pocket flaps (lymph vessel valves); the structure is ba-
temic circulation sically the same as the venous valves. The wall of the lymph vessels
• Fat transport: transport of fats resorbed in the gut as chyle and consists, like the wall of the veins, of:
transferred to the venous arm of the systemic circulation • an endothelial cell layer (Intima)
• Immune defence by interpositioned lymph nodes • a muscular layer (Media)
Chyle (milk juice) is the fat-rich milky lymph coming from the gut • a surrounding adventitia (Externa)
(the resorbed dietary fat is transported in the form of chylomicrons However, the media is much thinner than in the veins. The lymph
not in the blood but in the lymph in contrast to carbohydrates and is transported within the vascular system by both muscle contrac-
amino acids). tion of the media and as in the veins through the arterial pulse
wave, the muscle pump of the skeletal muscles and the suction ef-
Structure fect of the thorax when breathing (› Chap. 1.5.1).
The lymph vessel system starts with lymph capillaries (Vasa lym-
phocapillaria), which form networks similar to the blood capillar- Lymph nodes
ies in interstitial tissue of most organs (exception: central nervous In the human body there are up to 1000 lymph nodes, which are
system, cartilage, bone marrow). The lymph capillaries are blind incorporated in the lymph vessel system. Within the lymph node
incipient tubes, which are anchored in the surrounding tissue so there is a compartmentalization into cortex and medulla. Every
that they are opened by the tension from the connective tissue or
pressure from the interstitial fluid. From the capillary system the Table 1.11 Large lymphatic trunks.
vessels enlarge on a continuous basis. These are joined to:
• Lymph collectors (collection vessels) Lymphatic trunk Localisation Drainage area
• Lymph vessels: Vasa lymphatica, transport vessels, and interme- Truncus jugularis Cranial neck region Head
diary lymphoid organs, which are responsible for the filtration of
Truncus subclavius Lateral neck region Arm, chest (or thoracic)
a body region (regional lymph nodes) or receive the lymph of wall, back
various other lymph nodes (collection lymph nodes)
Truncus bronchomedi- Mediastinum Thoracic organs
• Lymphatic trunks (Trunci lymphatici, › Table 1.11) astinalis
• Large lymphatic trunks (they lead the lymph into the venous
Trunci intestinales Radix mesenterii (root of Gut
blood vessel system of the systemic circulation; at the confluence
the mesentery)
of the lymph vessel trunks from the lower body [lumbar trunk]
into the thoracic duct this is expanded to the Cisterna chyli) Truncus lumbalis Lumbar region Abdominal wall, buttocks,
pelvis, leg

39
1 General anatomy

V. jugularis interna

Truncus jugularis

Ductus lymphaticus dexter

(Angulus venosus)
Nodi lymphoidei cervicales
V. subclavia
Arcus ductus thoracici
Truncus bronchomediastinalis Pars cervicalis
Ductus
Truncus subclavius Pars thoracica thoracicus
Nodi lymphoidei axillares Pars abdominalis

Cisterna chyli
Nodi lymphoidei abdominis Trunci intestinales
parietales et viscerales
Trunci lumbales
Nodi lymphoidei pelvis
parietales et viscerales

Nodi lymphoidei inguinales

Vasa lymphatica

Drainage via Ductus lymphaticus dexter

Drainage via Ductus thoracius Fig. 1.34 Overview of the lym-
phatic system.

Vas lymphaticum
Lymph node efferens
artery
Lymph node vein
Hilus
Lymph nodes

Vas lymphaticum
afferens

Vasa lymphatica
a afferentia

Marginal sinus Trabecula

(Marginal
Follicular dendritic cells sinus) Intermediate sinus
in a secondary follicle
Capillary
Secondary follicle network
(B-cell zone)
Capsule
Interdigitating dendritic
cells in the paracortical
Paracortical zone zone
(T-cell zone)

Sinus wall cell

Lymphocyte
High endothelial Medullary sinus
venule Marginal sinus Capsule

b Macrophage
Vein Artery Vas lymphaticum Sinus wall cell
efferens

Fig. 1.35 Lymph nodes. a Afferent and efferent lymphatic vessels. b Schematic section.

40
 1.6 Mucous membranes, glands, serous cavities

lymph node has numerous afferent and few efferent but large lu- 1.6.1 Mucous membranes
men lymph vessels (› Fig. 1.35):
• The afferent Vasa lymphatica afferentia lead the lymph via bor- Depending on function the structure of the mucous membranes is
der sinuses and intermediary sinuses to medullary sinuses, via very different. Nevertheless, a distinction can be made between a
which the lymph is routed to the efferent vessels. Between the basic, uniform and three-layer blueprints. This consists of
sinuses there is organised lymphatic tissue. • Lamina epithelialis mucosae: specialised epithelium, that func-
• The Vasa lymphatica efferentia leave the lymph nodes at the hi- tions as protection, secretion and/or resorption
lus of the lymph node. Supplying blood vessels also enter and • Lamina propria mucosae: contains blood and lymph capillaries
exit from here (› Fig. 1.35). and serves the transport of substances and the immune defence
The lymph nodes come in various shapes (mostly lens or bean- system
shaped with a diameter of roughly 5–20 mm). • Lamina muscularis mucosae (only present in the gut): smooth
Up to the confluence into the venous blood vessel system, the muscles, which serve the motility of the mucous membrane
lymph flows mostly through several serially arranged lymph nodes. Under the mucous membrane there is a Tela submucosa (submu-
Lymph nodes belong functionally together with the spleen, tonsils cosal connective tissue) joined with with blood and lymph vessels.
(‘almonds’) and lymphoid tissue of the intestines and the rest of the
mucous membranes to the secondary lymphatic organs, which
are opposed to the primary lymphatic organs (bone marrow, thy- 1.6.2 Glands
mus) and all of which serve the immune defence system.
Exocrine glands
Exocrine glands drains the secretions via a duct system to the sur-
Clinical remarks face anatomy (skin, mucous membranes). Exocrine glands are e. g.
The examination of lymph nodes is part of every detailed sweat glands, sebaceous glands, scent glands, salivary glands, lacri-
physical examination of a patient in the palpable regions of mal glands, pancreatic glands, liver. The excretory duct system be-
the throat area, axilla (armpit) and groin. gins with an end piece, in which the glandular cells excrete the pro-
Lymph node enlargements can be a first indication of inflam- duced secretions. The excretory duct system often shows special-
mation processes (lymphadenitis) or malignant diseases (me-
izations, which further modify the extravasated secretions (e. g.
tastasis of a malignant tumor [lymphogenic tumour metastasis]
or of a generalised disease of the lymphatic system, e. g. salinity, viscosity). Exocrine glands are derivatives of epithelium
­HODGKIN's disease. and enter at the site on the epithelium, from which their develop-
Congestion within the lymph vessels, e. g. in the case of cer- ment took their source (exoepithelial glands). Some glands are
tain diseases or after separation of lymph vessels in the con- formed as single cells (e. g. cup cell) or in the form of multiple cells,
text of operations may cause a lymphodoema. The interstitial small intraepithelial units, known as endoepithelial glands.
tissue is hardened (indured) and the fluid collection in the
­tissue cannot be pressed away as in normal tissue oedema.
Endocrine glands
­After surgery, a manual lymphatic drainage therapy is often
conducted. Endocrine glands have no independent duct system. The secre-
tion-forming (hormone-forming) cells are covered directly from a
blood vessel network into which the hormones are directly fed.
Hormones are neurotransmitters that act via special receptors on
target tissue (e. g. the thyroid stimulating hormone (TSH) pro-
1.6 Mucous membranes, glands, serous cavities duced in the pituitary gland only works on thyroid cells).

The inner surfaces of the body (e. g. respiratory tract, digestive

tract, urogenital tract and also ocular surfaces, efferent lacrimal 1.6.3 Serous cavities
system and middle ear with adjacent spaces) are covered by mu-
cous membranes, which undertake organ-specific functions such Serous cavities of the body are:
as secretion and/or resorption except for a barrier function against • Cavitas pleuralis (pleural cavity)
micro-organisms. • Cavitas pericardialis (pericardial cavity)
There are also glands, which are functionally linked to the mucous • Cavitas peritonealis (peritoneal cavity)
membranes or independently undertake functions in the body. • Tunica vaginalis testis (testicular sheath; it is a separation from
Glands are cell associations that produce a secretion, which they the peritoneal cavity)
release as exocrine glands through a duct system to the mucosal Serous cavities are capillary spaces, which are filled with a thin lay-
surface or that they secrete into the blood as hormones (endocrine er of protein-rich liquids. The specialised epithelium (Serosa, Tuni-
glands). ca serosa, mesothelium) creates a moist smooth surface, which re-
Serous cavities are recesses in the body, which serve the relocation duces the friction caused by the movement of the organs to a mini-
of highly movable organs (lungs, heart, bowels). They are not asso- mum and keeps the organs together (capillary adhesion,
ciated with the external surroundings (with the exception of the comparable to two glass panels bonded together with fluid).
peritoneal cavity of women) and are lined by a thin serous coat The joint cavities (› Chap. 1.4.3), the covering of the tendinous
­(serosa). sheaths and bursae (› Chap. 1.4.4) are similar to the structure of
serous cavities.

41
1 General anatomy

Parietal and visceral sheet The firmness of these ‘ligaments’ is much lower than the ligaments
You can imagine a serous cavity as a closed bag. One side is the in- in the musculoskeletal system. Smaller peritoneal duplicatures are
terior of the bag and is referred to as the parietal sheet (Serosa pari- referred to as folds (Plicae) (e. g. caecal fold, recto-uterine fold).
etalis). The other side covers the respective organ and is referred to The special form of peritoneal skin duplication is the large network
as a visceral sheet (Serosa visceralis) (› Table 1.12). (greater omentum) that has no holding function, but a defence
function through the accumulation of immune defence cells.
Table 1.12 Names/nomenclature of the serous membranes.
Location of the abdominal and pelvic organs
Organ Parietal layer Visceral layer
The position of organs in the abdomen and pelvic cavity is defined
Lungs Parietal pleura Visceral pleura as follows:
Heart Pericardium Epicardium • Intraperitoneal: the organ is connected via a meso with the
peritoneal wall and/or neighbouring organs (e. g. stomach,
Stomach, intestines Parietal peritoneum Viscera peritoneum
spleen).
Testis Periorchium Epiorchium
• Retroperitoneal: the organ lies ‘behind’ the parietal peritoneum,
its other wall surfaces are surrounded by retroperitoneal connec-
Clinical remarks tive tissue (e. g. kidneys).
• Secondary retroperitoneal: the organ has been shifted during
Serous cavities can expand under pathological conditions to development from a former intraperitoneal position onto the
air or liquid-filled spaces. Thus, an injury to the lungs may
wall of the peritoneal cavity, so that on the wall side the visceral
cause a drawing in of air into the gap with collapsing of the
lungs (pneumothorax) or, under certain conditions this can peritoneum and parietal peritoneum are adhered to each other
lead to an overflow of fluid from the blood into the respective (e. g. parts of the duodenum, colon, pancreas).
cavity (pleural effusion, pericardial effusion, ascites), which is • Extraperitoneal: the organ has no relation to the peritoneal cav-
then gradually filled with this liquid. ity and is surrounded by connective tissue (e. g. prostate gland).
Adhesions of the two sheets after inflammation can severely
inhibit normal organ function, e. g. in the peritoneal cavity it is
referred to as adhesions.
1.7 Nervous system
The nervous system serves to
The serosa consists of three layers: • Receive stimuli,
• Serosal epithelium (mesothelium) • Transfer stimuli,
• Lamina propria (serosa connective tissue with blood and lymph • Stimulus processing and
vessels) • Stimulus response
• Subserosal tela (subserous layer) and forms the basis of
Functionally its purpose is to guarantee the formation of a transu- • Emotions
date (thin liquid film) for the reduction of friction between the pa- • Memory and
rietal and visceral sheets, as well as for absorption of excess gener- • Thought processes.
ated liquid to a uniform thin liquid film. The nervous system (› Fig. 1.36) is divided into:
• Central nervous system (CNS): consisting of the brain (enceph-
Mesenteries alon) and spinal cord (Medulla spinalis)
As described above parietal and visceral serosa form a closed bag. • Peripheral nervous system (PNS): consisting of spinal nerves
The envelope area of both sheets from the wall of the body cavity on (including the cervical plexus, brachial plexus, lumbosacral
the respective organ include the supply route (blood and lymph ves- plexus) and cranial nerves (Nn. craniales)
sels and nerve fibres) and the suspension device from connective The nervous system controls the activity of muscles and viscera, is
tissue. It is a serosa duplication and is depicted in the broader sense used to communicate with the environment and the interior of the
(generic term) as mesentery (mesentery or meso). Examples are: body (inner environment) and fulfils complex functions, such as
• Mesogastrium (gastric mesentery) storage of experience (memory), development of ideas (thinking)
• Mesentery (small bowel mesentery, in the narrower sense) as well as emotions and is used for rapid adjustment of the whole
• Mesocolon (large bowel mesentery) organism to changes in the outside world and the interior of the
• Mesohepaticum (liver mesentery) body. A distinction is made between:
• Mesovarium (ovarian mesentery) • Autonomic nervous system (vegetative, visceral nervous sys-
• Mesosalpinx (mesentery of fallopian tubes) tem) for control of visceral activity, mostly involuntary (› Fig.
• Mesometrium (uterine mesentery) 1.37); consisting of:
The attachment of the meso on the body cavity is often referred to – Sympathetic nervous system: mobilization of the body in the
as radix (e. g. the Radix mesenterii.) Functionally, the mesenteries event of activity and in emergency situations, antagonist of the
are therefore responsible for supplying blood and lymph vessels, parasympathetic nervous system. The nerve cells are located
innervation, the storage of excretory ducts (e. g. bile ducts) as well in the lateral horn of the thoracolumbar segment of the spinal
as the fixation of the organs involved in the form of retaining bands cord. It also includes the adrenal medulla.
(ligaments), e. g. as: – Parasympathetic nervous system: food intake and process-
• Broad ligament of the uterus (womb, uterus) ing as well as sexual arousal, antagonist of the sympathetic
• Gastrocolic ligament (ligament between stomach and large in- nervous system. The neurons are located in the brain stem
testine) and the sacral medulla.
• Hepatoduodenal ligament (ligament between liver and duode-
num)

42
 1.7 Nervous system

Encephalon
Nn. craniales

Medulla spinalis
Plexus cervicalis

Plexus brachialis

R. ventralis
n. spinalis

Cauda equina

Plexus
lumbosacralis

a b

Fig. 1.36 Structure of the nervous system. a Ventral view. b Dorsal view.

– Enteral nervous system (intestinal nervous system): regula- Clinical remarks

tion of intestinal activity, is under the influence of the sympa-
thetic and parasympathetic nervous systems. 1.7.1  Disorders of peripheral nerves
• Somatic nervous system (innervation of skeletal muscles, vol- Various diseases (e. g. diabetes mellitus, lack of vitamin B, in-
toxication with heavy metals and drugs, impaired blood circu-
untary perception of sensory input, communication with the en- lation and excessive alcohol consumption) can cause disor-
vironment) ders of the peripheral nerves. In this respect, deficits and/or
Both systems are closely interlaced and interact with each other. overexcitation of nerve cells (neurons) are possible. If many
Besides the nervous system, the endocrine system also participates nerves are affected at the same time, this is referred to as
in the regulation of the total organism. polyneuropathy.

1.7.2  Disorders of the autonomic nervous system

Disorders of the autonomic nervous system play a role in al-
most all medical disciplines. They can occur as independent
diseases (e. g. inherited autonomic neuropathy), as a result of
other diseases (e. g. autonomic neuropathy in diabetes melli-
tus or PARKINSON's DISEASE ) or as a response to external in-
fluences or other disorders (e. g. autonomic dysregulation in
the case of stress, severe pain or psychiatric disorders). De-
pending on the region of the autonomic nervous system af-
fected, disorders of the circulatory system, digestion, sexual
function or other functions can be predominant.

43
1 General anatomy

Ganglion
ciliare Glandula
lacrimalis

N. oculomotorius [III]
Oculus

Ganglion pterygopalatinum
Ganglion submandibulare

N. facialis
[VII]
N. glossopharyngeus [IX]
Parasympathicus
N. vagus [X] Ganglion
head part
oticum
Glandulae
oris

Sympathetic trunk
neck part Pulmo

Sympathetic trunk Cor

Ganglion stellatum
chest part [cervicothoracicum]
2

Sympathicus 1 3
C8/T1–L3
Ganglion
coeliacum
Enteric
nervous system

Ganglion
mesentericum
Sympathetic trunk superius
abdominal section Ganglion
mesen- Intestinum tenue
tericum
Plexus
inferius Glandula suprarenalis
Sympathetic hypogastricus
pelvic section superior

Parasympathicus
pelvic section S2–S4

“preganglionic”

“postganglionic” Rectum

1 Vasa
2 Mm. erectores Plexus hypogastricus inferior
Organa genitalia
pilorum
3 Glandulae Vesica urinaria

Fig. 1.37 Autonomic nervous system.

44
2 General embryology
Martin Scaal

2.1 Introduction . . . . . . . . . . . . . . 47 2.7 Development of

the entoderm . . . . . . . . . . . . . 61
2.2 Fertilisation . . . . . . . . . . . . . . . 47
2.2.1 Translocation and 2.8 Folding movements of
capacitation . . . . . . . . . . . . . . . 47 the embryo . . . . . . . . . . . . . . . 61
2.2.2 Acrosome reaction and 2.8.1 Craniocaudal curvature . . . . . 62
fusion of the germ cells . . . . . 48 2.8.2 Lateral folding up . . . . . . . . . . 62
2.2.3 Fusion of genetic material . . . 48
2.9 Extra-embryonic tissue . . . . . 63
2.3 Preimplantation 2.9.1 Trophoblast . . . . . . . . . . . . . . . 63
development . . . . . . . . . . . . . . 50 2.9.2 Chorionic cavity
2.3.1 Cleavage and compaction . . . 50 and yolk sac . . . . . . . . . . . . . . 63
2.3.2 Blastocysts and 2.9.3 Amnion . . . . . . . . . . . . . . . . . . 64
implantation . . . . . . . . . . . . . . 50 2.9.4 Allantois . . . . . . . . . . . . . . . . . 64
2.4 Gastrulation . . . . . . . . . . . . . . 51 2.10 Early development of
2.4.1 Two-leaved germinal disc . . . 51 the extremities . . . . . . . . . . . . 65
2.4.2 Creation of the germinal 2.10.1 Formation of
layers . . . . . . . . . . . . . . . . . . . . 51 the extremity buds . . . . . . . . . 65
2.10.2 Pattern formation in the
2.5 Development of extremities positions . . . . . . . 65
the ectoderm . . . . . . . . . . . . . 53
2.10.3 Origin of the skeleton
2.5.1 Induction of and the muscles of
the neuroectoderm . . . . . . . . . 53 the extremities . . . . . . . . . . . . 66
2.5.2 Neurulation . . . . . . . . . . . . . . . 54
2.5.3 Neural crest . . . . . . . . . . . . . . . 55 2.11 Early development of
the head and throat area . . . . 66
2.6 Development of 2.11.1 Pharyngeal arches . . . . . . . . . 66
the mesoderm . . . . . . . . . . . . 56 2.11.2 Pharyngeal grooves and
2.6.1 Axial mesoderm . . . . . . . . . . . 56 pharyngeal pouches . . . . . . . . 70
2.6.2 Paraxial mesoderm . . . . . . . . 56 2.11.3 Development of the tongue
2.6.3 Intermediate mesoderm . . . . 59 and thyroid gland . . . . . . . . . . 70
2.6.4 Lateral mesoderm . . . . . . . . . 60 2.11.4 Facial development . . . . . . . . 71
2.11.5 Development of
the oral and nasal cavities . . . 72
 CLINICAL CASE

Gastroschisis
10,000 births; however, the embryological reason for gastroschisis is
History unclear.
A 24-year-old female student confirms her pregnancy with a rapid test.
She goes with her boyfriend to the gynaecologist at the beginning of
the 9th week of pregnancy. The ultrasound findings are inconspicuous.
Further procedure
In a follow-up visit to the gynaecologist at the beginning of the 5th Through close regular monitoring using fine ultrasound, the develop-
month of pregnancy, ultrasound findings show normal growth of the ment of the abdominal wall and the condition of the protruding
foetus, but determine an irregular convolute on the foetal abdominal intestinal segments are kept under observation. If the opening
wall. becomes smaller (with the risk of incarceration of the intestinal
loops) or the intestinal wall is damaged by the amniotic fluid, an
immediate caesarean section is indicated. Immediately after birth
Further diagnostics and diagnosis damaged intestinal segments can be surgically removed, the
From the detailed ultrasound it can be seen that intestinal loops intestinal loops transferred into the abdominal cavity, and the
emerge through an opening in the abdominal wall to the right of the abdominal wall closed. Postoperatively, the child is temporarily fed
navel and protrude into the amniotic cavity. The diagnosis is parenterally until the intestines have regenerated. Regular controls
gastroschisis. Gastroschisis occurs in approximately 4.5 out of are carried out to exclude an ileus (bowel occlusion). The long-term
prognosis of the child is very good.

The 24-year-old student is a girlfriend of yours. Immediately after the gynecologist gave the
diagnosis, she was so nervous that she stopped listening to the doctor. Therefore, she asks
you to explain again exactly how the treatment will work. In addition, she would like to know
how good the prognosis of the disease is.
You make notes so that you do not forget:

A friend in need …

Tx: Sectio caesarea in the 34th-36th week of pregnancy with prior

induction of the lung maturation, postpartum gastric outlet probe,
parenteral nutrition via infusion, antibiotic prophylaxis,
elimination of torsion in the gut, humidity and sterile packaging
of the leaked abdominal viscera in a plastic bag, no mask
ventilation, operation: primary abdominal wall closure in the event
of a large defect a) suturing of a patch or b) provisional closure
using a silicone bag ("silo bag”), from which the viscera will be
reduced little by little so that the bag continues to shrink
Prognosis: 90% chance of survival, volvulus with intestinal necro-
sis as possible complication → resection: short bowel syndrome
 2.2 Fertilisation

Skills NOTE
Embryonic development is regulated by developmental genes,
After working through this chapter you should be able to: which specify the initially naive cells of the early embryo to form
• explain the process of fertilisation different cell types, and which orchestrate the arrangement of the
• explain pre-implantation development and the implantation diverse cell types into tissues, organs and the entire anatomical
of the embryo in the uterine wall as well as understand the bauplan of the body.
formation of extra-embryonic membranes
• explain the formation of the germ layers in the germinal disc
and understand their three-dimensional transformation to
the basic body shape 2.2 Fertilisation
• describe the principles of the early development of the ex-
tremities and the head and throat area
• explain the basic molecular and cellular mechanisms of em-
bryonic development (e.g. specification, differentiation, in- 2.2.1 Translocation and capacitation
duction, cell migration), providing examples.
Insemination, the fusion of female and male germ cells for forma-
tion of the zygote, usually takes place in the ampulla of the fallopi-
an tube (uterine tube, oviduct). Both the ovum and the spermato-
zoa have to get there from the gonads (translocation):
2.1 Introduction • In ovulation (› Fig. 2.1) the ovum leaves (oocyte), their ovary
wrapped in the Zona pellucida and in the Corona radiata, and
Human life begins with the fusion of two germ cells from the par- enters the fimbrial funnel of the fallopian tube. This is assisted
ents, a paternal spermatozoan and a maternal ovum, to create a ge- by sweeping movements of the fimbria, which during ovulation
netically new cellular individual, the zygote. The zygote contains in lay close to the ovary. The resulting flow of the liquid in the
its genome all the genetic information which autonomously con- tubes, assisted by peristaltic contractions of the fallopian tubes,
trols the subsequent development to become an adult human. This transports the ovum slowly into the ampulla.
development includes not only cell proliferation, but also the for- • The spermatozoa, as the cellular part of the semen, are deposit-
mation of different cell types and their arrangement into anatomi- ed by ejaculation into the vaginal vault (Fornix vaginae). By
cal structures. The basis for the differentiation of cells into specific beating the tails of the cilia, the spermatozoa actively pass
cell types is differential gene expression. Although each cell of an through the mucus barrier of the uterine cervix, which is pass-
organism contains all the genes of the individual genome, in each able due to the effect of oestrogen, into the uterine lumen and
cell only certain genes are selectively expressed and so only a cer- from there move largely passively by contractions of the uterus
tain set of proteins are synthesised. The determination of an em- into the fallopian tube. Here the spermatozoa undergo a matura-
bryonic cell for a specific developmental outcome is called deter- tion process under the influence of the tube epithelium called
mination (syn.: specification), their conversion into a particular capacitation. This process changes the protein configuration
type of cell is called differentiation. Crucial to both steps are mo- and the electrophysiological characteristics of the cell membrane
lecular signals, which are either formed by the cell itself (cellauton- at the sperm head. The spermatozoa are only capable of fertilisa-
omous) or originate from cells in the environment (induction). tion at this point. When they are in the vicinity of the ovum, the
Inductive interactions between cells also play an important role in capacitated spermatozoa greatly increase their beating action
the subsequent developmental stages. Similar differentiated cells and reach the oocyte by following a temperature gradient (ther-
are arranged into cell groups and tissues (histogenesis). The cell motaxis; the temperature in the ampulla is slightly higher than
groups and tissues are arranged as specific anatomical forms (mor- in the proximal oviduct) and the concentration gradient of the
phogenesis) and the forms in turn, together with other tissue molecules secreted by the oocyte (chemotaxis, including pro-
groups and make up to superordinate anatomical structures with a gesterone). Although more than 200 million spermatozoa are
specific spatial alignment, corresponding to the specific patterns of
human anatomy (pattern formation).
This is simply illustrated using the example of the development of
Fallopian tube
the humerus: from a cell population in the central mesenchyme of
the position of the extremities (determination), cartilage cells
emerge (differentiation). The resulting hyaline cartilage (histogene-
sis) is arranged in the form of a tubular bone with epiphyses and
diaphyses (morphogenesis), which lies between the shoulder blade Sperm
position and the position of the forearm bones (pattern formation).
Thus, in embryogenesis all organ systems of the body exist in a
functional cluster, which corresponds to the human blueprint.
In the ensuing foetal period this leads to coordinated growth and
Burst follicle Ampulla
to functional maturation of organ systems until birth. Postnatal de-
velopment through childhood, puberty, adults and senium are also
part of the developmental process of humans, which begins with Fimbria
Oocyte in the
the zygote and finally ends in death. 2nd division of maturity

This chapter entitled ‘General embryology’, describes early human

development from insemination to the formation of the basic blue- Fig. 2.1 Ovulation. The ovum is expelled from the GRAAF’s follicle
print of the body (basic body form). Special embryology (develop- and escapes via the fimbrial funnel into the ampullary part of the fal-
ment of the organ systems) is dealt with in the respective chapters. lopian tube, where it comes into contact with capacitated spermato-
zoa. [L126]

47
2 General embryology

ejaculated into the vagina, only approximately 200 reach the Triggered by the fusion, the ovum protects itself against multiple
ovum. fertilisation (polyspermy) by releasing enzymes from vesicles un-
The translocation of spermatozoa can take between 30 minutes up der its cell membrane (cortical granules) by exocytosis into the
to several days. It is not necessarily the fastest spermatozoon that Zona pellucida, which modifies the sperm receptors of the zona
fertilises the ovum because for capacitation to take place, a suffi- proteins in such a way as to prevent attachment of a spermatozoon
ciently long contact with the tube epithelium is required. (zona reaction). The fusion of the spermatozoon with the oocyte
also leads to activation of the ovum, which is accompanied by an
oscillating increase in Ca2+ concentration in the cytoplasm and is a
Clinical remarks prerequisite for the subsequent steps in fertilisation.
Birth control (contraception) can be achieved by restricting
the translocation of spermatozoa (condom, vaginal dia-
phragm, intrauterine device) or by preventing ovulation (hor-
Clinical remarks
monal contraceptives, ‘the pill’) or implantation (interception, In extracorporeal fertilisation (in vitro fertilisation, IVF) the oo-
emergency postcoital contraception). cytes are removed transvaginally by puncture of the ovary which
has previously been hormonally stimulated and mixed in a nu-
trient solution with spermatozoa which have been capacitated
by preincubation in a special medium. After successful fertilisa-
NOTE
tion up to 3 embryos in the 4-8 cell stage are introduced into
The fertilisation of the ovum by the spermatozoon typically occurs
the uterus (embryo transfer). The Zona pellucida can be re-
in the ampulla of the uterine tube.
moved mechanically or using a laser before embryo transfer to
facilitate implantation. In the case of insufficient sperm motili-
ty, a single spermatozoon can be selectively injected into an
2.2.2 Acrosome reaction and fusion of the germ ovum in vitro. Intracytoplasmic sperm injection (ICSI).
cells During preimplantation genetic diagnostics (PGD) individual
embryo blastomeres are removed before the embryo transfer
and are examined at a molecular genetic level for the pres-
The oocyte progresses into the fallopian tube surrounded by a ence of any gene defects. Due to the totipotency of early blas-
loose circle of follicular cells (Corona radiata) and a dense sheath tomeres, this sampling does not generally adversely affect the
of glycoproteins (Zona pellucida). Both layers must be penetrated development of the embryo; however, trophoblast cells are
by the spermatozoon that has reached the ovum, in order to reach increasingly being used for PGD at the blastocyst stage (blas-
the actual oocyte (› Fig. 2.2). Receptor proteins in the cell mem- tocyst biopsy). After selection, only healthy embryos are intro-
brane of the head of the spermatozoon, which has been prepared duced into the uterus and the other embryos are discarded.
by capacitation, bind to the glycoproteins of the Zona pellucida This is why PGD is ethically and legally controversial.
(zona proteins, ZP). As a result, the acrosome reaction is initiated,
whereby the vesicle membrane of the acrosome, a vesicle filled with
proteases on the tip of the sperm head, fuses with the superficial
cell membrane of the spermatozoon, so releasing the contents of 2.2.3 Fusion of genetic material
the acrosome. As a result of protease digestion, a channel is created
in the Zona pellucida through which the sperm can penetrate into At the time of fertilisation the ovulated oocyte is at the metaphase of
the ovum. The sperm head is located at a tangent to the cell mem- the 2nd division of maturity. Only when both germ cells fuse will
brane of the oocyte, and the cell membrane of the sperm head then the 2nd division of maturity be continued and finalised. In doing so,
fuses with that of the oocyte. another polar body is emitted, and the nucleus of the oocyte is pres-

Zona pellucida
Perivitelline gap

Corona radiata
Cytoplasm

Metaphase of the 2nd division of maturity

Fig. 2.2   Acrosome reaction
1 2 and fusion of the germ cells.
3 Spermatozoa penetrate through
1st polar bodies
4 the Corona radiata with secreted
enzymes (1) and lie with their
Plasma membrane of the oocyte heads on the Zona pellucida (2).
The acrosomal proteases are
released by the acrosome reac-
tion, and they penetrate the
1 2 Zona pellucida (3), so that the
spermatozoa can advance into
3 the oocyte. By the fusion of the
cell membranes of both germ
4
cells, the nucleus and also parts
of the middle and the tail of the
spermatozoa succeed in enter-
ing the cytoplasm of the oocyte
(4). [E347-09]

48
 2.2 Fertilisation

ent in the haploid state. It is now described as a female pronucleus ­ umans the zygote is only a transient division stage. After fertilisa-
h
(› Fig. 2.3a). Apart from the nucleus, parts of the neck and the tail tion of the ovum, the 2-cell stage of the genetically new embryo im-
of the spermatozoon penetrate into the oocyte, but are rapidly bro- mediately follows (› Fig. 2.4c). The gender of the embryo is deter-
ken down. The compressed core of the spermatozoon loosens after mined by the spermatozoon: if the fused spermatozoon carries a Y
fusion and becomes the male pronucleus. Both pronuclei replicate chromosome, the gene located on it SRY (‘sex-determining region
their DNA, together with their own centrosomes forming asters of Y’) ­ensures the formation of the male phenotype.
(star-shaped arrangements of microtubules) and come nearer to
each other (› Fig. 2.3b, c). With the fusion of both pronuclei both NOTE
nuclear envelopes collapse; the chromosomes are arranged on a In fertilisation, the cell membranes of oocyte and spermatozoon
common spindle apparatus and are rapidly distributed to both fuse, so the haploid nucleus of spermatozoon enters the oocyte as
daughter nuclei of the zygote, without forming an actual zygote core a male pronucleus, and male and female pronuclei jointly form the
with a common nuclear envelope (› Fig. 2.3d, › Fig. 2.4). In cell nucleus of the zygote.

Female
pronuclei

Fig. 2.3 Formation of the

Male zygote.
pronuclei a After a spermatozoon has pen-
etrated into the ovum, further
Degenerating ingress by other spermatozoa is
sperm tail
1st and 2nd polar bodies prevented by the zonal reaction
and the 2nd meiosis of the
2nd polar bodies oocyte is completed.
a b b The tail and mitochondria of
Mitotic spindle of the
the spermatozoon degenerate,
first zygote cleavage
and the nucleus increases in
size to the male pronucleus.
Chromosome c Male and female pronuclei
approach and merge by dissolu-
Zygote tion of the nuclear membranes
to become a zygote. d The chro-
mosomes of both pronuclei are
Termination of the immediately aligned to the divi-
pre-nucleus membrane
sion spindle and the zygote ini-
c d tiates the first cleavage division.
[E347-09]

Fig. 2.4 Cleavage, compaction

a b c and blastocysts. Illustrations of
human embryos in vitro.
a Oocyte shortly before fertilisa-
tion. Arrows = Zona pellucida.
b Zygote with fused, male and
female pronuclei (= arrow).
c First cleavage for 2-cell stage.
d 4-cell stage. e 8-cell stage. The
blastomeres are still rounded.
f Morula stage at the beginning
d e f of compaction. The cells are
compacted together and form a
epithelium-like outer cell layer.
g Morula after compaction.
h Early blastocyst still within the
Zona pellucida, with blastocoel
between the outer shell of the
trophoblast and the inner
embryoblast. i Blastocyst after
leaving the Zona pellucida.
Arrowhead = trophoblast, arrow
g h i
= embryoblast. [G394]

49
2 General embryology

2.3 Preimplantation development Clinical remarks

In the case of ectopic pregnancies implantation occurs out-
side the uterus. Over 90 % of these occur in the fallopian tube
2.3.1 Cleavage and compaction (tubal pregnancy) which can lead to the rupture of the fallopi-
an tube and a life-threatening haemorrhage in the mother. The
Cleavage positions reason for this is often adhesions to the mucous membranes
After fertilisation multiple mitotic divisions occur in the zygote of the tube.
while still in the Zona pellucida, which separate the cytoplasm of If after fertilisation the zygote passes through the fimbrian
the oocytes into several daughter cells (blastomeres) (cleavage po- funnel back into the abdominal cavity, the embryo can implant
in various locations within the peritoneum. Usually, it leads to
sitions). The cleavage positions occur relatively slowly at intervals
intra-abdominal bleeding and miscarriage, but in exceptional
of several hours, with staggered division levels. This means that the cases it can lead to abdominal cavity pregnancies carried to
first division of zygote cleavage occurs meridionally, whereas the full term and delivered by caesarean section.
second cleavage division runs around its equator and that the ca-
dence of division rhythm is individual in each daughter cell; there-
fore an odd number of blastomeres can also be present (› Fig.
2.4). During the first two division steps, the proteins which are re-
quired for cell maintenance and mitotic cell division, i.e. maternal 2.3.2 Blastocysts and implantation
genes, are synthesised by the mRNA of the oocyte, and are released
for translation by activation of the ovum. Between the 4-cell and Cavitation
8-cell stages the zygotic genes are activated for the first time, and After compaction the trophoblast cells deliver ions by pumping
from now on the embryo takes over the expression of its own Na+ into the interior of the morula, which draws an osmotic wake
genes, independently of the mother. of water behind it and the space between trophoblasts and embryo-
blasts is widened into a fluid-filled cavity (cavitation).
Compaction
After the 8-cell stage and the 3rd division (› Fig. 2.4) another deci- Hatching
sive event takes place: while the blastomeres so far approximately At the fifth day, the embryo which has now reached the lumen
resemble round balls that are loosely joined together, the outer cells of the uterus, leaves the narrowing Zona pellucida (› Fig. 2.4i,
closely join together in an epithelium-like lattice. They close off the › Fig. 2.5). The trophoblasts secrete proteases which create an
internal cells from the outside world by forming cell to cell contact opening in the Zona pellucida allowing the embryo free access to
between them (e.g. via the cell adhesion molecule E-cadherin) and the lumen of the uterus, like hatching from an eggshell, › Fig. 2.5a).
tight junctions (compaction, › Fig. 2.4f ). Up to this point all the Now not only cell division occurs, but there is also growth of the
cells of the young embryo are totipotent, meaning that every cell embryo.
has the potential to form a complete embryo on its own, which of-
ten happens in the case of identical twins. With compaction at the Blastocysts and implantation
16-cell stage (morula stage, › Fig. 2.4f, g) now the first differenti- Due to fluid retention, the embryo now has the shape of a blister
ation of cells takes place as the outer cells become differentiated (blastocyst, › Fig. 2.5, › Fig. 2.6) and on its inner wall the em-
from inner cells in terms of shape, protein configuration and devel- bryoblast is located excentrically. As soon as the blastocyst comes
opmental outcome. While the trophoblast cells and the chorion of into contact with the uterine wall, generally in the fundus of the
the placenta develop from the outer cells, the embryo itself is entire- uterus, it is attached with the embryonic pole to the maternal en-
ly made up of the inner cells (embryoblast or internal cell mass). dometrial cells and to the abundantly suffused extracellular matrix.
After the 64-cell stage, there is no more cell exchange between the After successful attachment of the blastocyst the trophoblast pro-
two cell populations. Up to this point, the entire development takes duces proteases, which locally digest the extracellular matrix of the
place within the Zona pellucida, which migrates through the fallo- endometrium and enable the blastocyst to sink into the uterus wall
pian tube to the uterus during this period. The Zona pellucida pro- (implantation, syn.: nidation). Approximately 10 days after fertili-
tects the embryo from premature implantation in the mucosa of the sation, the embryo is completely enveloped by the endometrium.
fallopian tube, which would lead to an ectopic (tubal) pregnancy
and is life-threatening for both, mother and embryo.

Fig. 2.5 Blastocyst leaving the

Zona pellucida. Illustrations of
human embryos in vitro.
a Hatching of the blastocyst
from the Zona pellucida (left).
b Blastocyst leaving the Zona
pellucida; the empty zona pellu-
cida is to the left of the blasto-
a b
cyst. [G210]

50
 2.4 Gastrulation

Decidua
Trophoblasts
Epithelium of the decidua
Embryoblast

Fig. 2.6 Blastocyst and incipi-

ent implantation.
Blastocyst cavity
a Free blastocyst. b The blasto-
cyst attaches with the embryon-
ic pole to the uterine mucosa;
Trophoblast the trophoblast begins to pene-
a b trate into the maternal tissue.
[L126]

NOTE NOTE
The embryo is implanted in the uterus as a blastocyst. The tropho- In a narrow sense, the embryo develops separately from the epi-
blast shell of the blastocyst forms part of the placenta; the embryo blast of the two-leaved germinal disc.
develops only from the embryoblast.

2.4.2 Creation of the germinal layers

2.4 Gastrulation
Before gastrulation, the embryo is present as a flat disc made of
morphologically uniform epithelioid cells, the embryonic epiblast.
2.4.1 Two-leaved germinal disc From now onwards, the aim of gastrulation is to form the basic
blueprint of the body from the epiblast, consisting of an outer shell
While the trophoblast of the implanted blastocyst develops into (ectoderm) a lining of the inner surface, i.e. the intestinal tube
parts of the placenta to serve nutrition of the embryo, the embryo- ­(entoderm), and the tissue lying between it (mesoderm).
blast undergoes further differentiation of cells (› Fig. 2.7). Em- On the edge of the epiblast disc there is a protrusion, caused by the
bryoblast cells which express the transcription factor Nanog are ar­ apicobasal elevation of the highly prismatic cells, which increasing-
ranged on the side facing the trophoblast, whereas those which do ly extends in a stripe-like fashion towards the middle of the germi-
not express Nanog, but the transcription factor Gata6 form a layer nal disc (primitive streak). This shows a nodular thickening there
adjacent to the blastocyst cavity. Both layers appear as round discs. (primitive node, HENSEN's node, › Fig. 2.8). The extension of
This creates the two-leaved germinal disc, in which the embryo- the primitive streak is achieved by intercalating of the cells along
blast is divided into 2 epithelioid leaves – the epiblast (Nanog-­ the longitudinal axis of the primitive streak (convergent extension).
positive) and the hypoblast (Gata6-positive). Simultaneously, the The position and cell movements of the primitive streak are con-
first of the 3 body axes of the embryo is defined, as the epiblast lies trolled by inductive signals from the underlying hypoblast. The
on the future dorsal side and the hypoblast lies on the ventral side. primitive node is located on the upper pole of the primitive streak.
The hypoblast cells proliferate and grow around the lumen of the Thus, even at this early stage, all other body axes are ultimately
blastocyst cavity, where they are now referred to as extra-embryo­ ­determined by the dorsoventral body axis, in particular the cranio-
nic entoderm and form the epithelium of the primary yolk sac caudal longitudinal axis, and also the left-right axis. On both sides
emerging from the blastocyte cavity. (› Fig. 2.7b). of the primitive streak, the epiblast cells release E-cadherin-medi-
ated cell to cell contacts, expand into the intercellular spaces by
NOTE synthesising hyaluronan, and move in the direction of the primi-
In a similar way to the trophoblast, hypoblast cells are also in- tive streak. The cells migrate into the primitive streak through a
volved in the formation of the embryonic shells and do not contrib- groove along the central line of the strip called the primitive
ute to the embryo. groove, at a depth, i.e. ventrally.
The first cells arriving there penetrate from a medial direction be-
In the epiblast, a thin cell sheet is secreted along the trophoblast shell tween the hypoblast cells and completely displace them laterally into
that is increasingly detached by confluent splits from the underlying the wall of the yolk sac. Now the migrating cells form the ventral
epiblast cells. This thin cell sheet, which is also referred to as amnio- floor of the embryo and are the progenitor cells of the entoderm.
blast, is the precursor of the later amniotic epithelium and, together The epiblast cells migrating somewhat later through the primitive
with the remaining epiblast, encloses a fluid-filled cavity, the amni- groove spread out driven laterally and cranially by repulsive signals
otic sac (› Fig. 2.7a). All that remains as material of the embryo are (e.g. secreted fibroblast growth factor, FGF) into the primitive streak.
the residual epiblast, which can therefore also be referred to as em- They form a loose mesenchymal cell association between the epiblast
bryonic epiblasts. Before the start of gastrulation the embryo en- and newly-formed entoderm and together they form the mesoderm.
closed by trophoblast is made up of the two-leaved germinal disc This means that the location of the migration through the primitive
with the epiblast and hypoblast, and ventrally and dorsally a fluid- streak is crucial to the future position of the mesoderm cells:
filled cavity is present (the two-vesicle stage): dorsally from the am- • The most cranially positioned migrating cells, i.e. through the
niotic cavity covered by amnioblast, ventrally the yolk sac coated in primitive node, penetrate between the entoderm cells and mi-
extra-embryonic entoderm emerging from the hypoblast . grate cranially where they initially form the head process and, as

51
2 General embryology

Uterus gland Capillary in the endometrium

Amnioblast Extra-embryonic Maternal sinusoid

somatic mesoderm
Lacunar network

Syncytio Primary umbilical

trophoblast vesicle (yolk sac)

Amniotic cavity
Epithelium of the
endometrium Endometrium
Yolk sac
epithelium Epiblast
Inner (basal)
surface of the Hypoblast Chorion
a cytotrophoblast
Cytotrophoblast
Amnion
Extra-embryonic
splanchnic
Uterus gland mesoderm

Extra-embryonic
d coelom

Syncytio
trophoblast Maternal blood
in lacunas

Maternal blood
Twin-layered Connecting stalk
Extra-embryonic germinal disc
coelom

Primary yolk sac Epithelium of the

endometrium
Key provisions Extra-embryonic
b Schlusscoagulum mesoderm
Secondary
umbilical vesicle
(yolk sac)
Eroded uterus gland Maternal blood Lacunary network

Amniotic sac

Uterus gland
Extra-embryonic
somatic mesoderm

Extra-
embryonic
coelom Remnant of primary yolk sac Endometrial epithelium
(extra-embryonic coelom)

Yolk sac e
epithelium

Twin-layered
germinal disc

c Cytotrophoblast

Fig. 2.7 Twin-layered germinal disc and complete implantation. a In the embryoblast epiblast, hypoblast and amnioblast have separated. The
amniotic sac is formed between the epiblast and the amnioblast. In the trophoblast, the cells adjacent to the endometrium join together into
multinuclear giant cell, syncytiotrophoblast. b The yolk sac epithelium developing from the hypoblast (syn.: extra-embryonic entoderm) has
fully surrounded the blastocyst cavity formation, now referred to as the primary yolk sac. The extra-embryonic mesoderm grows in between the
cytotrophoblast and the primary yolk sac. The syncytiotrophoblast arrodes the first endometrial vessels and the blood flows into the tropho-
blastic lacunae. c The cavities in the extra-embryonic mesoderm merge together with the extra-embryonic coelom. The trophoblastic lacunae
coalesce into a coherent network, through which the mother's blood flows. d The extra-embryonic coelom flows into a contiguous cavity (chorionic
cavity) that separates the yolk sac from the trophoblast. Thus the extra-embryonic mesoderm is divided into a visceral and a parietal sheet. The
primary yolk sac becomes increasingly constricted. e The chorionic cavity surrounds the entire nucleus, which only comes into contact with the
trophoblast via the connecting stalk. The proximal part of the constricted primary yolk sac forms the secondary yolk sac, the distal part becomes
the rudimentary exocoelomic cyst. [E347-09]

52
 2.5 Development of the ectoderm

Syncytiotrophoblast Primitive node

Primitive streak

Amnion
Extra-embryonic
mesoderm Amniotic sac

Twin-layered
germinal disc
Amniotic sac
Hypoblast
Primitive streak
Hypoblast Yolk sac

b Extra-embryonic mesoderm
a Epiblast
Primary yolk sac

14th - 15th day 16th day

Primitive streak Primitive node

Epiblast

Ectoderm

d
c Mesoderm Entoderm
Hypoblast Entoderm

Fig. 2.8 Gastrulation. a At the start of gastrulation the primitive streak is formed in the epiblast. b Epiblast cells migrate deeper through the
primitive groove which runs along the primitive streak and propagate on all sides beneath the epiblast. c The first cells migrating through the
primitive groove laterally displace the hypoblast and form the epithelial entoderm. d The subsequent cells remain as mesenchymal cells and
form the middle germ layer (mesoderm) separating the remaining epiblast cells, which are now known as ectoderm and entoderm. [L126]

gastrulation progresses, the Chorda dorsalis or notochord as trulation, the epiblast of the two-leaved germinal disc become the
the embryonic central axis. three germ-layered embryo which is still present as a flat germinal
• The cells migrating caudally to the primitive node through the disc but which together with the ectoderm, mesoderm and ento-
cranial section of the primitive streak form the mesoderm lateral derm already shows the principal structure of the vertebrate body;
to the central axis, the paraxial mesoderm. its body axes are defined in all three spatial planes.
• The cells migrate increasingly caudally to correspondingly form
the intermediate mesoderm and finally form the lateral meso-
derm (side plate mesoderm, › Fig. 2.9).
Clinical remarks
The cells of the epiblast that do not migrate deep through the Identical (monozygotic) twins are caused by the division of
primitive streak but after the completion of gastrulation remain in cells of a single germ cell at various stages of development.
the former epiblasts, now form another germinal layer to be the The most common is the division of blastomeres during cleav-
dorsal surface epithelium called the ectoderm. As a result of gas- age, and more rarely by the division of the embryoblast in the
blastocyst. In very rare cases, the separation occurs only
during gastrulation, with 2 primitive streaks being created.
Where incomplete separation of the two primitive streaks oc-
curs, both twins remain partially conjoined (‘Siamese twins’).

Axial mesoderm
(head process or notochord) NOTE
During gastrulation three germ layers arise from the epiblast, the
Paraxial mesoderm ectoderm, mesoderm and entoderm, and axes of the body are
Intermediate mesoderm ­established.
Lateral mesoderm
Extra-embryonic mesoderm
2.5 Development of the ectoderm

Fig. 2.9 Migration of mesoderm sections through the primitive 2.5.1 Induction of the neuroectoderm
streak. The more cranially the mesoderm progenitor cells migrate
through the primitive streak or the primitive node, the further medial- The cells of the epiblast, which during gastrulation do not migrate
ly the mesoderm sections are formed. [L126] deep in the primitive streak but remain in the layer of the former

53
2 General embryology

NOTE
19th day
The neuroectoderm as the building material for the nervous system
18th day is induced subsequently to gastrulation by the underlying chorda­
Head Neural plate mesoderm.
process

Primitive 2.5.2 Neurulation
node
Surface Shortly after the formation of the neural plate, its lateral edges, togeth-
ectoderm
Primitive streak er with the lateral superficial ectoderm begin to bulge dorsally (neural
Chorda dorsalis bulge), while at the same time, a longitudinal furrow is formed along
the midline of the neural plate (neural groove) (› Fig. 2.11).
Fig. 2.10 Formation of neural plate. The thickened neural plate is At this point, the neural plate in the area of neural groove comes
formed from neuroectoderm under the influence of the head exten- temporarily into contact with the underlying notochord, whereby a
sion or the chordamesoderm migrating through the primitive node. In
hinge is simultaneously formed, dorsally raising the neural folds up
the brain area the neural plate is wide, whereas in the spinal cord
area it is narrow. [L126] to the median sagittal axis just like the compressed pages of a book
(› Fig. 2.12).
epiblast, are referred to as ectoderm. Initially the ectoderm is a The driving force for this is the apical constriction of the cells in
flat, slightly oval epithelial disc. With progressive gastrulation, in the neural groove induced by the chorda dorsalis which take on a
the medial third of the ectoderm there is an elevation of the multi- wedge shape and the strong growth of the ectoderm sited laterally
layered epithelium, which stretches in a craniocaudal direction to the neural plate, which together with the underlying mesoderm,
from the prechordal plate up to the primitive node, and viewed displaces the neural bulge dorsally and medially. At the end of this
from the dorsal side displays an almost pear-shaped outline process, the neural bulges touch both sides dorsally at the midline,
(› Fig. 2.10). This thickened ectoderm section (neural plate) pro- firstly in the head and throat transition area and then progressing
vides the material for the nervous system (neuroectoderm), while like a zip cranially and caudally (› Fig. 2.11c, › Fig. 2.12d). This
the surrounding ectodermal epithelium forms the future superfi- leads to the division of different parts of the neural bulges: the lat-
cial ectoderm. eral portions of both neural bulges fuse at the furthest dorsal sec-
The formation of the neural plate is based on induction by the un- tion and connect the superficial ectoderm on both sides by a full
derlying axial mesoderm. The primitive node and the mesoderm epithelial coat, from which the epidermis of the skin results. The
sections emerging from the primitive node, the head process and respective medial components of both neural bulges join together
the notochord, function as a so-called organiser. They secrete sig- with the neural tube below the superficial ectoderm neural tube
nal molecules which induce the formation of the neural plate in the from which the brain and spinal cord arise (› Fig. 2.11c, d › Fig.
ectoderm above it (e.g. fibroblast growth factor 8, FGF8) and also 2.12e, f). At the end of neurulation the cranially and caudally pro-
inhibit the development of ectoderm cells into superficial ecto- gressing neural tube terminus remains as an open connection to
derm (‘bone morphogenetic protein antagonists’, BMPs, such as the amniotic cavity (anterior or posterior neuropore), which only
chordin). BMP seems to be a key molecule in the first differentia- closes later on. The posterior neuropore is located at the level of the
tion of the ectoderm: if the BMP signal pathway is active, superfi- sacral medulla and the caudally positioned subsequent sacral and
cial ectoderm is formed and if it is inhibited (by the axial meso- coccygeal segments of the spinal cord are formed by a fundamen-
derm) neuroectoderm is formed. tally different mechanism (secondary neurulation). From the
At the end of the 3rd week, the neural plate approximately resem- mesenchyme of the tail bud, which as a derivative of the primitive
bles the outline of a violin with a broad section at the head in streak provides the building material for the coccyx area in the 4th
which the structure of the forebrain and midbrain are already week, a solid cord of neural tissue initially develops, which receives
prominent and a narrow, elongated section in the area of what will a lumen (cavitation) by detachment of the cell contacts inside it
become the hindbrain and spinal cord (› Fig. 2.10). and soon connects to the caudal end of the neural tube formed by
(primary) neurulation.

19th day 20th day 22nd day 23rd day

Neural fold

Neural plate Heart system Neuroporus

anterior
Otic placode Heart system
Neural groove
Cutting edge Somite
of the amnion
Somite Cutting edge
of the amnion
Primitive node
Primitive streak Cutting edge
Primitive streak of the amnion
Cutting edge
of the amnion Neuroporus
a b c d posterior

Fig. 2.11 Neurulation. a, b The neural plate bulges on both sides of the centre line in the form of dorsal neural folds and forms the neural
groove. c At the start of the 3rd week, the neural folds fuse like a zip and form the neural tube. d Via Neuroporus anterior and posterior, the
neural tube remains fused for some time with the amniotic cavity. [L126]

54
 2.5 Development of the ectoderm

Clinical remarks NOTE

In neurulation, the neural plate folds into 2 neural bulges that
If the dorsal end of the neural tube is incomplete, the superfi- close dorsally in the median line to the neural tube.
cial ectoderm also does not close and the formation of the cal-
varia and the vertebral arches as the roof of the neural canal
does not accur. In anencephaly there is a defect in the closure
of the neural tube in the area of the forebrain and in rachischi- 2.5.3 Neural crest
sis in the area of the spinal cord. Contact of the exposed neu-
roectoderm with the amniotic fluid leads to necrotic tissue de- Between the superficial ectoderm and the neural plate, i.e. directly
generation in both cases. Newborn babies with anencephaly ventral to the fusing neural bulges, a 3rd cell population becomes
are not viable; rachischisis can lead to severe neurological de-
arranged, the neural crest cells (› Fig. 2.12f ). The neural crest
fects in the affected area.
cells leave the ectodermal epithelial association (epithelial-mesen-
chyme transition, EMT) and as mesenchymal progenitor cells mi-
grate to various points in the embryonic body. Emerging from
them are various derivatives, such as the neurons of the peripheral
Neural plate nervous system, chromaffin cells of the adrenal gland and skin me-
Neural crest lanocytes (truncal neural crest), and in the head area the skeleton
and connective tissue (head neural crest). The neural crest cells
a
are guided on their migration to the sometimes distant target areas
Epidermis by the nature of the extracellular matrix and controlled by attrac-
Hinge zone tion and repulsion of molecular gradients (chemotaxis). In the
of the notochord truncal neural crest 3 cell flows can be distinguished (› Fig. 2.13):
• under the superficial ectoderm laterally (melanocyte precursor)
• in each cranial half of the somites (progenitors of spinal ganglion
b
cells)
Chorda dorsalis • ventrally between the neural tube and somites (progenitors of
sympathetic ganglion cells, ganglion cells of the intramural plex-
us of the viscera and the adrenal medulla).
Only after arrival at the destination do the cells differentiate ac-
c cording to their location; however, the determination probably al-
ready occurs in the course of migration created by environmental
Neural groove signals (specification of cell outcomes by induction).

Clinical remarks
Congenital bowel disease (congenital megacolon,
HIRSCHSPRUNG's disease) is based on a defect of the migra-
d tion behaviour of neural crest cells that form the intramural gan-
glia of the enteral nervous system of the large intestine. These
Dorsolateral
hinge zone

Spinal ganglion

e Melanocytes

Neural crest
Border strand of the
sympathetic nervous
system

Epidermis Adrenal medulla

f
Cells of the
neural crest

Neural tube Intramural nerve

system of the intestine
Fig. 2.12 Neurulation. a The neural plate is initially a flat disc. b, c It
then increasingly develops along a hinge zone in contact with the Fig. 2.13 Migration routes of neural crest cells in the trunk. The neu-
chorda dorsalis to neural folds. d, e Due to the growth of the surface ral crest cells migrate at the time of neural tube closure from the neu-
ectoderm, the neural folds are pressed in a medial direction along a ral folds to their target areas. The main routes are the subectodermal
dorsolateral hinge zone (d) and finally fuse in the midline into a mesenchymal dorsal to the somites (melanocyte precursors), through
closed neural tube (e). f Thereby the neuroectoderm is separated the cranial half of the sclerotome (spinal ganglion precursor) and
from the surface ectoderm and the neural crest cells migrate from the ventrally between somites and neural tube (precursor of chromaffin
neuroectodermal epithelium. [L126] cells of the adrenal gland and the intestinal ganglia). [L126]

55
2 General embryology

neural crest cells chemotactically follow the molecular attrac- ly extended caudally in the ‘fairway’ of the primitive node (› Fig.
tant glial cell line-derived neurotrophic factor (GDNF), which 2.8, › Fig. 2.9). At the same time, the primitive streak is gradually
they recognise through the RET membrane receptor. In the shortened, while the germinal disc grows in total, becomes longer
case of defects in either the expression of the GDNF ligand or and in the cranial section the structures of the head are already
the RET receptor, the innervation of the affected intestinal
formed. Finally, at the caudal aspect of the embryo, only the tail
segments is omitted. Due to the resulting lack of peristalsis
the contents of the intestines oral to the diseased intestinal bud remains as the rudiment of the primitive streak where gastru-
portion accumulate and must therefore be surgically removed. lation continues to take place in a modified form until the forma-
tion of the mesoderm of the embryo is completed towards the end
of the 4th week.
NOTE
Neural crest cells originate from the ectodermal neural bulges and NOTE
migrate to the end of the neural tube as mesenchymal progenitor The notochord forms an embryonic axis organ. It is made up of me-
cells in very different target areas of the body, where they are dif- soderm cells from the primitive node and plays an important role
ferentiated as different cell types. as a signal centre in the development of the nervous system and
the somites. In the course of the formation of the vertebral column,
the cells of the chorda presumably enter the nucleus pulposus of
the intervertebral discs.

2.6 Development of the mesoderm

2.6.2 Paraxial mesoderm
2.6.1 Axial mesoderm
Somitogenesis
The epiblast cells, which during gastrulation penetrate through the The mesoderm cells, which in the course of gastrulation move-
primitive node, i.e. the most cranial section of the primitive streak ments come to rest on both sides immediately lateral to the mid-
into the middle germ layer, remain in the midline of the embryo line, form the paraxial mesoderm. They originate from cells that
and migrate cranially as axial mesoderm past the primitive node. migrate caudally of the primitive node through the cranial primi-
In doing so they temporarily penetrate the newly formed entoderm tive streak. Presumably cells of the caudal portion of the primitive
of the midline, displacing it laterally. At this stage, the axial meso- node also succeed in entering the paraxial mesoderm. The paraxial
derm is referred to as the chordal process (syn.: chordal plate, mesoderm is initially created as solid mesenchyme strips bilateral
head process). The chordal process subsequently dissolves as a sol- to the notochord and is referred to as presomitic mesoderm (syn.:
id strand from the entoderm dorsally, and the entoderm cells co- segment plate). The cells at the cranial end of the segment plate
alesce again in the midline and form the pharyngeal entoderm of undergo a mesenchyme epithelial transition (MET) and are ar-
the future (prospective) foregut (› Fig. 2.14). Thus the rod-shaped ranged into epithelial balls (somites) enclosing within it a central
chorda dorsalis is formed from epitheloid mesoderm cells. lumen filled with some mesenchymal cells (somitocoel). This pro-
Only the most cranial part of the axial mesoderm remains mesen- cess progresses as a result of rhythmic motion of a caudally pro-
chymal as part of the prechordal mesoderm (head mesoderm) gressing gastrulation every 4–5 hours, so that the segment plates
and in the course of further development forms the extraocular are continuously segmented as they are extended caudally, in a
muscles. In the further process of gastrulation, the primitive node craniocaudal direction by the formation of somites (somitogenesis
shifts increasingly in a caudal direction, while continuously emit- › Fig. 2.15).
ting mesoderm cells in a cranial direction. The notochord is equal-

Primitive pit with neurenteric canal

Amnion

Body stalk

Ectoderm
Prechordal plate Fig. 2.14 Development of the
Allantois
Section plane b
axial mesoderm. a Longitudinal
section through an embryo in
Chorda extension Cloacal- the middle of the 3rd week. The
Wall of the yolk sac membrane mesodermal cells migrating
Section plane c
a through the primitive nodes
travel cranially in the midline
and form the chordal process
and then the prechordal meso-
derm and the chorda dorsalis.
b The chordal process displaces
the entoderm temporarily into
Notachordal plate the midline. c Later the chordal
b c Chorda process splits from the ento-
Entoderm derm, coming to rest between
the entoderm and the neural
Intra-embryonic Intra-embryonic
mesoderm mesoderm tube and forms the chorda dor-
salis. [L126]

56
 2.6 Development of the mesoderm

Surface
ectoderm Epithelial somite

Neural tube Somitocoel

Intermediate
Neural tube
mesoderm

Somites Lateral plate

a mesoderm

Intermediate mesoderm Entoderm

Chorda dorsalis
Lateral mesodermic plate

Dermomyotome
Superficial ectoderm
Segment plate Sclerotome

Somatopleura

Coelom
Tail bud
Splanchnopleura
b
Fig. 2.15 Somitogenesis. Scanning electron microscopy image of
somitogenesis in a bird embryo. The paraxial mesoderm migrating Aorta
during gastrulation on both sides of the neural tube through the cra-
nial primitive streak forms a mesenchymal stripe (segment plate),
which continuously produces somites at the cranial end by drawing
in of segment limits. In the course of development the segment plate Dermomyotome
is extended by continuation of gastrulation in the tail bud, so that
during somitogenesis the embryo continuously grows in a caudal Myotome
direction. [G394]
Sclerotome

The somitogenesis of both halves of the body occurs in a strictly

synchronous manner and is temporally regulated by the oscillating c
expression of genes, e.g. of the notch signalling pathway, syn.: ‘seg-
mentation clock’). Somitogenesis begins on the 20th day of devel­ Fig. 2.16 Somite maturation. a Transverse section through an
embryo at the level of a newly formed somite. The somite is a hollow
opment at the level of the auditory placodes, and comes to a stop
epithelial ball, whose somitocoel contains mesenchyme. b After a
after the creation of the coccygeal segments in the 5th week. This few hours the ventral half of the somite becomes mesenchymal and
creates the foundation for the segmental blueprint of the trunk: 5 forms the sclerotome. The dorsal half forms an epithelial sheet, the
occipital, 7 cervical, 12 thoracic, 5 lumbar, 5 sacral and 8–10 coccy- dermomyotome. c From the dermomyotome, cells migrate ventrally
geal pairs of somites develop, whereby the most recently formed and form a 3rd compartment, the myotome, containing embryonic
coccygeal somites partially degenerate again. The segmental iden- muscle cells. [L126]
tity of somites, i.e. their region-specific properties, e.g. as cervical
segments, will be conferred on them by a different expression of mites by diffusion and induces EMT. These mesenchymal cells form
various Hox genes, in each segment, which encode transcription the building material of the body skeleton and are therefore referred
factors with homeobox DNA-binding domains (segment-specific to as sclerotome (Gr.: ‘skleros’, hard). Accordingly, the sclerotome
‘Hox code’). cells migrate in an amoeba-like way (› Fig. 2.17)
The paraxial mesoderm positioned cranially to the auditory plac- • in a ventromedial direction around the notochord to form the
ode (paraxial head mesoderm) does not undergo any segmenta- vertebral body,
tion and, together with the prechordal mesoderm provides the • in a dorsomedial direction around the neural tube to form the
building material for parts of the muscles and connective tissue of vertebral arches and
the head. • in the lateral abdominal wall to form the ribs.
The dura mater of the vertebral canal also originates from the
NOTE sclerotome. Within a segment the cranial and caudal halves of the
Somites are segmental portions of the paraxial mesoderm, from sclerotome have different properties. Due to the expression of the
which the skeletal muscles of the body and the axial skeleton origi- repellent effects of the signal molecule ephrin in the caudal half of
nate. the sclerotome, neural crest cells and motor neurons migrate from
the spinal cord only into the cranial half of the respective
sclerotome, in order to form the spinal nerves. The segmental or-
Somite maturation: sclerotome ganisation of the peripheral nervous system therefore emerges sec-
Only a few hours after their formation, the ventral side of the epithe- ondarily as a result of the segmentation of the paraxial mesoderm.
lial somites dissolves into a loose mesenchymal cell bond (epithe­
lial-mesenchyme transition, EMT, › Fig. 2.16). The reason for this Somite maturation: dermomyotome and myotome
is the signal protein formed in the notochord and the basal plate of The epithelial cells of the dorsal half of the somites remaining out-
the tube called sonic hedgehog (Shh), which reaches the ventral so- side the effect of Shh, form a nearly rectangular sheet under the

57
2 General embryology

Ectoderm
Dorsomedial Ectoderm
dermomyotomal lobes
Chorda dorsalis
Myotome Motion
Neural tube
segment

Dermal Spinal system

mesenchyme Cranial
sclerotome
Chorda dorsalis
Dermal mesenchymale

Section plane b
Myotome
Ventrolateral
a Sclerotome dermomyotomal lobes b Arthrotome Caudal sclerotome

Fig. 2.17 Somite differentiation. a Transverse section through a mature somite. The sclerotomal mesenchyme (yellow) encloses the chorda
dorsalis and the neural tube as an annex to the vertebral body and vertebral arch and forms a lateral offshoot as the annex of the ribs. Dorso-
laterally, the sclerotome is limited by the myotomal annex of the back muscles. On one side the epithelial dermomyotome develops into myo-
tome cells and on the other side into dermal connective tissue progenitor cells. The dermomyotomal epithelium only survives at the dermomy-
otomal lips and provides further annex material for both cell lines. b Oblique horizontal section through a. In the cranial section, neural crest
cells form spinal ganglia. Between the cranial and caudal halves of the somite lie the cells of the arthrotome, from which the vertebral joints
develop. They mark the future border between two vertebrae. A mobile segment consists at this stage of two adjacent vertebral systems, the
intermediate joint system and the myotomal muscle fibres of a somite. [L126]

influence of signals from the superficial ectoderm (especially se- site of the segmentally organised trunk musculature (› Fig. 2.17,
creted glycoproteins of the Wnt family, otherwise called ‘Wint’) › Fig. 2.18). The specification of the dermomyotomal progenitor
and the cover plate of the neural tube. This sheet is made up of cells to skeletal muscles is in turn induced by Wnt signals that are
highly prismatic epithelial cells called the dermomyotome . This formed in the cover plate of the neural tube and the superficial ec-
designation gives the impression that the cells of the dermomyo- toderm. The Wnt signals induce the expression of muscle-specific
tome form the building material of dermal connective tissue and regulator genes in the dermomyotome cells, such as the transcrip-
skeletal muscles. Following successful EMT, migrating dermomyo- tion factor MyoD, which determine the fate of their development
tomal cells take several steps ventrally between the dermomyo- as muscle cells and initiate the muscle-specific differentiation of
tome and the sclerotome, and there form a third somite compart- cells. From the medial (epaxial) section of the myotome the au-
ment, called the myotome. The myotome consists of primordial, tochthonous back muscles develop, while from the lateral (hypaxi-
single mononuclear muscle fibres which extend in a craniocaudal al) section the intercostal muscles and the muscles of the abdomi-
direction from segment border to segment border and form the nal wall develop. The segmental arrangement of myotome fibres

Myotomal fibres

Dermomyotome

Fig. 2.18 Myotome formation.

WOLFFIAN duct a The first myotome cells formed
are taken from the dorsomedial
lip of the dermomyotome and
form the epaxial myotome fibres
from which the autochthonous
Neural tube Aorta
muscles later arise. b Then the
ventrolateral lip of the dermo-
a Dorsal aortas b
myotome forms hypaxial myo-
tome fibres, from which the ven-
trolateral abdominal wall
muscles are formed. In addition,
the cranial and caudal edges of
the dermomyotome and later on
also the central dermomyotome
contribute myotome fibres. c At
the level of the extremity system
Extremity no hypaxial myotomes are
bud formed. The hypaxial dermomy-
otome cells migrate as muscle
progenitor cells into the extremi-
ty system. d After the dissolu-
c d tion of the central dermomyo-
tome, the cells migrate into both
the myotome and the subecto-
Dorsomedial Ventrolateral Cranial and caudal
dermal mesenchyme where they
dermomyotomal lobes dermomyotomal lobes lobes of the dermomyotome form the dermis and subcutis.
[G210]

58
 2.6 Development of the mesoderm

remains unchanged in the deep layers of the back muscles and in Clinical remarks
the intercostal muscles and in the cross-segmental systems of the
Errors in the regulation of Hox gene expression in the paraxial
trunk muscles it is only shown in the innervation. In the area of
mesoderm can lead to shifts in the segment identity of indi-
the extremity position no hypaxial myotome is formed, instead vidual vertebrae (homeotic transformation). Examples include
the cells of the lateral (hypaxial) dermomyotome migrate into the cervical ribs, for which topographically cervical vertebrae have
extremity buds as a precursor of the muscles of the extremities a a thoracic identity, or atlas assimilation, where the topo-
(› Fig. 2.21). graphically highest cervical vertebra has an occipital identity
Dermomyotomal cells that do not form muscles, migrate dorsally and becomes part of the occiput. Particularly clinically rele-
under the superficial ectoderm and form the dermis and subcutis vant is the sacralisation of the lumbar vertebral vein. It leads
to the extension of the birth canal (assimilation canal pelvis or
of the back (› Fig. 2.17, › Fig. 2.18). These cells are often re-
‘long pelvis’) and can be an indication for birth by caesarean
ferred to according to their developmental outcome as der- section.
matomes but within the dermomyotome cannot be morphologi-
cally distinguished. Only the dermis of the back is derived from so-
mites, the dermis of the ventral trunk wall and the extremities
derive from the side plate mesoderm and that of the head origi- NOTE
nates from the neural crest of the head. A cervical vertebra arises from the sclerotomes of each of two adja-
cent halves of somites.

NOTE
Origin of the musculoskeletal system: the autochthonous muscu-
lature arises from the epaxial myotomes, the thoracic and abdomi- 2.6.3 Intermediate mesoderm
nal wall musculature arise from the hypaxial myotomes and the ex-
tremity muscles arise from muscle progenitor cells, which migrate The paraxial mesoderm is associated with the lateral mesoderm by
from the lateral dermomyotomes to the extremity site. The skeletal
muscle in the region of the pharyngeal arches is derived from the
a narrow strip of mesenchymal cells, referred to as intermediate
lateral dermomyotomes of the occipital somites and the unseg- mesoderm and contains the building material of the embryonic
mented paraxial head mesoderm. kidneys (› Fig. 2.16, › Fig. 2.19). At the level of the occipital so-
mites, the intermediate mesoderm appears to be absent. In the area
of cervical segments, at the start of the 4th week an initially solid
Development of the movement segment thread from the mesenchyme is dorsolaterally affiliated, which rap-
The derivatives of a single somite form a so-called movement seg- idly becomes an epithelial tube channel (prerenal duct). It is ex-
ment, i.e. the adjacent halves of two neighbouring vertebrae and tended in a caudal direction in the course of the caudally progress-
the joints, muscles and ligaments lying between them (› Fig. ing growth of the embryo in approximately the same way as the
2.17b). The vertebral joints and intervertebral discs arise from the segmentation front of the paraxial mesoderm. This growth is en-
somitocoel cells located at the centre of the somite (arthrotome), sured by the proliferation of a blastema at the caudal tip of the
with the border between two vertebrae running through the mid- duct. As a result, the intermediate mesoderm is divided into:
dle of the somites. A single vertebral body is conversely formed • the epithelial prenephric and mesonephric duct (ductus meso-
from the cranial and caudal halves of the sclerotome of two neigh- nephricus, WOLFFIAN duct), which reaches as far as the cloaca
bouring somites. Therefore, the macroscopically visible segmenta- caudally, and
tion of the spine is offset towards the primary segmentation of the • the ventromedially adjacent mesenchyme, which depending on
embryo by the somites in one half of a segment (resegmentation). the developmental stage of the kidneys (pronephros and meso-
nephros) is referred to as pronephrogenic or mesonephrogenic
mesenchyme.

23rd day 25th day 28th day

Rest of the
Pronephros pronephros

Somites Mesonephros Mesonephros

Intermediate
mesoderm WOLFFIAN duct
Ureteric bud

Metanephrogenic
Mesonephrogenic
blastema
mesenchyme
a b c Cloaca

Fig. 2.19 Development of the intermediate mesoderm. Embryo drawn to demonstrate the intermediate mesoderm, shown transparently.
a The intermediate mesoderm lies laterally to the somite and on day 23 is made up of pronephrogenic and mesonephrogenic mesenchyme.
b The distant cranially lying pronephros degenerates after inducing the formation of the WOLFFIAN duct. The mesonephros begins to form urinary
­corpuscles. c Before the junction of the WOLFFIAN duct into the cloaca, the ureteric bud grows together into the metanephric mesenchyme and
forms the definitive kidney (metanephros). [L126]

59
2 General embryology

While the pronephros remains without any function and degener- NOTE
The intra-embryonic coelom is the primary abdominal cavity and
ates, the WOLFFIAN duct and mesonephrogenic mesenchyme separates the side plate mesoderm into a parietal and a visceral
form the functioning embryonic mesonephros by mutual induc- sheet. From the coelom, the body cavities (peritoneal cavity, pleu-
tion. As development continues, the ureteric bud branches off from ral cavity, pericardial cavity) develop.
the caudal portion of the WOLFFIAN duct; in males the cranial
portion of the WOLFFIAN duct becomes the seminal duct (Vas
deferens, › Fig. 2.19). Somatopleure
From the mesenchyme of the somatopleure during further devel-
NOTE opment, the connective tissue of the ventrolateral trunk wall and
The kidneys as well as the urinary and seminal tracts arise from the extremities arise, including the dermis and subcutis of the skin;
intermediate mesoderm. however, thoracic and abdominal wall muscles and the ribs come
from somites. Streams of migrating cells from the lateral
sclerotome penetrate the mesenchymal matrix of the thoracic so-
matopleure in a segmental arrangement and form the ribs. There-
2.6.4 Lateral mesoderm fore, the ribs in developmental terms are extensions of the spine. In
the trunk the only skeletal element is the sternum from the mesen-
Coelom chyme of the somatopleure. It is produced by chondral ossification
Laterally to the intermediate mesoderm there extends over the en- from 2 bilateral systems (sternal borders), which fuse with the
tire length of the trunk a wide, unsegmented tissue stripe (lateral ventral closure of the embryo.
mesoderm), which in the early embryo changes laterally into the The thoracic hypaxial myotomes push forward between the seg-
extra-embryonic mesoderm and thus constitutes the lateral margin mental rib sites by the consecutive recruitment of muscle progeni-
of the germinal disc. The lateral mesoderm (syn.: side plate meso- tor cells from the hypaxial dermomyotomes ventrolaterally, and
derm) is divided into two superimposed epithelial plates, which form the intercostal muscles. In the abdominal area where no ribs
are separated by a slit-shaped cavity (coelom): are formed, the hypaxial myotomes, having lost their morphologi-
• The posterior plate is referred to as the somatic (syn.: parietal) cally recognisable segmentation, grow into the somatopleure and
side plate mesoderm (› Fig. 2.16). Together with the overlying form the abdominal wall muscles. Aponeuroses and connective tis-
superficial ectoderm, it forms the outer wall of the coelom (so- sue of the thoracic and abdominal wall muscles arise from the side
matopleure). plate mesoderm.
• The plate located ventrally to the coelom is called the visceral The limb systems arise from a local bulging of the somatopleure
side plate mesoderm and together with the underlying entoderm due to the strong proliferation of the somatic mesenchyme (› Fig.
forms the inner wall of the coelomic cavity (splanchnopleure, 2.21, › Chap. 2.10). This creates the connective tissue and the
› Fig. 2.20). skeleton of the extremities from the somatic side plate mesen-
The coelomic cavity opens laterally in the germinal disc stage into chyme. The skeletal muscles of the extremities arise in turn from
the extra-embryonic coelom (syn.: chorionic cavity). After the the somites. Unlike the trunk muscles, they do not originate from
ventral closure of the embryo resulting from the lateral cleavage the myotomes, but they arise from highly mobile myogenic pro-
(› Chap. 2.8.2), the lateral mesoderm fuses ventromedially to the genitor cells, which are disassociated from the hypaxial dermomy-
ventral trunk wall, with the exception of the umbilical cord. The otomes of the somites at the level of the extremity systems, and mi-
coelom joins onto the embryonic abdominal cavity. grate into the mesenchymal matrix of the extremity buds, where
The mesodermal cell layer of the somatopleure and splanchnopleu- they are differentiated into muscle fibres (› Fig. 2.21).
re directly adjacent to the coelomic cavity remains epithelial and
covers the abdominal cavity as parietal and visceral serosa. The NOTE
deeper lying cells of both mesodermal layers become mesenchymal The ventrolateral body wall and the extremities arise from the so-
(EMT) and form the somatic mesenchyme between the serosa and matopleure, with the exception of the muscles, which originate
the ectoderm and the visceral mesenchyme located between the from the somites.
serosa and the entoderm (› Fig. 2.21).

Chorda Paraxial Intermediate Amnion Neural groove Somatopleure Somite

Amniotic sac mesoderm mesoderm
Intra-embryonic Intermediate
Lateral Ectoderm Parietal mesoderm
mesoderm coelomic cavity
mesoderm
Intercellular
columns in
the lateral Entoderm
plate

Visceral
mesoderm
Splanchno-
a Paraxial mesoderm b Dorsal aorta c pleurale d Entoderm

Fig. 2.20 Development of the lateral mesoderm. a The lateral mesoderm or lateral plate mesoderm lies at the edge of the germinal disc lateral-
ly to the paraxial and intermediate mesoderm. b The coelom is formed by the formation of fissures in the lateral mesoderm. c The dorsal por-
tion of the lateral plate mesoderm and the ectoderm (somatopleure) lying above it are merged into the wall of the amniotic cavity. The ventral
portion of the side plate mesoderm and the underlying entoderm (splanchnopleure) are included in the wall of the yolk sac. d The coelom is
located between the somatopleure and the splanchnopleure. [L126]

60
 2.8 Folding movements of the embryo

Dermomyotome

Myotome Somite

Neural tube Sclerotome

Progenitor cells of the extremity

muscles from the hypaxial
dermomyotome Fig. 2.21 Mesoderm develop-
Chorda ment. Semi-schematic
Aorta
cross-section through an
Apical ectodermal
embryo towards the end of the
ridge
WOLFFIAN duct 4th week. The somatopleure
forms the ventrolateral abdomi-
Embryonal tubule
Ectoderm nal wall and the splanchnopleure
Somatic forms the wall of the gut and the
Mesenterium Somatopleure mesentery. The extremity annex
mesenchyme
Parietal layer occurs as a thickening of the
somatopleure and is colonised
Visceral serosa by myogenic progenitor cells
Visceral mesenchyme Splanchnopleure from the somites, which are
Entoderm arranged ventrally and dorsally
as a premuscle mass. [L126]

Splanchnopleure Lung diverticulum

The splanchnopleure envelops the entodermal intestinal tube and
its appendages after the ventral closure of the abdominal wall
(› Fig. 2.21). It forms the visceral serosa and the underlying sub- Buccopharyngeal
Foregut
peritoneal, subpleural and subpericardial connective tissue as well membrane
as the connective tissue and the smooth muscles of the gastroin-
testinal tract and the lungs. In the most cranial section of the lateral
Heart
mesoderm, the site material of the myocardium (cardioembryonic Duodenum
plate) forms in the splanchnopleure which, after fusion of the Hepatic system
paired heart system is surrounded by the most cranial section of Vitelline duct
the coelom as the pericardial cavity.
Midgut

NOTE Allantois
The splanchnopleure gives rise to the mesodermal wall of the gas-
Hindgut
trointestinal tract and the heart.
Cloacal membrane

Fig. 2.22 Development of the entoderm. Embryo towards the end of

2.7 Development of the entoderm the 4th week. The vitelline duct divides the intestines into the fore-
gut, midgut and hindgut. The oral and anal openings of the gut are
initially closed (buccopharyngeal membrane or cloacal membrane).
The entoderm is initially present as a flat, epithelial layer of the
[L126]
ventral surface of the three-leaved germinal disc. The embryo
forms the roof of the yolk sac with quasi ‘open abdomen’. As part of
the formation of the definitive body shape by cleavage movements The wall of the gastrointestinal tract and the organs annexed to the
of the embryo (› Chap. 2.8), the entoderm is ventromedially intestines, including the lungs, are formed from the entodermal ep­
drilled in and attaches to the ventrally closed intestinal tube ithelium of the intestinal tube by inductive interaction with the
(› Fig. 2.21). The connection to the yolk sac remains only at the surrounding mesenchyme of the splanchnopleure (and the neural
navel in the form of the vitelline duct (Ductus omphaloentericus, crest in the pharyngeal gut).
Ductus vitellinus). The intestinal section in the area of the vitelline
duct is referred to as the midgut, sections located further towards NOTE
the mouth are defined as the foregut; and the sections located ab- The epithelial lining of the intestinal tube and its annex organs de-
orally thereof are designated as the hindgut (› Fig. 2.22). The em- velop from the embryonic entoderm. Conversely, the smooth mus-
bryonic intestinal tube remains closed at its cranial and caudal end: cles and connective tissue of the gastrointestinal tract are derived
• The buccopharyngeal membrane arises from the meso- from the splanchnopleure.
derm-free prechordal plate and closes the entodermal foregut
opposite the ectoderm-lined stomatodeum.
• The cloacal membrane opens into the hindgut opposite the 2.8 Folding movements of the embryo
ectoderm-lined proctodeum.
After the repositioning of the development-linked umbilical hernia Until the start of the 4th week, the embryo is a flat germinal disc,
towards the end of the 3rd month the vitelline duct obliterates but which has stretched from an initial round plate into a longitudinally
can persist in the adult ileum in approximately 3% of cases as oval plate. Along the primitive streak, the germ layers of ectoderm,
MECKEL's diverticulum. mesoderm and entoderm are formed as part of gastrulation. Dor-

61
2 General embryology

sally above the embryo is the amniotic cavity, the base of which is (Ductus omphaloentericus) comes to rest caudally to the heart
formed from superficial ectoderm. Ventrally beneath the embryo is (› Fig. 2.23).
the secondary yolk sac, the roof of which is formed by the ento- • The tail bud is raised at the caudal end of the embryo from the
derm. The germ layers and the coelom merge laterally and seam- amnion, and curves together with the hindgut ventrally. The al-
lessly into the extra-embryonic tissue. The embryonic ectoderm lantois comes to rest in the area of what will later become the
merges into the amniotic epithelium, the somatic lateral mesoderm umbilical cord, caudal of the vitelline duct. The resulting blind
merges into the extra-embryonic mesoderm of the chorionic cavity, ending section of the gut arising from the tail fold (tail gut),
the visceral lateral mesoderm merges into the extra-embryonic me- caudal to the cloaca, is then obliterated.
soderm of the yolk sac, and the entoderm merges into the yolk sac
epithelium. The embryonic coelom is openly connected laterally to
the chorionic cavity. The three-dimensional shape of the embryo, 2.8.2 Lateral folding up
in which the body wall encloses the abdominal cavity and the intes-
tinal tube, only emerges in the course of the 4th week by folding As a result of the strong growth in the course of the 4th week, the
movements of the germinal disc in the sagittal and transverse germinal disc bulges to form a cap lying over the yolk sac, which is
planes. In this way the embryo develops a blueprint typical of verte- narrowing at the same time to become the vitelline duct (› Fig.
brates (basic body form). The extra-embryonic parts of the embryo 2.24). As a consequence as well as the craniocaudal curvature,
then form the foetal parts of the pla­centa, and the embryo only re- there is lateral folding; somatopleure and splanchnopleure
mains linked to this via the umbilical cord. (› Chap. 2.6.4) bend ventromedially, while the paraxial meso-
derm and the axillary organs (notochord and neural tube) retain
NOTE their dorsal location. The somatopleure and splanchnopleure final-
The three-dimensional shape of the embryo occurs in the course of ly fuse in a zip-like fashion in the ventral centre line; only in the
the 4th week by craniocaudal and lateral cleavage movements. area of the navel does the embryo remain ventrally open to the yolk
sac. On the outside the amnion, which is attached to the ectoderm,
unfolds together with the somatopleure of the embryo and lies over
2.8.1 Craniocaudal curvature the thus formed umbilical cord as an epithelial cover. Therefore,
the embryo is covered on all sides by the amniotic cavity, and the
In the sagittal plane the head folds are formed at the cranial end of ectoderm of the amniotic fluid flows round it.
the embryo and the tail fold forms at the caudal end: On the ventral side, the entoderm curves together with the
• The head fold is created by the strong growth of the brain sys- splanchnopleure ventromedially and attaches in the ventral centre
tem in the cranial neural tube, which bulges in a cranial and line to the foregut. As a result, the left and right embryonic coelom
ventral direction. The heart system positioned in front of the cavities also connect to the shared abdominal cavity, and the con-
head of the embryo is overgrown by the head structures press- nection between the embryonic coelom and the chorionic cavity,
ing cranially and displaced ventrally and caudally in relation to which exists up to this point, is closed.
the head and throat area (the descent of the heart). The yolk
sac is narrowed cranially in such a way that the vitelline duct

Entoderm Foregut Hindgut

Amniotic sac
Cloacal membrane

Body stalk
Prechordal plate

Heart system Allantois

Cardiac tube

Pericardial
a b cavity

Fig. 2.23 Craniocaudal curva-

Hepatic diverticulum ture; longitudinal sections. a An
Cardiac tube Lung bud 18-day-old embryo in the germi-
Midgut nal disc stage. b A 20-day-old
Pharyngeal embryo during neurulation.
membrane
Vitelline Heart system and tail bud rotate
Cloacal membrane duct ventrally. c A 21-day-old
embryo. As a result of the
Allantois
descent of the heart and the for-
mation of the hind gut, the yolk
sac becomes increasingly con-
stricted. d A 30-day-old embryo.
Remnants of the
pharyngeal membrane Yolk sac The intestinal tube has closed
and only remains in contact with
c d the yolk sac via the vitelline
duct. [L126]

62
 2.9 Extra-embryonic tissue

Amniotic sac Surface

ectoderm

Parietal
mesoderm
Intra-
Visceral embryonic
mesoderm coelomic cavity
Gut
a b c
Transition from the
Yolk sac gut into the yolk sac

Fig. 2.24 Lateral folding; cross-sections. a A 21-day-old embryo. Somatopleure and amnion grow together ventrolaterally. b A 22-day-old
embryo. The yolk sac becomes increasingly constricted. c A 30-day-old embryo. The splanchnopleure together with the entoderm has closed to
become the intestinal tube. The somatopleure together with the ectoderm has closed onto the ventral wall of the trunk and the amnion com-
pletely envelops the embryo. Between the somatopleure and the splanchnopleure the coelom which is now closed becomes the embryonic
abdominal cavity. [L126]

Clinical remarks 2.9.2 Chorionic cavity and yolk sac

If as part of the lateral folding, the ventromedial closure of the In the middle of the 2nd week the embryo still displays the basic
abdominal wall remains incomplete, the coelom remains open
towards the amniotic cavity and intestinal loops can freely pro-
form of the blastocyst despite the differentiation processes in the
trude into the abdomen (gastroschisis), or in the thorax the embryoblast and trophoblast; however, the blastocoel will be re-
heart can protrude freely in the amniotic cavity (Ectopia cordis). ferred to thereafter as the primary yolk sac. This is covered on the
inside by the hypoblast cells displaced laterally during gastrulation
(› Chap. 2.4) (primary yolk sack epithelium, syn.: HEUSER's
membrane). Between the cytotrophoblast and primary yolk sac ep-
ithelium migrates as a loose aggregation into the cells of the extra-
2.9 Extra-embryonic tissue embryonic mesoderm. While trophoblast and extra-embryonic
mesoderm display strong growth, the primary yolk sac lags behind
Only some of the cells of the early embryo become part of the actu- in terms of growth and becomes detached from the cytotropho-
al embryo (› Chap. 2.3.1). Other cells develop into extra-embry- blasts. This creates lacunae in the growing extra-embryonic meso-
onic structures, whose function is to supply the embryo with nu- derm, which continue to coalesce and finally form a large, continu-
trients and oxygen and the creation of a favourable intrauterine en- ous cavity between the primary yolk sac and the trophoblast (cho-
vironment. Finally, the extra-embryonic tissues largely go into the rionic cavity, syn.: extra-embryonic coelom, › Fig. 2.25). The
placenta and at birth are expelled as the afterbirth. extra-embryonic mesoderm covers the chorionic cavity externally
at the border to the cytotrophoblast (parietal extra-embryonic
mesoderm) as well as inside at the border to the yolk sac (visceral
2.9.1 Trophoblast extra-embryonic mesoderm). In the primary yolk sac, however,
there is annular constriction and detachment of the distal part of
As early as the first week the embryoblast and trophoblast separate the yolk sac, which loses its connection to the embryo (exocoelo-
in the blastocyst (› Chap. 2.3.1). At implantation, the trophoblast mic cyst) and finally perishes (› Fig. 2.25). The proximal part of
fully penetrates into the endometrium of the uterus and as such is the yolk sac is lined by a succeeding population of hypoblast cells
the contact with the maternal tissues. At the edge of the endometri- and now forms the secondary (syn.: definitive) yolk sac. This
um, the trophoblast cells fuse into a single giant cell with multiple means that the wall of the secondary yolk sac consists of an inner
nuclei (syncytium), which surrounds the embryo like a shell. In epithelial layer formed from hypoblast (extra-embryonic ento-
the course of further growth, the cells of the highly proliferating derm) and an outer layer of visceral extra-embryonic mesoderm,
cellular trophoblasts are in constant fusion (cytotrophoblast) with demarcating the yolk sac from the chorionic cavity. Later blood
the external syncytiotrophoblast, thus growing and penetrating cells (haematopoiesis) and original germ cells arise from the vis-
further into the uterus wall. Within the syncytiotrophoblasts, ceral extra-embryonic mesoderm of the yolk sac. The outer wall of
membrane-covered, extracytoplasmic vacuoles (trophoblastic la- the embryo, which is made up of parietal extra-embryonic meso-
cunae) are formed, which increasingly fuse and form an intracellu- derm and the trophoblast, is named the chorion. The majority of
lar, fluid-filled system of channels. Where syncytiotrophoblast the foetal placenta arise later from the chorion.
come into contact with maternal blood vessels, their vessel walls
dissolve and the maternal blood flows into the trophoblastic lacu- NOTE
nae. Thus the syncytiotrophoblast is switched towards the end of Although the embryo of mammals and of humans has no yolk, a
the 2nd week between the arterial and venous leg of the endometri- yolk sac is formed as with the embryos of egg-laying vertebrates.
al vessels, and the incipient uteroplacental circulation enables the The yolk sac is phylogenetically preserved, because the original
supply of the growing embryo by the maternal blood. germ cells and blood cells arise from the wall of the yolk sac, mak-
ing it also essential for mammalian embryos.

63
2 General embryology

Eroded uterine gland

Lacunary network
2.9.3 Amnion
Maternal blood

Amniotic sac
The amniotic epithelium exists from the beginning of the 2nd
week as a separation of the dorsal epiblast and envelopes the am­
Uterine gland
niotic cavity lying initially dorsal to the germinal disc. It merges
on the border into the surface ectoderm of the germinal disc and is
therefore referred to as extra-embryonic ectoderm. In the course
Extra-embryonic
coelom
of embryonic folding movements in the 3rd week (› Chap. 2.8),
(chorionic cavity) the amniotic cavity completely envelopes the entire embryo up to
Yolk sac
the body stalk. Together with the yolk sac, the amniotic epithelium
epithelium facing the chorionic cavity is covered with visceral extra-embry-
onic mesoderm. In the course of the 2nd month , the embryo and
the amnion surrounding it grow stronger than both enveloping
Cytotrophoblast chorionic cavities so that at the end of the 3rd month the lumen of
a
the chorionic cavity is entirely displaced by the amnion and, to-
Twin-layered
germinal disc
gether with the chorion, the amnion forms the wall of the amniot-
ic sac (› Fig. 2.26).
Extra-embryonic
Phylogenetically, the amnion should be understood as an adapta-
parietal mesoderm
Maternal sinusoid tion to life on land. It enables embryonic development within the
egg in dry environments, in the form of a liquid-filled amniotic
Lacunary network
cavity, which encloses the embryo similar to an aquarium, and pro-
tects it from drying out. In the secondary development transposed
Primary within the moist environment of the uterus of mammals and hu-
chorionic villus
mans this feature again becomes less important. Due to their devel-
opment in the amniotic cavity, reptiles, birds and mammals are
Endometrium
grouped together as amniotes.

Chorion
Clinical remarks
Primary The amniotic fluid is formed from the amniotic epithelium,
yolk sac drunk by the foetus, partly reabsorbed by the foetal intestines
and passed through the placenta into the maternal blood,
b
partly excreted through the foetal kidneys and urine back into
Extra-embryonic coelom the amniotic sac. If this balance is disturbed, too little (oligo-
Extra-embryonic (chorionic cavity) hydramnios, risk of malformations due to compression) or too
visceral mesoderm much (polyhydramnios, risk of rupture of the membrane) am-
niotic fluid may be present. This can be treated by amniotic
Maternal blood infusion or amniotic puncture.
Body stalk In cases of a suspected foetal genetic abnormality, as part of
the prenatal diagnosis, the amniotic cavity can be punctured
through the abdominal wall, uterine wall, chorion and amni-
on. The paediatric cells floating in the amniotic fluid can be
removed at minimum risk to the foetus and genetically tested
Secondary (amniocentesis).
yolk sac

NOTE
The amnion completely envelops the foetus and in the foetal peri-
Extra-embryonic od forms the amniotic sac and the foetal portion of the placenta to-
parietal mesoderm gether with the chorion.
c

Remnant of the Epithelium of the

primary yolk sac endometrium 2.9.4 Allantois
(exocoelomic
cyst)
From the ventral wall of the hind gut an entodermal diverticulum
Fig. 2.25 Early development of extra-embryonic tissue. called the allantois, is pulled into the extra-embryonic mesoderm of
a A 12-day-old embryo. The syncytiotrophoblast taps into vessels of the body stalk. Here it seems to play a role in the development of the
the maternal endometrium so that the maternal blood flows freely umbilical vessels. The important function of the allantois for other
into the trophoblast lacunae. Due to the formation of fissures the amniotes is the storage of nitrogen metabolites (embryonic bladder);
chorionic cavity forms in the extra-embryonic mesoderm. b A 13-day-
this is irrelevant in mammals and humans due to the excretory func-
old embryo. As a result of the confluence of the chorionic fissures,
the chorionic cavity becomes a cohesive cavity. The primary yolk sac tion of the placenta. The allantois becomes narrower as it continues
is constricted annularly. c A 14-day-old embryo. The rest of the prima- in its developmental process into a duct (urachus), which is obliter-
ry yolk sac is cut off as the exocoelomic cyst; the secondary yolk sac ated postnatally to the Lig. umbiliacale medianum. The bladder is
is coated with entoderm cells. [E347-09] at the junction of the allantois into the entodermal cloaca.

64
 2.10 Early development of the extremities

Amnion Body stalk

Chorionic villus

Germ disc

Yolk sac

a Chorion
a b

Growing amniotic cavity

(expansion direction indicated
by arrow heads)

Body stalk

Embryonic bowel
M
Yolk sac
E
b Chorionic cavity

Chorionic cavity

Amniotic sac c d AER

Fig. 2.27 Extremity buds; scanning electron microscopy images. a A

Fetal bowel
26-day-old embryo. The arm system (arrow) is already recognisable,
Umbilical cord the leg system first appears later on day 28. b A 29-day-old embryo
(with amniotic sac) with well-demarcated arm bud (arrow). It is located in the side plate
mesoderm lateral to the segmental somites. c A 32-day-old embryo,
Yolk sac lateral view of an extremity bud. The apical ectodermal ridge (AER,
arrow) pulls as an ectodermal sickle-shaped thickening in an antero-
c
posterior direction over the tip of the extremity bud. The rectangle
indicates the sectional plane in d. d Longitudinal section through a
limb bud; E = ectoderm, M = mesenchyme. In the area of apical ecto-
Amniotic sac
dermal ridge (AER) the ectoderm is thickened. [G394]

Umbilical cord
somatic side plate mesoderm and an epithelial sheath made from ec-
toderm (› Fig. 2.27). The strong growth of the extremity buds comes
Placenta
(chorion frondosum)
from the action of growth factors of the FGF family (fibroblast
growth factor). The expression of FGF10 in the mesenchyme of the
Remnants of
extremity buds induces the expression of FGF8 in the distal ecto-
the yolk sac derm, which maintains the expression of FGF10 in the mesenchyme
and so, by mutual induction (positive feedback loop), interacts with
Amnion the continued proliferation of the mesenchyme of the extremities.
d
Chorion laeve
2.10.2 Pattern formation in the extremities positions
Fig. 2.26 Subsequent development of extra-embryonic tissue.
a 3rd week: the amnion covers the dorsal surface of the embryo, the The position of the basic blueprint of the extremities (pattern for-
chorionic cavity between the embryo and the trophoblast is relatively
large. b 4th week: in the course of the unfolding movements, the
mation) along the three spatial axes is largely determined by 3 sig-
amnion envelopes the entire embryo except the umbilical cord. c The nal centres.
amnion grows strongly, while the lumen of the chorionic cavity and A decisive factor for the creation of the longitudinal axis (proxi-
yolk sac become relatively smaller. d The amnion has fully displaced modistal pattern formation) of the limbs are signals from the distal
the chorionic cavity and now forms the amniotic sac. The yolk sac ectoderm of the extremities bud. These cells become increasingly
recedes back to the rudimentary stage. [E347-09] highly prismatic and form a crescent moon-shaped (apical ectoder-
mal ridge, AER), which runs crescent-shaped from the posterior to
the anterior edge over the tip of the extremities bud (› Fig. 2.21,
2.10 Early development of the extremities › Fig. 2.27, › Fig. 2.28). The cells of the AER continually secrete
FGF8 (› Chap. 2.10.1) and by doing so not only control the length
of growth of the limb, but also the successive creation of the shoul-
2.10.1 Formation of the extremity buds der, upper arm, forearm and hand, with the proximal structures cre-
ated earlier and the distal structures created later. Apparently, the
In the 4th week laterally protruding arch-shaped bulges (extremity mesenchymal cells form more distal structures, the longer and stron-
buds) form in the somatopleure, bilaterally at the level of the lower ger they are exposed to the FGF signals from the AER.
cervical and the lower lumbosacral somites. The extremity buds are Anteroposterior pattern formation, i.e. the arrangement of ana-
made up of a highly proliferating mesenchymal nucleus made from tomical structures in the radioulnar or tibiofibular axis, is based on

65
2 General embryology

2.10.3 Origin of the skeleton and the muscles of

the extremities

The precursor extremity mesenchyme from the somatopleure of

FGF10 FGF8 the lateral mesoderm provides the building material for connective
and supporting tissues of the limb. Here the mesenchyme is con-
solidated, dependent on the above-mentioned pattern formation
a b Shh processes to become chondrogenic zones, from which the later
parts of the skeleton arise.
Fig. 2.28 Induction processes in the development of the extremities. The musculature of the extremities, on the other hand, is not de-
a Proof of the expression of sonic hedgehog (Shh) in the zone of rived from the somatopleure but is formed from the progenitor
polarising activity (ZPA) by in situ hybridisation. [G394] b Simplified cells (myoblasts) from the hypaxial dermomyotomes of the so-
presentation of induction processes in the extremities bud. FGF8
mites, which migrate into the connective tissue matrix of the ex-
from the AER induces the expression of FGF10 in the extremity mes-
enchyme and this in turn, maintains the expression of FGF8 (positive tremities systems and are arranged as ventral and dorsal premuscle
feedback loop). In addition, the Shh in the ZPA indirectly maintains masses on the future flexor and extensor sides of the extremities
the expression of FGF8 in the AER and vice versa. As a result, the (› Fig. 2.21). The splitting and positioning of the anatomical
proximodistal pattern formation via FGF and the anteroposterior pat- muscles arising from the premuscle masses is probably controlled
tern formation via Shh are coupled together. [L126] by signals from the local connective tissue.

the activity of the signal molecule sonic hedgehog (Shh). The Shh
is expressed in a mesenchymal area on the posterior edge of the ex-
Clinical remarks
tremities mesenchyme (zone of polarising activity, ZPA, › Fig. Disorders of the complex regulation of pattern formation of
2.28). Based on the ZPA, the expression of Shh, which is in turn ac- the extremities can lead to a variety of congenital malforma-
tivated by FGF from the AER, forms a concentration gradient by tions, e.g. polydactylism as a result of a mutation of Shh regu-
diffusion in the extracellular fluid space of the extremities mesen- lator sequences and brachydactylism as a result of a mutation
in the gene for an FGF receptor.
chyme along the anteroposterior axis. The Shh acts as a morpho-
gen: a high concentration of Shh and long-lasting exposure of the
cells in the posterior mesenchyme conveys ulnar positional infor-
mation, a low concentration of Shh in the anterior mesenchyme NOTE
conveys radial positional information. The skeleton of the extremities develops locally in the extremity
As with the regionalisation of the paraxial mesoderm (› Chap. buds and originates from the mesenchyme of the somatopleure.
2.6.2), Hox genes play an important role in the specification of the The musculature migrates into the extremity buds and derives from
the somites.
cells along both the proximodistal and anteroposterior axes
(› Fig. 2.29). Thus, for example, the skeleton of the forearm (zeu-
gopod) is specified by a combined expression of Hox11, in addition
to Hox9 and Hox10 (hox code). 2.11 Early development of the head and throat
The dorsoventral pattern formation of the extremities is con- area
trolled by the interaction of multiple genes in ectoderm and mes-
enchyme; a key role is played by a secreted signal molecule
(Wnt7a), which is expressed exclusively in the dorsal ectoderm 2.11.1 Pharyngeal arches
and at the beginning of a signal cascade seems to control the differ-
ent development of flexor and extensor sides of the extremities. In the body wall of the head-throat area the pharyngeal arches are
formed in the 4th week in cranio caudal sequence, (pharyngeal
NOTE arches, branchial or gill arches). Phylogenetically these go back to
The proximodistal pattern formation of the extremities is controlled the gill arches of fish and, in their basic arrangement recall the gill
by signals from the apical ectodermal ridge (AER) and the antero- apparatus of sharks. Between the pharyngeal grooves depressed
posterior pattern formation of the extremities is controlled by sig- into the surface ectoderm and in the entodermal gut wall of evert-
nals from the zone of polarising activity (ZPA). ed pharyngeal pouches the pharyngeal arches protrude as mesen-

Hox 9

Hox 10

Hox 11

Hox 12 Fig. 2.29 Hox genes determine

the identity of the arm skeleton.
Hox 13 The pattern formation of the
extremities skeleton, such as
hand, wrist, forearm, upper arm
and shoulder blade is deter-
mined by different combinations
of expression of hox genes (here
hox 9-13). [G394]

66
 2.11 Early development of the head and throat area

Ventricle

Pharyngeal
2 3 arch
1
4
6 Cartilage Pharyngeal
groove

Cranial
nerve
Pharyngeal
Artery pocket

Laryngo-
tracheal
groove Floor of the
pharyngeal
gut
Neural tube
a b c

Fig. 2.30 Pharyngeal arches. a Scanning electron microscopy image of the embryo at the beginning of the 5th week. The numbers 1–4 and 6
identify the individual pharyngeal arches; the line shows the section direction in b. b Frontal section through the pharyngeal arch region, dor-
sal view. Each pharyngeal arch has a skeletal element, an artery and a cranial nerve branch. c Scanning electron microscopy image of a pharyn-
geal arch by frontal section as in b. Each pharyngeal arch is covered on the inside by entodermal epithelium and on the outside by ectodermal
epithelium and is filled with mesenchyme. a und c: [G394]; b: [L126]

chymal ridges (› Fig. 2.30). Unlike fish gills the pharyngeal the cranial neural crest. Skeletal musculature also migrates into
grooves and pouches, which are equivalent to gill slits, are not con- the mesenchyme of the pharangeal arches. It comes from both the
tinuous, instead they are closed at one end. In humans, only 5 of dermomyotomes of the occipital somites (and form the muscles of
the original 6 pharyngeal arches are formed. They are designated the larynx and tongue) as well as from the unsegmented cranially
from cranial to caudal as arches 1 (mandibular arch), 2 (hyoid located paraxial cranial mesoderm (forms the head muscles).
arch), 3, 4 and 6 (› Table 2.1). From comparative anatomy we Thus, each pharyngeal arch is covered laterally by ectoderm and
know that the 5th arch is absent in humans. Again, equivalent to medially by entoderm and contains the derivative of neural crest
fish gills each arch contains a skeletal element, an artery as a mesenchyme and a skeletal element arising from it. There is a cranial
branch of the ventral aorta and a characteristic cranial nerve nerve branch, an aortic arch and skeletal muscle migrated from the
(› Fig. 2.30). The mesenchyme, from which the skeleton and paraxial mesoderm (› Fig. 2.30, › Fig. 2.31, › Fig. 2.32, › Fig.
­connective tissue of the pharyngeal arch originates, comes from 2.33, › Fig. 2.34).

2nd pharyngeal arch artery

1st pharyngeal pouch
3rd pharyngeal arch artery

Mesencephalon 4th pharyngeal arch artery

6th pharyngeal arch artery

Esophagus
RATHKE’s
pouch Lung bud
Fig. 2.31 Pharyngeal arch arter-
Thyroid
Dorsal aorta ies. The pharyngeal arch arteries
diverticulum run in the same way as the gill
Esophagus
arteries of fish, from the ventral
”Ventral aorta“ Truncus arteriosus aorta through the pharyngeal
Heart (joint outflow tract of the heart) arches to the dorsal aorta.
[E347-09]

Fig. 2.32 Innervation of the

pharyngeal arches and origin of
the neural crest cells. a The
Cranial nerves pharyngeal arches are supplied
V VII IX X by the cranial nerves, trigeminal
Mesencephalon
nerve [V], facial nerve [VII], glos-
Eye Rhombomere 1 sopharyngeal nerve [IX] and
Rhombomere 2 vagus nerve [X] b The pharynge-
Pharyngeal arch 1 al arch mesenchyme of the
Rhombomere 3
respective arches originates
Pharyngeal arch 2
a Rhombomere 4 from the head neural crest of
Pharyngeal arch 3 Rhombomere 5
different sections of the embry-
onic brain (rhombomeres). The
Pharyngeal arch 4 Rhombomere 6 neural crest cells migrate into
b Ear vesicles Rhombomere 7 the pharyngeal arches depend-
ing on the segment. [E347-09]

67
2 General embryology

Table 2.1 Pharyngeal arches.

Pharyngeal arch Skeletal element Nerve Muscles Artery

1 (Mandibular arch) • From maxillary cartilage (quadratus): Incus, N. trigeminus [V], From paraxial head mesoderm: mas- (A. maxillaris)
Ala major ossis sphenoidalis N. mandibularis [V/3], ticatory muscles, M. digastricus ven-
• From MECKEL's cartilage: Malleus, Lig. N. maxillaris [V/2] tor anterior, M. tensor veli palatini,
sphenomandibulare M. tensor tympani
• By desmal ossification: Os maxillare, Os
zygomaticum, Os temporale pars squamo-
sa, Mandibula
2 (Hyoid arch) From REICHERT's cartilage: Stapes, Proc. sty- N. facialis [VII] From paraxial head mesoderm: (A. stapedia)
loideus, Lig. stylohyoideum, Cornu minus and mimic facial muscles including
upper part of the hyoid bone M. buccinator and Mm. auriculares,
M. digastricus venter posterior,
M. stylohyoideus, M. stapedius
3 Cornu majus and lower part of the hyoid bone N. glossopharyngeus From paraxial head mesoderm: Parts of the A. carotis communis
[IX] M. stylopharyngeus and A. carotis interna
4 Laryngeal skeleton N. vagus [X], From occipital somites: • 4th left aortic arch: Arcus Aortae
N. laryngeus superior M. cricothyroideus, M. levator veli • 4th right aortic arch: Truncus
palatini, M. constrictor pharyngis brachiocephalicus
6 Laryngeal skeleton N. vagus [X], From occipital somites: inner laryn- A. pulmonalis
N. laryngeus inferior geal muscles

Spina ossis
sphenoidalis
Hammer
Location of the inner ear system
Cartilage of the Anvil Ear ossicle
1st pharyngeal arch Cartilage of the Lig. spheno-
(MECKEL) Stirrup
2nd pharyngeal mandibulare
arch (REICHERT)
Proc. styloideus

Former position of Lig. stylohyoideum

MECKEL’s cartilage
Os hyoideum,
Cornu majus
Os hyoideum,
Cornu minus Thyroid cartilage

a Body of the os hyoideum b Cricoid cartilage

Cartilage of the Cartilage of the Cartilage of the Cartilage of the 4th and
1st pharyngeal arch 2nd pharyngeal arch 3rd pharyngeal arch 6th pharyngeal arches

Fig. 2.33 Skeleton of the pharyngeal arches. The cells of the head neural crest form characteristic skeletal elements in the pharyngeal arches;
from these, in the course of further development, different bones and ligaments arise. [E347-09]

M. temporalis
M. orbicularis oculi
M. auricularis anterior
M. occipitofrontalis,
Unsegmented cranial venter frontalis M. occipitofrontalis,
paraxial mesoderm venter occipitalis
Occipital somites M. buccinator
M. stylohyoideus
M. orbicularis oris
M. digastricus,
M. masseter venter posterior

M. stylopharyngeus
M. mylohyoideus

Pharyngeal muscles
M. digastricus,
a venter anterior b
Platysma

M. sternocleidomastoideus Clavicula

Muscles of the Muscles of the Muscles of the Muscles of the 4th and
1st pharyngeal arch 2nd pharyngeal arch 3rd pharyngeal arch 6th pharyngeal arches

Fig. 2.34 Muscles of the pharyngeal arch. a The skeletal muscles of the pharyngeal arches develop from the cranial paraxial mesoderm, both
from the unsegmented cranial mesoderm as well as from the occipital somites. b From here the myogenic cells migrate into the pharyngeal
arch mesenchyme and differentiate into individual muscle groups that are innervated by the cranial nerves according to their origin. [E347-09]

68
 2.11 Early development of the head and throat area

NOTE the hammer (malleus) of the middle ear, and in the mandibular
In the human embryo 5 pharyngeal arches are formed, each of
which contains a skeletal element, an artery and a cranial nerve.
ridge MECKEL's cartilage, becomes the anvil (incus) of the mid-
They are covered outside by ectoderm and inside by entoderm. dle ear. The bones of the definitive upper and lower jaw are created
by desmal ossification from the neural crest mesenchyme. The
main nerve is the N. trigeminus with the N. maxillaris[V/2] and
Mandibular arch the N. mandibularis [v3], supplying the immigrated musculature
The 1st pharyngeal arch (mandibular arch, › Table 2.1) arises at in the mandibular arch (e.g. masticatory and palate muscles). The
the beginning of the 4th week as the first of the pharyngeal arches. 1st aortic arch passing through the mandibular arch probably re-
It is arched like a brace and consists of two branches, a cranial mains partially unchanged as the maxillary artery.
maxillary ridge and the caudally connecting mandibular ridge.
Between them is the stomatodeum; › Fig. 2.37. However, some Hyoid arch
authors consider the maxillary ridge to be a separate formation of Approximately 2 days after the mandibular arch the hyoid arch is
the mesenchyme of the head cranial to the 1st pharyngeal arch. The formed as the 2nd pharyngeal arch (› Table 2.1). Its mesenchyme
mesenchyme of the mandibular arch is derived from neural crest is mainly derived from rhombomere 4 and forms REICHERT's
cells of the mesencephalon and segments (rhombomeres) 1 and 2 cartilage, from which the stirrup (stapes) of the middle ear, the
of the hind brain. A cartilage element (Quadratum) is formed in styloid process and parts of the hyoid bone arise. The main nerve
the maxillary ridge, which by chondral ossification later becomes is the N. facialis [VII] which innervates the muscles of the middle

Germ layer derivatives

Ectoderm Mesoderm/mesectoderm Entoderm

Foramen caecum
Thyroid bud
Pharyngeal Tongue ridges
grooves arches Tongue
Pharyngeal pouches
1 1. Recessus
1 tubotympanicus
2. Meatus
2 acusticus
2 3.
Sinus 3 externus Tonsilla palatina
3 4
cervicalis 4.
4
Cervical
5. vesicles Inferior epithelium from
Tuberculum impar the 3rd pharyngeal pouch
Esophagus
a Thymus
Superior epithelium from
the 4th pharyngeal pouch
b
Tympanic cavity and
tuba auditiva Tongue

Tympanic membrane Foramen caecum

Auricular hump
Meatus acusticus externus

Lymphatic tissue

Tonsilla palatina
Skin of the neck

Superior epithelial body

Tonsillar sinus Inferior epithelial body

Thymus
Former position of Thyroid
the sinus cervicalis

c Thyroid Inferior epithelium Superior epithelium

and thymus

Fig. 2.35 Development of the pharyngeal grooves and pharyngeal pouches. a Frontal section through the pharyngeal arch region of a 5-week-
old embryo. The 2nd pharyngeal arch grows in a caudal direction and covers the 3rd and 4th pharyngeal grooves, so that the cervical sinus is
temporarily made from them. b Only the first pharyngeal groove survives as the external acoustic meatus. From the first pharyngeal pouch, the
tubotympanic recess forms as a precursor of the tympanic cavity and the entodermal neck organs develop from the 2nd–4th pharyngeal
pouches. c Derivatives of pharyngeal pouches and their caudal displacement. [E347-09]

69
2 General embryology

ear and throat formed by the muscle cells of the 2nd pharyngeal 2.11.3 Development of the tongue and thyroid gland
arch (stapedius muscle, stylohyoid muscle and posterior digastric
muscle) and the mimetic muscles probably migrating from the At the ventral floor of the pharynx, where the pharyngeal arches
2nd pharyngeal arch in the subcutis of the head and neck. Whether come together bilaterally in the median line, at the end of the 4th
remnants of the 2nd aortic arch, which passes through the hyoid week unpaired, entoderm-covered (at the junction to the stomode-
arch, remain in the arteries of the middle ear (e.g. A. stapedia), is um, also ectoderm covered) mesenchyme ridges protrude (› Fig.
contentious. 2.36). In the mandibular arch area, this is the Tuberculum impar,
which is flanked on both sides by the paired lateral lingual swell-
3rd pharyngeal arch ings. Caudal from here follows the Copula, in the area of the hyoid
Pharyngeal arches 3–6 do not have individual names. The 3rd pha- arch, in the area of arches 3 and 4 of the hypobranchial eminence
ryngeal arch (› Table 2.1) is mainly formed from neural crest cells and immediately prior to the inlet of the larynx of the epiglottal
of rhombomere 6, which, together with the hyoid arch, forms the eminence. The lateral tongue swellings of the mandibular arch
Os hyoideum. It is innervated by the N. glossopharyngeus [IX] and strongly proliferate and overgrow the Tuberculum impar, and in
contains the myoblasts (muscle progenitor cells) of the stylopharyn- doing so they fuse in the midline and form the anterior two thirds
geus muscle. The 3rd aortic arch enters the A. carotis communis and of the dorsum of tongue, with its mucous membrane coming from
the proximal portion of the A. carotis interna. the ectoderm. The Copula of the 2nd pharyngeal arch is over-
grown by the hypobranchial eminence forming the rear third of
4th and 6th pharyngeal arch the back of the dorsum of the tongue, the mucosa of which is at
The caudal pharyngeal arches form (› Table 2.1) only at the start least partially derived from the entoderm. The rearmost part of the
of the 5th week and are morphologically less clearly defined than tongue at the junction to the oropharynx comes from part of the
the first 3 arches; they show only vague grooves. They contain neu-
ral crest cells from the most caudal sections of the hindbrain at the
Lateral tongue torus
transition to the neural tube and form the cartilage skeleton of the Pharyngeal arches
larynx. Together, they are innervated by the N. vagus [X] and ac- 1 Tuberculum impar
cordingly assigned to the muscles of the larynx and throat of the
4th and 6th pharyngeal arches. The 4th aortic arch takes on the 2 Foramen caecum
definitive aortic function, even if it is asymmetric, and forms the 3
aortic arch on the left and the innominate artery on the right. The Copula
4
6th aortic arch becomes on both sides the A. pulmonalis. Hypobranchial groove
a
Esophagus Laryngotracheal groove
2.11.2 Pharyngeal grooves and pharyngeal pouches

Pharyngeal grooves and pharyngeal pouches delimit the pharyn- Direction of growth of
the 3rd pharyngeal arch
geal arches from each other superficially or towards the pharynx.
mesoderm
Only the 1st pharyngeal groove remains, and develops into the
external ear canal, which is only separated by the tympanic mem-
brane from the 1st pharyngeal pouch; from the pharynx, the tym- Hypobranchial groove
panic cavity of the middle ear and the Tuba auditiva arise. Hence
the eardrum is covered up to the ear canal by ectodermal epitheli-
um, and up to the tympanic cavity it is covered by entodermal epi- b
thelium. All other pharyngeal grooves disappear because the 2nd
pharyngeal arch grows caudally over to close pharyngeal grooves
2–4. By the inductive interaction of the entodermal epithelium Oral section Sulcus medianus
with the mesenchyme of the pharyngeal arches, the pharyngeal of the tongue
pouches 2–4 develop into the lymphatic and endocrine appending
organs of the pharynx. Thus, Sulcus terminalis
• from the 2nd pharyngeal pouch the Tonsilla palatina emerges,
• from the 3rd pharyngeal pouch the Glandula parathyroidea
inferior and part of the thymus and Pharyngeal Foramen caecum
section of
• from the 4th pharyngeal pouch, the Glandula parathyroidea the tongue
superior
c Epiglottis
are formed. The existence of a 5th pharyngeal pouch as a protru-
sion from the 4th pharyngeal pouch, from which the ultimobran-
chial body (C-cells of the thyroid gland) arises, is still a matter of Pharyngeal arch derivatives of the tongue
contention (› Fig. 2.35). 1st pharyngeal arch 2nd pharyngeal arch
(N. mandibularis [V]) (Chorda tympani [VII])

Clinical remarks 3rd pharyngeal arch 4th pharyngeal arch

(N. glossopharyngeus [IX]) (N. vagus [X])
If the overgrowing of the pharyngeal grooves by the 2nd pharyn-
geal arch remains incomplete, a pharyngeal groove may persist Fig. 2.36 Development of the tongue. View of the floor of the
as a branchiogenic fistula with underlying lateral neck cysts. pharynx in frontal section. a, b Development of the tongue structures
during the 4th–6th weeks. c Adult tongue. [E347-09]

70
 2.11 Early development of the head and throat area

epiglottal eminence and has entodermal mucous membrane. The geal membrane from the foregut. On the border of the two maxil-
muscles of the tongue arise from migrating myoblasts of the occip- lary bulges, the ectoderm of the frontal process thickens to form
ital somites. The heterogeneous origin of the tongue from various paired olfactory placodes. In the middle of each of these, the ecto-
pharyngeal arches and the paraxial mesoderm is the reason for its derm sinks to form olfactory pits, from which the olfactory area of
complex innervation. the nose is formed. The ectoderm bulges in a horseshoe shape
The Foramen caecum is depressed between the Tuberculum impar around the olfactory pits with the underlying mesenchyme forming
and the Copula in the floor of the pharynx. At its base, a solid ento- the medial and lateral nasal bulge. Both nasal bulges grow much
dermal epithelium bud grows ventrally and caudally to the mesen- larger, increasingly overgrowing the olfactory pits. The nasolacrimal
chyme of the neck (Ductus thyroglossus), which soon loses its groove sinks between the lateral nasal bulge and the maxillary bulge
connection to the tongue system, and at the end of the 7th week as from which the Ductus nasolacrimalis will later arise. Together with
an isolated, twin-lobed entodermal island approaches the entoder- the maxillary bulges and the eyes positioned to the sides of the fron-
mal tracheal tube, where it is already developing laterally in the tal process, the nasal bulges on both sides are increasingly shifted
12th week as a functional thyroid gland. medially. At the end of the 7th week the medial nose bulges on both
sides fuse together in the midline into the nasal bridge, nasal sep-
NOTE tum and philtrum (› Fig. 2.37). The lateral nasal bulge forms the
The tongue is formed in the base of the pharynx as part of the pha- lateral nasal wall and the nostrils. The nasolacrimal groove is over-
ryngeal arches 1–6 and myoblasts of the occipital somites. grown by the lateral nasal bulge and the maxillary bulge, so that both
fuse together. In the meantime, the eyes migrate from their original
lateral position towards the front, taking up their final position on
2.11.4 Facial development both sides of the nose. The mandibular bulges on both sides, posi-
tioned caudally to the stomodeum, are medially joined forming the
The face develops, starting at the end of the 4th week, from 5 facial arch-shaped lower jaw system.
eminences, the paired maxillary and mandibular swellings of the
1st pharyngeal arch and the unpaired frontal process, which covers NOTE
the forebrain (› Fig. 2.37). The frontal process consists of mesen- The face is essentially created in a paired fashion and develops
chyme originating from the cranial neural crest from the midbrain from the left and right maxillary and nasal bulges, which migrate
and forebrain, and, like the facial eminences of the mandibular arch, from lateral to medial, fusing together with the unpaired forehead
is covered with ectoderm. The facial eminences demarcate the ecto- bulge in the midline. The mandibular bulges, which form the lower
jaw, are joined medially from the beginning.
dermal stomodeum, which is then sealed off by the buccopharyn-

Frontal process
Frontal process
Olfactory placode
Upper jaw process Buccopharyngeal membrane
Upper jaw process
Stomatodeum
Mandibular process
Heart swelling
Mandibular process 2nd and 3rd pharyngeal arches

a b

Frontal process
Medial nasal torus

Olfactory placode Eye Olfactory aperture

Upper jaw torus Nasolacrimal groove Lateral nasal torus

Mandibular torus
Stomatodeum
c d

Lateral nasal torus Medial nasal prominence

Eye
Upper jaw torus

Nasolacrimal groove
Mandibular torus
Philtrum
e f

Fig. 2.37 Facial development. The face develops from the unpaired forehead projection and the paired maxillary and nasal ridges by shifting
the structures medially, where they finally fuse. [L126]
a 3.5 weeks. b 4 weeks. c 5 weeks. d 6 weeks. e 7 weeks. f 10 weeks.

71
2 General embryology

2.11.5 Development of the oral and nasal cavities ing at the end of the 6th week, the two primary nasal cavities open
via the primitive choanae into the oral cavity. As a result of the fu-
Nasal and maxillary bulges do not only fuse on the surface, but sion of the palate plates and the formation of the secondary palate,
also in the depths of the stomodeum (› Fig. 2.38). The buccopha- the internal nostrils shift via the definitive choanae into the naso-
ryngeal membrane is torn down at the end of the 3rd week and pharynx. Within the resulting definitive nasal cavity, which arises
connects the ectodermal oral cavity with the entodermal foregut. in the rear section of the oral cavity, the nasal septum grows aris-
From the maxillary processes in the roof of the mouth the devel- ing from the medial nasal prominences with the palate, completely
oping palatal plates from both sides grow initially downwards to separating both halves of the nose from each other. The paranasal
the floor of the mouth, then rise balcony-like in a medial direction sinuses occur postnatally as sacculations of the nasal cavity.
and finally join together at the end of the 7th week in the midline.
Therefore, together with the intermaxillary segment (primary
palate) arising from the medial nasal bulges, the secondary palate
Clinical remarks
is formed, separating the mouth from the nasal cavity. The paired Cleft lip, jaw and palate arises due to the incomplete medial
primary nasal cavities originate from the tubular olfactory pits fusion of the facial prominences and the palatal plates. The
growing far into the mesenchyme of the frontal process. Its floor is malformations may occur very variably on one or two sides,
formed from the intermaxillary segment and later from the thin affecting the nose, upper lip and palate.
bucconasal membrane (syn.: oronasal membrane). After ruptur-

Nasal cavity
Primary
Nasal septum palate

Palatal plate
Tongue

a b

Nasal septum
Nasal cavity
Eye

Oral cavity Primary

Palatal plate palate

Tongue
c d

Foramen incisivum

Nasal cavity

Nasal concha Nasal septum

Fusing of
palatal plates
Oral cavity
Tongue Uvula
e f

Fig. 2.38 Development of oral and nasal cavities. The primary oral cavity is divided by the medial fusion of the palatal plates of the maxillary
ridges into the oral cavity and the nasal cavity. [L126]
a, b 6.5 weeks. c, d 7.5 weeks. e, f 10 weeks.

72
MUSCULO­
SKELETAL
SYSTEM
3 Torso
4 Upper extremity
5 Lower extremity
3 Torso
3.1 Ventral torso wall . . . . . . . . . . 76 3.3 Spine, spinal cord
3.1.1 General structure . . . . . . . . . . 76 and thorax . . . . . . . . . . . . . . . . 114
3.1.2 Thoracic wall . . . . . . . . . . . . . . 77 3.3.1 Embryology . . . . . . . . . . . . . . . 115
3.1.3 Diaphragm . . . . . . . . . . . . . . . 87 3.3.2 Spine . . . . . . . . . . . . . . . . . . . . 115
3.1.4 Abdominal wall . . . . . . . . . . . . 90 3.3.3 Spinal cord site . . . . . . . . . . . . 129
3.3.4 Thorax . . . . . . . . . . . . . . . . . . . 132
3.2 Dorsal torso wall . . . . . . . . . . 104
3.2.1 General structure . . . . . . . . . . 104
3.2.2 Back muscles . . . . . . . . . . . . . 105
3.2.3 Vascular, lymphatic
and nervous systems
of the dorsal torso wall . . . . . 112
3 Torso

Skills spaces (ICS) are used as horizontal orientation lines, and vertical
orientation lines are also used, so that certain points can be de-
After processing this chapter, you should be able to:
scribed, similar to a coordinate system (› Table 1.4, › Fig. 1.6).
• find your bearings topographically using anatomical guides
on the torso and systematically assign the regions
• reproduce the layer-shaped structure of the torso wall, in Palpable bone points
particular the location and function of the torso wall muscu- Palpable bone points on the ventral trunk wall are:
lature in the thoracic and abdominal areas and the neck • Claviculae
area • Insisura jungularis sterni
• describe the topographical course of blood vessels and • Acromioclavicular joint (shoulder joint)
nerves, in particular the course of intercostal vessels and
• Sternum with Angulus sterni (LUDOVICI, transition between
nerves
• describe the attachment and origin of the oblique abdomi- the Manubrium sterni and Corpus sterni; serves as orientation
nal muscles and explain the weak points of the abdominal for counting the ribs)
wall as predilection sites for abdominal wall ruptures • Proc. xiphoideus
• describe the innervation and the structure of the diaphragm • Ribs (exception: Ist rib)
and the points of entry and designate emerging structures • Costal arch
• describe the autochthonous muscles in the back, including • Crista iliaca, Spina iliaca anterior superior, Tuberculum pubi-
the neck muscles as well as the corresponding fascia and
cum, Symphysis pubica
posture and movement functions of the head and torso
• name bypass circulations
• outline the morphological principles of lumbar tapping, epi- NOTE
dural anaesthesia and pleurocentesis To reliably determine the height of the ribs and the intercostal
spaces (ICS), one begins at the Angulus sterni, which corresponds
to the attachment of the 2nd rib. The Ist rib is not palpable under
the Clavicula, so that one palpates downwards from the Angulus
sterni.
3.1 Ventral torso wall
Martin Gericke, Martin Krüger (with contribution from In the transition area to the neck, the clavicle and the Incisura
Ingo Bechmann) jugularis of the Manubrium sterni are cranially easily palpable. Be-
low the collar bones, the M. pectoralis major can be well defined.
Between the M. pectoralis major and the M. deltoideus, lies the
3.1.1 General structure Fossa infraclavicularis (MOHRENHEIM'S fossa, › Chap.
4.10.1), in the depths of which the neurovascular bundle runs to
The ventral trunk wall ranges from the Clavicula and the Insisura the arm. In the case of lean bodied people, the coracoid process of
jugularis notch of the breastbone up to the iliac crests, the liga- the shoulder blade can be felt at its lateral margin of the Proc.
ments and the upper edge of the Symphysis pubica. It comprises coracoideus. This can be facilitated by abducting and adducting
the lateral and anterior chest wall, as well as the lateral and anterior the arm at the same time; however, palpation of the Proc. cora-
abdominal wall. The costal arch forms the border between the tho- coideus does not often succeed due to the body's constitution.
racic and abdominal wall. The border to the dorsal torso wall con- ­Laterally the muscle serrations of the M. serratus anterior can be
stitutes the rear axillary line (Linea axillaris posterior, see below). recognized, especially in an abducted arm which intrudes into the
upper serrations of the M. obliquus externus abdominis with its
Orientation lines lower serrations. This zigzag line is referred to as GERDY's line.
For everyday clinical application, it is practical to use a uniform The transition to the epigastrium is marked by the easily palpable
and unambiguous nomenclature to describe locations on the skin, costal arch and the Proc. xiphoideus.
for the precise identification of puncture and auscultation sites, or
surgical access routes. The course of the ribs or the intercostal

M. deltoideus

M. pectoralis major

Linea alba
M. serratus anterior
M. rectus abdominis

M. rectus abdominis,
M. obliquus externus abdominis Intersectio tendinea

Spina iliaca anterior superior

Fig. 3.1 Surface relief of the

thoracic and abdominal wall of
a young man.

76
 3.1 Ventral torso wall

Surface relief ral space. The normally existing adhesion between the pleural
The construction of the anterior torso wall (› Fig. 3.1) shows sheets is annulled and the lung retracts toward the hilus due
­significant individual differences. Apart from the gender and age-­ to its elastic properties. If this occurs with no identified cause
specific shape of the thorax and the pelvis as well as the size and or injury from the outside, it is called an idiopathic sponta-
neous pneumothorax. Typically, it occurs in tall, slim built
shape of the mammary glands, it is essentially dependent on the
males and patients with otherwise healthy lungs (gender bal-
expression of the subcutaneous and intra-abdominal fat tissue and ance men to women around 3 : 1). The cause is often mal-
the muscles. formed lung tissue in the form of so-called bullae in the tips of
In the case of muscular people of normal weight it is easy to recog- the lungs, which are spontaneously ruptured. The incidence of
nize the M. pectoralis major (in women mostly covered by the idiopathic spontaneous pneumothorax is given as 4 per
breasts). It also stands out in a well-trained ‘six-pack’ on the ab- 100,000. Small sized pneumothorax (tips or coating pneumo-
dominal wall (M. rectus abdominis with Intersectiones tendineae thorax) can be treated conservatively. In the case of attenuat-
ed breathing sounds, severe shortness of breath or a change
and Linea alba). Laterally, the M. obliquus externus abdominis
in vital parameters (hypotension, a drop in oxygen saturation)
can be seen, the muscle-aponeurosis transition of which is particu- the placement of a thorax drainage is indicated. This should
larly elevated, slightly above the Spina iliaca anterior superior as be done in the case of a life-threatening tension pneumotho-
muscle covering. Its muscle serrations interfere with the muscle rax even at the scene of the accident and should not be post-
serrations of the M. serratus anterior in the area of the lateral rib poned until arrival in hospital or even until after the x-ray diag-
arch. The superficial veins often shimmer through the abdominal nostics.
skin.

The chest wall is differentiated into four layers:

3.1.2 Thoracic wall • Superficial: skin, subcutaneous fat and mammary glands
• Ventral muscles of the shoulder girdle and the upper limbs
• Sternum, ribs and intercostal muscles
• Inner layers: Fascia endothoracica and Pleura parietalis
Clinical case
Pneumothorax Superficial layer
Case study Skin
A 23-year-old man presents in the emergency department of On the sternum the skin is relatively tightly connected with the
the university clinic. While presenting his case to the on-call Membrana sterni but otherwise it can be easily relocated. In wom-
doctor he reports the sudden occurrence of chest pains, which en and children there is often lanugo on the breast skin; in men
are accompanied by substantial shortage of breath during this is often stronger terminal hair. If it is less well-developed, there
stress. The pain first started 2 hours ago at rest when he was
is often stronger and longer terminal hair around the areolae.
standing in the shower. The patient does not complain of any
other disorders, such as diarrhoea, nausea or dizziness. There
are also no pre-existing conditions. The patient has also not Subcutaneous tissue, Tela subcutanea
undertaken any long distance car or air travel recently, which In the area of the mammary glands the subcutaneous fat is
would indicate a risk factor for a pulmonary embolism. The well-pronounced, otherwise less distinctly pronounced. Starting
medical history also shows an ‘appendectomy’ at the age of from the throat area the Platysma radiates as a mimetic skin mus-
9 years. The patient does not smoke and does not take any cle via the clavicle into the subcutis. In the area of the sternum phy-
medications.
logenetic residues of this skin muscle can sometimes remain,
Initial examination which then can be referred to as M. sternalis.
The patient is 188 cm tall and of slim build. He weighs 72 kg.
The vital parameters (blood pressure, heart rate, oxygen satu- Vascular, lymphatic and nervous systems
ration, body temperature) are initially within normal range. On Arteries
auscultation there is an attenuated respiratory sound above The arterial supply of the skin (› Fig. 3.12, › Fig. 3.13, › Fig. 3.2)
the right lung. is ensured through
• Rr. perforantes of the A. thoracica interna
Further diagnostics
• Rr. cutanei laterales of the Aa. intercostales posteriores
The subsequent chest x-ray confirms that the suspected diag-
• A. thoracica lateralis (branch of the A. axillaris)
nosis of a spontaneous pneumothorax is confirmed.
• A. thoracodorsalis
Therapy and follow-up
Due to the increasing shortness of breath and the deteriorat- Veins
ing vital signs, the doctor decides to conduct a thoracic drain- The venous drainage (› Fig. 3.14, › Fig. 3.2, › Fig. 3.15) takes
age in the emergency department (BÜLAU drainage). During place via:
the inpatient stay the patient recovers quickly and can be dis- • Accompanying veins of the abovenamed arteries
charged from hospital 7 days later. • the V. thoracoepigastrica, which in turn leads into the V. axil-
Clinical symptoms laris
A pneumothorax is a condition where air has entered the pleu-
ral space, which would normally not be found there. In cases Cutaneous nerves
of pneumothorax the air from the outside enters the pleural The chest area is sensitively innervated (› Fig. 3.2) by
space due to a defect in the chest wall and the Pleura parieta- • cranial: Nn. supraclaviculares (C3–C4) from the Plexus cervi-
lis or from the inside by a defect of the Pleura visceralis and calis
leads to the cancellation of the negative pressure in the pleu- • caudal: segmentally from the intercostal nerves, of which the
Rr. cutanei laterales in the midaxillary line perforate the fascia

77
3 Torso

Nn. supraclaviculares; Nn. thoracici, Nn. intercostales,

A.; V. cervicalis superficialis Rr. cutanei anteriores pectorales

Plexus venosus areolaris

V. cephalica

A; V. thoracica lateralis;
N. thoracicus [T2], N. intercostalis,
R. cutaneus lateralis pectoralis
A. thoracica interna*;
Vv. thoracicae internae

V. thoracoepigastrica

A.; V. epigastrica superior

T3
T4
T5 M. obliquus externus abdominis
T6
Nn. thoracici, Nn. intercostales, T7
Rr. cutanei laterales pectorales T8 T9
T9 Nn. thoracici, Nn. intercostales,
T10 Rr. cutanei anteriores abdominales
T11
T12
T12

Anulus umbilicalis
Vv. paraumbilicales

Vv. subcutaneae abdominis Chorda arteriae umbilicalis

A.; V. circumflexa ilium superficialis A.; V. epigastrica inferior

N. iliohypogastricus,
N. genitofemoralis, R. femoralis
R. cutaneus anterior

A.; V. epigastrica superficialis M. rectus abdominis

N. femoralis, R. cutaneus anterior N. ilioinguinalis

V. saphena magna A. pudenda externa;

Vv. pudendae externae

Fig. 3.2 Epifascial and deep vessels and nerves of the abdominal wall in the female. Ventral view; * clinically also A. mammaria interna.

• medial: Rr. cutanei anteriores, which extend from parasternal which at the time of birth is still at the level of the body surface and
to lateral in the area above the M. pectoralis major only later, sometimes only after puberty, forms the nipple. The apo-
crine Glandulae areolares of the areolae occur in the 5th–6th foe-
Mammary gland tal month.
Development
As early as the 4th developmental week a thickening of the ecto- Location, structure and function
derm stands out on the lateral abdominal wall, the ventral epider- The mammary gland (breast, › Fig. 3.3) is formed in both sexes
mal ridges . It develops during the 5th week to a milk line, where- and is regarded as a secondary sexual characteristic. Its functional
by it results in the sprouting of 6 strands in the underlying mesen- status and its macroscopic and microscopic structure are subject to
chyme. In animals, the milk line extends at regular intervals from hormone-related, distinctive sex and age differences. The fully
the axillary region to the groin and differentiates further; in hu- formed mammary gland of a woman of childbearing age ranges
mans it recedes back to the 4th pair of glands at the level of the craniocaudally from around the IInd or IIIrd to VIth rib, as well as
IIIrd–Vth ribs. Originating from the milk line, in humans a lentic- in the horizontal expansion of the parasternal line to the front axil-
ular protrusion is formed, which sinks like a cone into the underly- lary line and often towers over a craniolateral offshoot (Proc. axil-
ing mesenchyme. Several epithelial cones sprout from this epitheli- laris) up into the armpit. As Lobus axillaris it can transcend the
al bulb, from which the Sinus and Ductus lactiferi later emerge. lower margin of the M. pectoralis major. The main part of the glan-
The blunt ends of the epithelial cones branch out later and form the dular body is movably connected with the Fascia pectoralis super-
subsequent lobar structure. Under the influence of sex hormones, ficialis and the Lobus axillaris with the fascia of the M. serratus an-
the epithelial structures are channelled in the 7th–8th month and terior. Both breasts are separated in the area of the sternum by the
form a lumen. The milk ducts drain into the skin on a gland field, mammary sinus (Sinus mammarum).

78
 3.1 Ventral torso wall

Fascia pectoralis
M. pectoralis major

M. pectoralis major

Areola mammae
Ligg. suspensoria mammaria*
Papilla mammaria
Glandulae areolares Sinus lactiferi

Ductus lactiferi

Lobi glandulae mammariae

Adipose tissue

Fig. 3.3 Breast (Mamma). Ventral view.

Fig. 3.4 Breast (Mamma). Sagittal section; * clinically also COOPER
On the usually much darker pigmented Areola (Areola mammae) ligaments.
the tapered nipple (Papilla mammae) rises into which 12–15 milk
ducts flow (› Fig. 3.3). The position is usually projected in men
onto the 4th intercostal space (ICS). The situation is much more Clinical remarks
variable in women. In both sexes, it also depends on the nutritional
In rare cases the nipples (athelia) or breasts (amastia, breast
status and the condition of the connective tissue, which changes in aplasia) are missing on one or both sides. Also excess nipples
particular due to age. The projection onto the chest wall can be sig- (polythelia) or breasts (polymastia) along the entire milk line
nificantly shifted due to this. are possible. This is usually hereditary and can also affect
The Areola mammae is surrounded by a ring of 10–15 small eleva- men. The rudimentary mammary tissue does not usually de-
tions, which are formed by larger packages of apocrine scent glands velop further in men after birth. Particularly in the context of
(Glandulae areolares). Together with sebaceous and eccrine sweat hormonal disorders, men can nevertheless grow breasts (gy-
glands, the secretions during breastfeeding create an airtight clo- naecomastia) . This is more common in puberty and should
not regarded as pathological at this point in time.
sure between the oral cavity of the infant and the nipple of the Too large breasts (mammary hypertrophy) not only disturbs
mother, which is important for the suckling process, ensuring that the affected women cosmetically, but is often also associated
the child does not constantly inspire additional air. Due to the with shoulder and back pain.
complex arrangement of smooth muscle fibres in the area of the Through the transfer of maternal hormones from breast-feed-
nipple and areola, the nipple can become erect, partly due to tactile ing mothers, the mammary glands of infants of both sexes can
stimuli and as such becomes ‘tangible’ for the infant. secrete the first milk (Colostrum) (used to be more commonly
The glandular body of each breast is structured by strong connec- known as ‘witches’ milk’).
tive tissue septa into 15–24 glandular lobes, each of which has a
separate excretory duct (Ductus lactifer) (› Fig. 3.4). Each Duc-
tus lactifer extends from the outlet in the area of the Papilla mam-
mae to the Sinus lactifer. By merging several ducts the number of Vascular, lymphatic and nervous systems
openings does not always correspond to the number of glandular Arteries
lobes. The individual glandular lobes in turn are structured into The arterial blood supply (› Fig. 3.5, › Fig. 3.2) occurs from
smaller lobes, from which the excretory ducts flow into the respec- • Rr. mammarii mediales (via Rr. perforantes from Aa. intercos-
tive Ductus lactifer. tales anteriores) of the A. thoracica interna
The support of the glandular body is guaranteed by connective tis- • Rr. mammarii laterales of the (via Rr. cutanei laterales) from
sue strands (Ligg. suspensoria mammaria, COOPER ligaments) Aa. intercostales posteriores
which extend from the skin to the Fascia pectoralis superficialis • Rr. mammarii laterales of the A. thoracica lateralis.
(› Fig. 3.4). The spaces between this connective tissue framework
are filled with adipose tissue. Veins
In the case of pregnancy, the glandular bodies are supplied with a The venous drainage takes place via two venous networks (­ › Fig. 3.5,
much greater amount of blood. It increases under hormonal influ- › Fig. 3.2):
ence and thus displaces the interlobular connective tissue. The milk • A superficial vein network with the Plexus venosus areolaris
secretion takes place after birth essentially by the influence of pro- drains into the V. thoracica lateralis and further into the V. axil-
lactin, which is formed in the anterior lobes of the pituitary gland. laris.
The milk supply is ensured by oxytocin from the posterior lobe of • A deep vein network drains via the anterior intercostal veins into
the pituitary gland, which leads to contraction of myoepithelial the V. thoracica interna to the V. brachiocephalica.
cells. Breast milk is an emulsion of fat droplets in an aqueous sugar
and electrolyte-containing protein solution. In the first few days NOTE
after birth the breast gland secretes the first milk (Colostrum), During pregnancy and breast feeding the superficial veins can be
which is characterised by an extremely high content of immuno- elevated due to increased circulation through the surface of the
globulins that guarantees the infant ‘nest protection’ and protection skin.
against infections.

79
3 Torso

Lymph vessels In the context of breast cancer screening, breast cancer should
The lymph vessels have a great practical clinical significance due to be detected as early as possible. During inspection, attention
the high prevalence of breast cancer. In the same way as for the should be paid to differences between both breasts, contrac-
veins, the lymph drainage is divided into a superficial and a deep tion of the skin and other superficial changes. The glandular
body is inspected by palpation for calluses or nodes and the
network. The latter is located in the glandular body and is connect-
movability in the glandular body, as well as assessment across
ed to the superficial network. There are 3 main lymph drainage the chest wall. For this purpose, the chest is divided into 4
passages (› Fig. 3.5): quadrants, which meet in the mamilla and must be carefully
• Axillary drainage: this passage is the most important (about palpated within the framework of the screening examination. It
three quarters of the lymph of the breasts). The lymph of the lat- is important to ensure that the submamillary region is not ne-
eral parts is drained via the Nodi lymphoidei paramammarii glected, which is often referred to clinically as a ‘5th quadrant’.
and Nodi lymphoidei axillares pectorales to paraclavicular and The regional lymph nodes are also palpated. They are divided
under clinical topographic and oncosurgical aspects into 3 lev-
cervical lymph nodes.
els. The M. pectoralis minor acts as a border (› Fig. 3.5):
• Interpectoral drainage: the lymph of the rear parts of the glan- • Level I: lateral to the M. pectoralis minor (Nodi lymphoidei
dular body are drained between the Mm. pectoralis major and axillares humerales [laterales], Nodi lymphoidei axillares
minor via the Nodi lymphoidei interpectorales to the Nodi subscapulares, Nodi lymphoidei axillares pectorales, Nodi
lymphoidei axillares apicales. lymphoidei paramammarii)
• Parasternal drainage: the lymph of the medial parts of the breast • Level II: below or above the M. pectoralis minor (Nodi lym-
is drained via the Nodi lymphoidei parasternales cranially to the phoidei axillares centrales, Nodi lymphoidei interpectorales)
• Level III: medial of the M. pectoralis minor (Nodi lymphoidei
deep cervical lymph nodes and/or into the Truncus jugularis.
axillares apicales).
Lymph drainage takes place from level I to level II and from
Nerves there to the Nodi lymphoidei axillares apicales in level III.
The sensory innervation takes place via Rr. cutanei anteriores and From here the lymph passes into the Truncus subclavius. The
laterales of the intercostal nerves, which mainly originate from parasternal drainage passages on both sides are interconnect-
segments T2–6. ed. They drain into mediastinal and intercostal drainage pas-
sages that are clinically relevant for metastases in the lungs,
pleura and mediastinum.
Clinical remarks The sentinel lymph nodes are understood as the first lymph
node situated in the lymph drainage area of a malignant tu-
Breast cancer (› Fig. 3.6) is the most common malignant tu- mor. In most cases it is therefore the first metastatic lymph
mour disease in women between 35 and 55 years old in Ger- node to be colonised. The number of affected lymph nodes in
many. In rare cases men can also be affected. Overall, breast the three levels is directly related to the survival rate in breast
cancer is the main cause of cancer-related deaths after lung cancer. Metastases on the contralateral side are possible via
cancer and bowel cancer in women. In about 60% of all cases the connected parasternal lymph nodes.
the upper outer quadrant of the breast is affected (› Fig. 3.7). Lymph node metastases within the Nodi lymphoidei axillares
Breast carcinoma originates mostly from the epithelium of the pectorales (SORGIUS group) may cause irritation of the N. in-
Ductus lactiferi (ductal carcinoma) and metastasizes into the tercostobrachialis resulting in radiating pain in the affected
axillary lymph nodes, less often into the parasternal (retroster- arm. This can even be the first indication of breast cancer.
nal) lymph nodes.

Nodi lymphoidei
axillares apicales

A. thoracoacromialis,
R. pectoralis
Level I Level II Level III

Nodi lymphoidei Nodi lymphoidei

axillares centrales interpectorales*

Nodi lymphoidei A.; Vv. thoracica(e)

axillares humerales interna(e)
[laterales]

Nodi lymphoidei
axillares sub-
scapulares
Nodi lymphoidei
Proc. axillaris
parasternales
Nodi lymphoidei axillares pectorales
A.; V. thoracica lateralis

Nodus lymphoideus paramammarius

Aa.; Vv. mammariae
mediales
Aa.; Vv. mammariae laterales

Nodi lymphoidei paramammarii

Fig. 3.5 Blood supply and mam-

mary gland lymph drainage;
* clinically also ROTTER nodes.

80
 3.1 Ventral torso wall

costarum innervated by the Rr. ventrales of the intercostal nerves

originate from these ventral positions.

Intercostal muscles
The intercostal muscles (Mm. intercostales, › Table 3.1) are taken
from the ventral attachments of myomas and keep their metamere
(segmental) arrangement in ontogenesis. According to location
and course of the intercostal muscles, a distinction is made be-
tween (› Fig. 3.8, › Fig. 3.9, › Fig. 3.10):
• Mm. intercostales externi
• Mm. intercostales interni
• Mm. intercostales intimi
The Mm. intercostales externi (exterior) are inspiration muscles
(inspiration), the Mm. intercostales interni (middle) and intimi
Fig. 3.6 Mammography of malignant breast cancer. [O541]
(interior) are expiration muscles (expiration).

Mm. intercostales externi

The Mm. intercostales externi (› Fig. 3.8, › Fig. 3.10, › Table 3.1)
correspond with the course of the M. obliquus externus abdominis.
≈ 60% ≈ 15% Hence, they run from the upper posterior to lower anterior. There-
fore, they extend from the Tubercula costarum to the transition of
≈ 10% the cartilage bone border of the ribs. Their origin each lies on the
Crista costae. From here, each muscle runs to the respective next
≈ 5%
≈ 10% lower rib. The Mm. intercostales externi pass between the rib carti-
lage in a connective tissue tendon plate (Membrana intercostalis
externa). The Mm. intercostales externi are covered by the Fascia
thoracica externa between the ribs.

Mm. intercostales interni

Fig. 3.7 Frequency of occurrence of breast cancer in relation to the The Mm. intercostales interni (› Fig. 3.8, › Fig. 3.10, › Table 3.1)
localisation in percent. run analogue to the M. obliquus internus abdominis and cross the
Mm. intercostales externi vertically. They extend dorsally from the
Ventral muscles of the shoulder girdle and the upper Angulus costae ventrally to the sternum. They extend obliquely in a
extremity cranioventral direction from the top edges of the inner surface of
These include the Mm. subclavius, pectoralis major , pectoral mi- each rib to insert into the next higher rib. The Mm. intercostales in-
nor and serratus anterior. These so-called immigrated muscles are terni pass from the Angulus costae medially into the Membrana in-
discussed in › Chap. 4.3.4. tercostalis interna. Between the rib cartilages, they are referred to
as Mm. intercartilaginei. Between the ribs, the Mm. intercostales
Thoracic wall muscles are covered on the inside of the chest, apart from by their own mus-
Note: to be able to understand the location and function of the tho- cle fascia (Fascia thoracica interna) by the Fascia endothoracica.
racic wall muscles, it is helpful to first read the section ‘Bony tho-
rax’. This is discussed in › Chap. 3.3.4. Mm. intercostales intimi
The autochthonous muscles of the rib cage include the intercostal The intercostales intimi muscles (› Table 3.1) are an inconstant
muscles, the M. subcostalis and the M. transversus thoracis. In separation of the Mm. intercostales interni and thus have the same
evolution the Mm. serrati posteriores have the same origin; how- course as they do, and together include the intercostal vessels and
ever, during ontogenesis they have shifted dorsally over the autoch- nerves. In many textbooks the Mm. intercostales intimi are not
thonous muscles of the back. Also the parts of the Mm. levatores viewed as independent muscles, but counted as Mm. intercostales

Tuberculum anterius [caroticum]

M. scalenus posterior (Vertebra cervicalis VI)

M. scalenus medius M. scalenus anterior

M. scalenus anterior
M. longus colli

Membrana intercostalis
interna Membrana intercostalis
interna

Mm. intercostales
Mm. intercostales
externi
interni
Mm. intercostales
Lig. longitudinale interni Fig. 3.8 Posterior wall of the
anterius thorax (Cavea thoracis). Ventral
view.

81
3 Torso

M. sternohyoideus

M. sternothyroideus
Cartilago costalis I

Manubrium sterni

Mm. intercostales interni Corpus sterni

M. transversus thoracis

Diaphragma,
Centrum tendineum
Foramen venae cavae
Mm. intercostales interni
Proc. xiphoideus
Fig. 3.9 Anterior wall of the
thorax (Cavea thoracis). Dorsal
view.

interni. As part of the Mm. intercostales interni, the Mm. intercos- vertebrae and the Ist and IInd thoracic vertebra obliquely caudally
tales intimi are covered on the inside of the chest by the Fascia en- and laterally to the IInd–Vth ribs (› Fig. 3.33, › Table 3.1).
dothoracica (see below).
M. serratus posterior inferior
Mm. subcostales The thin muscle is covered by the M. latissimus and runs on both
The Mm. subcostales are referred to as the lower rib muscles sides of the Procc. spinosi of the XIth and XIIth thoracic vertebrae
(› Table 3.1) and have the same fibre course as the Mm. intercos- and the Ist and IInd lumbar vertebra obliquely caudally and lateral-
tales interni; however, they skip at least one segment, so that mus- ly to the IXth –XIIth ribs (› Fig. 3.33, › Table 3.1).
cular connections to adjacent intercostal space (ICS) are created.
They vary in number and frequency. Function of the ventral thoracic musculature
The contraction of the Mm. intercostales externi and intercartilag-
M. transversus thoracis inei leads to elevation of the ribs. This increases the volume of the
The M. transversus thoracis (› Fig. 3.9, › Table 3.1) is located on thorax. These are sometimes referred to as inspiration muscles or
the inside of the chest. It originates from the sides of the sternum inspirators because they enable inspiration. The Mm. intercostales
and from the Proc. xiphoideus and is attached to the rib cartilage interni and M. transversus thoracis act as rib lowerers; they are
of the IInd–VIth ribs. The muscle fibres run horizontally or in a supported by the Mm. intercostales intimi and the Mm. subcos-
slightly ascending course. tales. As a result, these muscles effect the expiration.

M. serratus posterior superior Inner layers of the chest wall

The very thin muscle is covered by the M. rhomboideus and runs Fascia endothoracica
on both sides of the Procc. spinosi of the VIth and VIIth cervical The Fascia endothoracica is a layer of connective tissue, which
covers the inside of the thorax (› Fig. 3.10). It therefore represents
Table 3.1 Thoracic wall muscles.

Innervation Origin Attachment Function

Mm. intercostales externi
Nn. intercostales Crista costae Next deeper rib Rib lifter, inspiration
Mm. intercostales interni
Nn. intercostales Inner surface of the upper rib edge Sulcus costae Rib sinker, expiration
Mm. intercostales intimi
Nn. intercostales Inner surface of the upper rib edge Sulcus costae (inside) Rib sinker, expiration
Mm. subcostales
Nn. intercostales Inner surface of the upper rib edge Sulcus costae (inside) Rib sinker, expiration
M. transversus thoracis
Nn. intercostales (T2–6) Sternum Costal cartilage (II–VI) Rib sinker, expiration
M. serratus posterior superior
Cranial Nn. intercostales Procc. spinosi of the VIth and VIIth IInd–Vth rib each lateral to the Angulus Rib lifter, inspiration
c­ ervical vertebrae and the Ist and IInd costae
thoracic vertebrae
M. serratus posterior inferior
Caudal Nn. intercostales Procc. spinosi of the XIth and XIIth Caudal edge of the IXth–XIIth rib Lowers the IXth to XIIth rib, as an antag-
t­ horacic vertebrae and the Ist and IInd onist of the diaphragm and also active
lumbar vertebrae on forced inspiration

82
 3.1 Ventral torso wall

Pleural gap Pleura visceralis pleura costalis), the vertebral body, the sternum and the upper dia-
Teeth of the Pulmo phragmic surface (Pleura diaphragmatica) as well as the area of
M. serratus anterior N.; A.; V. intercostalis
the mediastinum as Pleura mediastinalis (› Fig. 3.10). It consists
of one layer of squamous epithelium.
Pleura parietalis

Fascia endo- Vascular, lymphatic and nervous systems of the chest wall
thoracica
The vessels and nerves of the thoracic wall are arranged segmental-
ly analogue to the intercostal muscles and the skeleton. They run as
Aa. and Vv. intercostales posteriores and Rr. ventrales of the spinal
nerves (intercostal nerves) to the anterior axillary line in the Sulcus
costae. The vein lies above and the accompanying nerve below the
artery (› Fig. 3.11).

Arteries
The Aa. intercostales posteriores (1 and 2) of the two top ICS are
branches of the A. intercostalis suprema, which originate from
the Truncus costocervicalis from the A. subclavia. The Aa. inter-
costales posteriores of the ICS 3–11, as well as the Aa. subcostales
are direct branches from the Aorta thoracica (› Fig. 3.12). As it
­is located slightly left of the spine, the respective right intercostal
arteries are longer. They extend in front of the spine, but behind
the oesophagus and behind the V. azygos, as well as the right sym-
pathetic trunk to the respective Sulcus costae. The left-sided Aa.
intercostales posteriores run behind the V. hemiazygos accessoria
M. intercostalis
intimus (section
and the V. hemiazygos to the ICS.
Dermis
M. intercostalis of the M. inter- Approximately at the height of the rib heads, the arteries emit one
Subcutis costalis internus)
internus R. dorsalis, from which the R. spinalis for the supply of the spinal
M. intercostalis
externus Adipose tissue Costa Rr. collaterales cord, the spinal meninges and the spinal nerve emerge. After forma-
tion of branches to supply the autochthonous back muscles, the R.
Fig. 3.10 Structure of the thoracic wall. [L127] dorsalis divides into a R. cutaneus medialis and a R. cutaneus lat-
eralis (› Fig. 3.13, › Fig. 3.65). The main trunk courses further to
the connective tissue contact between the thorax inner wall in the the lower edge of the respective rib ventrally and emits in its course
form of the costal periosteum and internal thoracic fascia covering a R. collateralis (R. supracostalis) to the upper edge of the respec-
the Mm. intercostales interni/intimi on one side and the Pleura pa- tive lower rib and a R. cutaneus lateralis to the skin (› Fig. 3.13).
rietalis on the other side. The Fascia endothoracica is strongly Ventrally, the top 6 ICS are supplied by the A. thoracica interna
formed, especially in the area of the pleural dome and is referred to (› Fig. 3.13) and the lower ICS by the A. musculophrenica. These
as SIBSON's fascia (Membrana suprapleuralis, cervicothoracic usually emit 2 Aa. (Rr.) intercostales anteriores per ICR, which
diaphagm). The stability of the pleural dome is also improved by anastomise with the respective Aa. intercostales posteriores and the
connective tissue threads from the Ist rib (Lig. costopleurale) and Rr. collaterales.
fibres of the Fascia prevertebralis (Lig. pleurovertebrale). The A. thoracica interna runs as a branch of the A. subclavia on
both sides of the sternum caudally. In the area of the Trigonum
Pleura parietalis sternocostale of the diaphragm it emits the A. musculophrenica
The parietal pleura (rib lining) covers the inside of the thorax in (› Fig. 3.12).
the area of the cervical pleura (Cupula pleurae), the ribs (rib lining,

Costa VIII
M. serratus anterior
V. intercostalis posterior
M. serratus anterior, Fascia A. intercostalis posterior
N. intercostalis (T8)
M. intercostalis internus
Pulmo
M. intercostalis externus Pleura visceralis [pulmonalis]
Pleura parietalis, Pars costalis;
Fascia endothoracica
Costa IX Fascia thoracica interna

Pleura parietalis,
Pars diaphragmatica

Pars costalis diaphragmatis

Cutis; Tela subcutanea
Hepar
Fascia thoracica externa
Peritoneum viscerale
Peritoneum parietale
* Fig. 3.11 Intercostal space in
Costa X Recessus costodiaphragmaticus
cross-section; * Position of the
needle during thoracentesis

83
3 Torso

Rr. thymici A. subclavia sinistra

A. thoracica superior
A. carotis communis sinistra
A. axillaris

A. vertebralis R. clavicularis

R. acromialis
A. subclavia dextra
R. deltoideus A. thoraco-
Truncus brachiocephalicus acromialis
Rete acromiale

A. thoracica interna* Rr. pectorales

A. subscapularis
Rr. intercostales anteriores

A. thoracica lateralis
Rr. mammarii mediales

A. pericardiacophrenica
A. pericardiacophrenica

A. thoracia interna
Rr. sternales

A. thoracodorsalis
Rr. perforantes

Rr. tracheales et bronchiales

(Trigonum sternocostale)

A. musculophrenica

Rr. mediastinales

A. epigastrica superior

A. epigastrica inferior
R. obturatorius

A. circumflexa ilium profunda

R. pubicus A. iliaca externa

Fig. 3.12 Arteries of the anterior torso wall; * clinically also A. mammaria interna.

R. cutaneus lateralis R. cutaneus medialis

R. dorsalis R. spinalis

A. intercostalis posterior R. collateralis

Pars thoracica aortae

[Aorta thoracica]
R. cutaneus lateralis

R. mammarius lateralis

R. mammarius medialis

R. perforans
R. intercostalis anterior
Fig. 3.13 Course and exit points
A. thoracica interna* of the intercostal arteries in the
Rr. sternales intercostal space; * clinically
also A. mammaria interna.

84
 3.1 Ventral torso wall

Clinical remarks ly into the V. thoracica interna (› Fig. 3.14, › Fig. 3.15) and dor-
sally into the Vv. azygos and hemiazygos and hemiazygos accessoria
An aortic coarctation (Coarctatio aorta) is a narrowing of the
(› Fig. 3.16). In doing so, they form venous anastomoses between
aorta in the area of the aortic arch, which is considered as a
vascular malformation. Due to the constriction bypass circula- both drains. The V. intercostalis suprema flows from the first inter-
tions are formed in order to maintain blood supply to parts of costal space into the V. vertebralis or V. brachiocephalica. The Vv.
the trunk wall and lower extremities (› Fig. 6.11): intercostales posteriores of the 2nd and 3rd ICS unite on both sides
• Horizontal bypass circulation: between the Aa. thoracicae to the V. intercostalis superior, which flows into the V. azygos on
internae and Aorta thoracica via Rr. intercostales anteriores the right(› Fig. 3.16) and into the V. brachiocephalica on the left.
and Aa. intercostales posteriores to supply the thoracic and
abdominal organs (› Fig. 3.13). The intercostal arteries ex-
pand and lead to rib usures. Clinical remarks
• Vertical bypass circulation: to supply the trunk wall and the
lower extremities between Aa. subclaviae and Aa. iliacae Thrombosis, masses or the growth of tumours can lead to in-
externae via Aa. thoracicae internae, epigastricae superi- flow congestion of the Vv. cavae superior and inferior or the Vv.
ores and epigastricae inferiores (within the rectus sheath, iliacae communes. As a result, the following bypass circula-
see below) as well as in the area of the abdominal wall over tions can form between the V. cava superior and V. cava inferi-
the Aa. musculophrenicae, epigastricae inferiores and cir- or (cavocaval anastomoses, › Fig. 3.14):
cumflexae ilium profundae (› Fig. 3.12). • between the V. iliaca externa and V. cava superior via V. epi-
For the operative revascularization of the heart (bypass opera- gastrica inferior, V. epigastrica superior, V. thoracica interna
tion) in the case of severe coronary stenosis (coronary artery and V. brachiocephalica
narrowing), the A. thoracica interna is primarily used, except • between the V. femoralis and V. cava superior via V. circum­
for the superficial V. saphena magna (of the leg). flexa ilium superficialis/epigastrica superficialis, V. thoraco-
epigastrica, V. axillaris and V. brachiocephalica
• between the V. iliaca interna and V. cava superior via Plexus
venosus sacralis, Plexus venosi vertebrales externi and in-
terni, Vv. azygos and hemiazygos
Veins • between the Vv. lumbales and V. cava superior via Vv. lum-
The venous drainage takes place via veins, which run together with bales ascendentes, Vv. azygos and hemiazygos.
the respective arteries. The Vv. intercostales anteriores flow ventral-

V. subclavia V. brachiocephalica sinistra

Vv. pectorales V. cava superior

V. scapularis dorsalis
V. thoracica interna*
V. cephalica

V. thoracoacromialis V. intercostalis posterior

V. axillaris Rr. perforantes

V. thoracica lateralis
(Trigonum sternocostale)

V. thoracodorsalis
Vv. intercostales
Rr. perforantes anteriores

V. thoracoepigastrica
V. epigastrica superior

Plexus venosus areolaris

Vv. paraumbilicales
Rr. perforantes
V. epigastrica inferior
V. epigastrica superficialis

V. cava inferior

V. iliaca communis
V. circumflexa ilium superficialis
V. iliaca interna
Vv. pudendae externae

V. iliaca externa
V. saphena accessoria

V. saphena magna V. femoralis

Fig. 3.14 Veins of the anterior torso wall; * clinically also V. mammaria interna.

85
3 Torso

Cavocaval anastomoses are differentiated from portocaval Lymph vessels

anastomoses. The latter are circumventions of the liver The lymph vessels of the Pleura parietalis and intercostal muscles
­between the portal vein and upper/lower vena cava run dorsally to the Nodi lymphoidei intercostales in the area of
(› Chap. 7.3.11). the Angulus costae and drain from here into the Ductus thoraci-
cus . The ventral parts of the deep chest wall layers drain into the
Nodi lymphoidei parasternales, which are located along the A.
V. azygos Vertebra
and V. thoracica interna. From there, the lymph moves cranially via
V. hemiazygos
the Nodi lymphoidei cervicales profundi in the Truncus jugu-
Vv. intercostales
posteriores accessoria laris and left into the Ductus thoracicus.

Innervation
The ventral trunk wall is innervated segmentally from the Rr. ven-
trales of the thoracic spinal nerves and thus from the intercostal
nerves. Cranially, the Nn. supraclaviculares from the Plexus cer-
vicalis are involved in the sensory innervation in the area of the
clavicle . In the course of the intercostal nerves the sensitive Rr. cu-
tanei laterales exit at around the height of the middle axillary line.
In the segments T1–3 they branch to the Nn. intercostobrachiales
which sensitively innervate the skin of the medial upper arm. The
Vv. intercostales V. hemiazygos segments T4–6 emit Rr. mammarii laterales to the mammary
anteriores V. thoracica glands. In the area of the first 6 ICS the Rr. cutanei anteriores of
interna Sternum the intercostal nerves pass parasternally through the fascia and in-
nervate the skin in the ventral area. From here the Rr. mammarii
Fig. 3.15 Course and exit points of the intercostal veins in the inter-
costal space. [L266] mediales pass from the segments T3–6 to the mammary glands.

V. brachiocephalica sinistra V. jugularis interna

V. intercostalis suprema
V. subclavia

V. brachiocephalica dextra

V. intercostalis superior dextra V. hemiazygos accessoria

Vv. intercostales V. cava superior

V. azygos V. hemiazygos

V. subcostalis
V. lumbalis ascendens

V. cava inferior
V. iliaca interna

Vv. lumbales
V. iliaca externa
V. iliolumbalis

V. circumflexa ilium profunda

V. iliaca communis

V. epigastrica superficialis
V. sacralis mediana

V. circumflexa ilium superficialis

V. sacralis lateralis

V. femoralis dextra V. femoralis sinistra

V. epigastrica inferior V. pudenda externa

Fig. 3.16 Azygos system.

86
 3.1 Ventral torso wall

Clinical remarks spleen. In the case of pneumothorax a MONALDI drainage is

usually conducted through the 2nd ICS in the midclavicular
The intercostal spaces are of high practical clinical relevance. line. The MONALDI drainage differs from the BÜLAU drainage
For various reasons, there may be an accumulation of fluid in by a smaller lumen.
the pleural space between the chest wall and lung surface. If a
thoracentesis has to be conducted to remove liquid, the posi-
tional relationships of the vascular, lymphatic and nervous sys-
tems on the lower edge of the ribs are important. The punc-
tures are performed so that the puncture needle is inserted 3.1.3 Diaphragm
into the thorax directly above the upper edge of the rib to mini-
mise the risk of vascular injuries (› Fig. 3.11). This procedure
The dome-shaped diaphragm (Diaphragma) separates the thorac-
involves penetration of the following structures with the punc-
ture needle in the order from outside to inside (› Fig. 3.10): ic cavity from the abdominal cavity. It shows characteristic pas-
• Cutis/Subcutis sageways for the oesophagus, blood and lymph vessels and nerves.
• Fascia musculi serrati The diaphragm is also the most important inspiration muscle.
• M. serratus anterior
• Fascia thoracica externa Development
• M. intercostalis externus The development is based on 4 structures:
• M. intercostalis internus/intimus
• Septum transversum
• Fascia thoracica interna
• Fascia endothoracica • Plicae pleuroperitoneales
• Parietal pleura • Periesophageal connective tissue
A longer-term accumulation of fluid or air in the pleural space • Mesodermal ridges growing on the side of the body wall
often requires pleural drainage, which is usually created in The Septum transversum forms a mesenchymal plate between the
the 4th–5th ICS in the front or middle axillary line (› Fig. 6.49). heart and liver. The largest part of the Centrum tendineum emerg-
It is conducted for serothorax (serous effusion), haemothorax es from the septum. The Plicae pleuroperitoneales close the coe-
(blood effusion), pyothorax (bacterial putrid effusion) or hae- lomic canals (pleuroperitoneal canals). In doing so, they grow from
matopneumothorax (blood and air after trauma) mostly as a
BÜLAU drainage. This corresponds to the puncture in the ‘tri-
lateral and dorsal to the septum transversum and join together
angle of safety’, i.e. between the lateral margin of the M. pec- with the septum and with the mesenchyme surrounding the oe-
toralis major and the anterior margin of the M. latissimus dorsi sophagus (perioesophageal connective tissue). Tissue projections
at the height of the nipples. Pleural tapping or drainage below of the parietal mesoderm seal the diaphragm borders and attach it
the 6th ICS is avoided due to the risk of injuries to the liver or to the body wall. The developmental process does not occur in the
chest, but in the neck area. Therefore, the diaphragm is innervated

Pars sternalis diaphragmatis Proc. xiphoideus

Vv. phrenicae inferiores (Trigonum sternocostale): A.; V. thoracica interna,

N. phrenicus sinister, R. phrenicoabdominalis
Centrum tendineum
Hiatus oesophageus: Oesophagus;
Foramen v. cavae: V. cava inferior Trunci vagales anterior et posterior

N. phrenicus dexter, N. phrenicus sinister,

R. phrenicoabdominalis R. phrenicoabdominalis

Pars costalis diaphragmatis A. phrenica inferior

Pars lumbalis diaphragmatis,

N. splanchnicus major
Crus dextrum, (Pars lateralis)

Lig. arcuatum mediale (Trigonum lumbocostale)

Lig. arcuatum laterale V. hemiazygos

Costa XII M. quadratus lumborum

Proc. costalis vertebrae lumbalis I N. splanchnicus minor

V. azygos
M. psoas major

Pars lumbalis diaphragmatis,

Crus dextrum, (Pars medialis) Truncus sympathicus

Lig. arcuatum medianum; Hiatus aorticus: Aorta abdominalis;

Hiatus aorticus Ductus thoracicus

Fig. 3.17 Diaphragm (Diaphragma) and posterior abdominal wall.

87
3 Torso

mainly from the cervical segments C3–C5. The nerve fibres of the 3 Pars sternalis
segments together form the N. phrenicus. With the descent of the The Pars sternalis originates on the rear surface of the Proc.
heart and growth in length, the diaphragm shifts up to the inferior xiphoideus of the breastbone and with smaller parts from the rear
thoracic aperture and the N. phrenicus on both sides extends in lamina of the rectus sheath and extends to the Centrum
length (30 cm in adults); however, the intercostal nerves are also tendineum.
involved in the innervation.
Centrum tendineum
Structure The Centrum tendineum (› Fig. 3.17) forms the joint attachment
The diaphragm (› Fig. 3.17) consists of a muscular (Pars muscu- tendon of the muscular parts of the diaphragm. To the right of the
laris) and a fibrous part (Centrum tendineum), which serves the centre line it is limited by the Foramen venae cavae, through
diaphragm muscles as an attachment due to its central position. which the V. cava inferior passes. Projected into the respiratory
The sinewy muscle origins include the whole lower thoracic aper- central position, the Centrum tendineum is approximately at the
ture of the lumbar spine via the ribs to the sternum. The muscle height of the border between the Corpus and Proc. xiphoideus of
­origins are divided accordingly into Pars lumbalis, Pars costalis the sternum. The Centrum tendineum is fused on the thoracic side
and Pars sternalis. with the pericardium and on the abdominal side it is fused with the
Area nuda of the liver.
Pars lumbalis
The muscle-packed pars lumbalis originates on both sides of the Topographical relationships of the diaphragm
ventral side of the spine, so that a differentiation can be made be- Above the liver the right diaphragmatic dome is approximately 1–2
tween the right (Crus dextrum) and left crus of the diaphragm cm higher than the left, whereby in meteorism (excessive gas de-
(Crus sinistrum). Both diaphragm legs are muscle strands: posits in the gut, distension) the left diaphragmatic dome can ap-
• Crus dextrum: it is longer and wider than the Crus sinistrum proach the height of the right one. At maximum expiration the
and originates in the lumbar bodies I–IV, as well as the interven- right pleural dome projects to the upper edge of the IVth rib and at
ing Disci intervertebrales. the height of the VIIIth thoracic vertebrae. In inspiration position
• Crus sinistrum: it is shorter and narrower than the Crus dex- the right diaphragmatic dome is in contrast at the height of the
trum and fixed to the lumbar bodies I and II, as well as the cor- VIth rib and XIth thoracic vertebrae. On the left the pleural dome
responding intervertebral discs. is situated both for inspiration and expiration positions, by half or
Depending on the school of teaching, both crura are divided into 2 one ICS and half a vertebra lower than on the right side. The dia-
(Crus mediale and Crus laterale) or 3 sections (Pars lateralis, Pars in- phragm is higher when lying than when standing.
termedia and Pars medialis). Here, the division is into three sections.
The Pars medialis of the Crus dextrum forms a loop around the Diaphragm openings and penetrating structures
­oesophagus (Hiatus oesophageus). and is connected to the Pars Numerous structures penetrate or move around the diaphragm
medialis of the Crus sinistrum on the midline via a connective tis- (› Fig. 3.17):
sue arch (Lig. arcuatum medianum, aortic arcade). The aorta • The Trigonum sternocostale is located at the transition between
(Hiatus aorticus) and the Ductus thoracicus run behind the arch, Pars sternalis and Pars costalis. The A. epigastrica superior runs
but in front of the spine. ventral in front of the fibrous triangle as a terminal branch of the
Further laterally the Pars intermedia of the Crus dextrum forms a A. thoracica interna and its accompanying veins and with lymph
2nd tendinous arch, which extends beyond the M. psoas (psoas ar- vessels.
cade) and is referred to as Lig. arcuatum mediale. On the left side, Note: The Trigonum sternocostale is referred to clinically and also
the Lig. arcuatum mediale of the Pars medialis and the Pars inter- in many anatomy textbooks as the ‘LARREY cleft’; however, this
media is formed. The tendon arches are on the sides of the Ist and term should not be used, as when LARREY described his work on
IInd lumbar vertebrae and fixed laterally at the Proc. transversus of pericardial puncture he did not puncture caudally (i.e. from the
the Ist lumbar vertebra. peritoneal cavity) through the Trigonum sternocostale but pene-
Even further laterally the Partes laterales of the Crus dextrum and trated the diaphragm left and cranially with a scalpel after a punc-
the Crus sinistrum each bridge the M. quadratus lumborum (qua- ture between the costal arch and Proc. xiphoideus. The usual teach-
dratus arcade) as the Lig. arcuatum laterale . The arch is medial ing opinion that the A. thoracica interna penetrates through this
both at the Proc. transversus of the Ist lumbar vertebra and fixed triangle and passes into the A. epigastrica superior is also not en-
laterally to the XIIth rib. tirely correct since the vessels run ventrally of the Trigonum ster-
The Ligg. arcuata mediale and laterale are also called HALLER'S nocostale.
arches. • At the transition of the Pars costalis and Pars lumbalis there is
usually a muscle-free triangle (Trigonum lumbocostale,
NOTE ­B OCHDALEK triangle) which is sealed by connective tissue
The Pars lumbalis diaphragmatis is divided into: and serous membranes.
• Crus dextrum (Pars lateralis, Pars intermedia, Pars medialis) • The Nn. splanchnici major and minor run on both sides through
• Crus sinistrum (Pars lateralis, Pars intermedia, Pars medialis) the diaphragm crus (usually between the Pars medialis and Pars
intermedia of the respective Crus dextrum or sinistrum).
• The V. azygos (not always, see below) and the V. hemiazygos
Pars costalis pass through the right or left diaphragm crus (between Pars me-
The greater Pars costalis originates on the right and left of the cos- dialis and Pars intermedia).
tal arch and of the cartilaginous parts of the VIIth–XIIth ribs and • The oesophagus penetrates into the oesophageal hiatus slightly
extends to the Centrum tendineum. left above the Hiatus aorticus at the height of the Xth thoracic
vertebra through the Pars medialis of the Crus dextrum. With it

88
 3.1 Ventral torso wall

run the Trunci vagales anterior and posterior, the Rr. oesopha- Vestibulum
geales of the A. and V. gastrica sinistra as well as lymph vessels. gastrooesophageale
• The aorta runs behind the tendinous arch (Lig. arcuatum medi- Herniated fundus
anum, aortic arcade) of the Partes mediales of the Crus dextrum Diaphragm

and Crus sinistrum and in front of the XIIth thoracic vertebra a

little to the left of the centre line (Hiatus aorticus). The Ductus
thoracicus and sometimes the V. azygos. also penetrate through
the Hiatus aorticus. a b
• The Foramen venae cavae lies in the Centrum tendineum ap-
proximately at the height of the transition from the VIIIth to the Fig. 3.18 Acquired diaphragmatic hernias (scheme). a Axial hiatal
IXth thoracic vertebrae slightly to the right of the spine. The V. cava hernia. b Paraesophageal hiatal hernia. [L141]
inferior penetrates through the foramen from the abdominal
cavity into the chest. The Foramen venae cavae is also used by – Aa. pericardiacophrenicae (branches of the A. thoracica in-
the N. phrenicus dexter for passage. terna)
• The N. phrenicus sinister penetrates the Pars costalis on the – Aa. phrenicae superiores (branches of the Aorta thoracica).
left-hand side or enters through the Hiatus oesophageus. • From the abdominal cavity side:
• The sympathetic trunks run on both sides behind the Lig. ar- – Aa. phrenicae inferiores (branches of the Aorta abdominalis).
cuatum mediale.
Other small vessels and nerves, e. g. for the diaphragm muscles or Veins
branches of some intercostal nerves also penetrate at certain places The venous drainage occurs via:
through the diaphragm. • Vv. phrenicae superiores into the V. azygos and the V. hemiazy-
gos
NOTE • Vv. phrenicae inferiores into the V. cava inferior.
The diaphragm (Daphragma) is the main breathing muscle, without
which adequate breathing is not possible. It separates the thoracic Lymph vessels
cavity from the abdominal cavity and is penetrated by many struc- The lymph drainage takes place within the muscles via its own
tures, such as the oesophagus and V. cava inferior. lymph ducts to the lymph ducts of the pleura and peritoneum.

Innervation
Clinical remarks The motor and sensory innervation for the most part is effected by
Diaphragmatic hernia (Hernia diaphragmatica) can be con- the Nn. phrenici from the segments C3–C5 of the Plexus cervica-
genital or acquired. In both cases, abdominal viscera pass lis. The Nn. phrenici run left and right over the front of the M. sca-
over into the thoracic cavity. If the shifted organs are covered lenus anterior and pass through the upper thoracic aperture into
by peritoneum (hernial sac), one speaks of true hernias: the chest. Here they stretch between Pleura mediastinalis and peri-
• Congenital diaphragmatic hernias (BOCHDALEK hernias) are
cardium through the thoracic cavity to the diaphragm surface. In
usually gaps in the diaphragm through which abdominal or-
gans (stomach, intestines, liver, spleen) pass into the thorax their course they sensitively innervate the Pleura mediastinalis, the
and can impair lung growth and breathing after birth. In ad- Pleura diaphragmatica and the pericardium. On the right, the N.
dition to life-threatening dyspnea in a newborn child, cardi- phrenicus penetrates through the Foramen venae cavae in the Cen-
ac symptoms may also occur due to suppression of the trum tendineum; on the left, it usually passes alone near the Cen-
heart. Congenital diaphragmatic hernias are more likely to trum tendineum through the Pars costalis diaphragmatis. Both Nn.
be on the left than on the right side, usually have no hernial phrenici branch out below the diaphragm and motor innervate the
sac and are often in the Trigonum sternocostale (MORGAGNI muscles and sensory the Peritoneum parietale on the diaphragm.
hernia) or lumbocostale (BOCHDALEK hernia).
• Acquired diaphragmatic hernias are usually hiatal hernias or
In addition, the adjacent intercostal nerves are involved and the
paraesophageal hiatal hernias. In a hiatal hernia part of the N. subclavius as the so-called accessory phrenic nerve can be
stomach also passes through the slit-shaped Hiatus ­involved in the innervation.
­oesophageus (› Fig. 3.18). If the cardia of the stomach is
pulled up through the diaphragm into the chest, it is called NOTE
an axial hiatal hernia (› Fig. 3.18). There are also mixed The diaphragm innervation is carried out via the N. phrenicus. It in-
forms. In severe cases, the majority of the stomach can slide nervates
into the chest (thoracic stomach, ‘upside-down stomach’). • by motor nerves
A flattening of the pleural dome in the x-ray image can indi- – diaphragm muscles
cate a reduced retraction force of the lungs, e. g. in the case of • by sensory nerves
an emphysema or pneumothorax. During pregnancy or in the – Pleura mediastinalis
case of fluid accumulation in the abdominal cavity (ascites)
– Pleura diaphragmatica
there can be a shift of the diaphragm borders in a cranial di-
– Pericardium
rection.
– Peritoneum parietale on the diaphragm

Vascular, lymphatic and nervous systems Clinical remarks

Arteries
The diaphragm is supplied at its upper and lower side with blood: Damage to the N. phrenicus causes paralysis of the muscles
on the affected side with an elevated diaphragm (Relaxatio
• from the thoracic cavity side:
diaphragmatica).
– Aa. musculophrenicae (branches of the A. thoracica interna)

89
3 Torso

Diaphragm function, respiratory mechanics and accessory 3.1.4 Abdominal wall

breathing muscles
Respiration and the breathing muscles are also described in
› Chap. 6.5.4.
Based on the relaxed breathing position, contraction of the Mm.
Clinical case
intercostales externi, the Mm. intercartilaginei, Mm. scaleni and Indirect inguinal hernia
the diaphragm results in inspiration: The ribs are raised, the dia- Case study
phragm is flattened out and the thoracic volume is increased. The An 84-year-old retired man in poor general state of health visits
external forces that act on the chest and also the elastic restorative a general practitioner for a second opinion. The patient has
forces of the chest and the lungs are therefore overcome. The fur- suffered severe weight loss (approx. 8 kg) and a significant
ther the ribs are lifted, the greater the resistance and the more pow- loss of power within 1 year. He also reports cramp-like abdomi-
nal pains after each food intake, which have the effect that he
er is required. In doing so, the thorax in the upper section expands
hardly eats anything at all. Today, in particular, he feels partic-
more in the longitudinal diameter (sternocostal breathing type) ularly unwell and has not yet eaten anything. He sometimes
and stretches more in the lower section in the diameter (flank also suffers from severe diarrhoea. His family doctor treated it
breathing). The enlargement in the caudal section leads to the ex- from the onset of the complaints with the suspected diagnosis
pansion of the diaphragm, thereby enabling a mechanically favour- ‘heartburn’. The prescribed tablets to reduce gastric acid pro-
able starting position for diaphragm contraction (costodiaphrag- duction had not helped him. A gastroscopy 3 months ago has
matic breathing type). The interplay of extension of the inferior shown no pathological findings. Previous conditions reported
by the patient include 2 operations (1945 shrapnel injury;
thoracic aperture and contraction-related flattening of the dia-
1991 inguinal hernia left) and a well-adjusted high blood pres-
phragm expands the Recessus costodiaphragmaticus on both sure (current measurement RR 125/80). Until a few months
sides. Under physiological conditions both types of breathing are ago, he had independently managed a large plot of land and
normally combined. Under resting conditions the inspiration is looked after his wife who recently received a ‘new hip’.
dominated by contraction of the Mm. scaleni, which slightly raise
the Ist and IInd ribs. Through the tone of the intercostal muscles Initial examination
the rest of the ribs are raised slightly so that the chest is mainly ex- During physical examination a dry tongue and persisting skin
panded from below by diaphragm contraction. The Mm. intercos- folds give an indication of severe exsiccosis. Blood pressure,
heart rate and auscultation findings are normal. The pulse is
tales externi and intercartilaginei are only activated for increased
easily palpable on both sides and the indicative neurological
inspiration. In addition to the abovementioned muscles that act on examination is without pathological findings. When the doctor
inspiration, the following muscles can be activated in forced inspi- asks the patient to take off his clothes for a rectal examina-
ration due to physical stress or during illnesses (e. g. bronchial tion, the old man asks whether this is really necessary. His old
asthma) (accessory breathing muscles). The burden of the weight family doctor had always spared him that procedure. The doc-
of the shoulder girdle on the thorax can be reduced by the Mm. tor tells him that many ulcers in bowel cancer may be easily
rhomboidei, levatores scapulae and trapezii. As the force of the detected in the early stages with the finger or through blood
shoulder girdle acts in an expirational manner on the chest, less on the glove. One should also regularly check the prostate at
his age. The patient then reluctantly agrees to the manual pal-
force has to be applied on inspiration due to the elevation of the pation examination. The investigation, however, remains with-
shoulder girdle. By supporting the arms on the thighs, as can fre- out pathological findings, except for an enlarged prostate
quently be observed in athletes following a competitive event, the gland which is in keeping with the age of the patient. During
Mm. pectorales majores, minores and serrati anteriores are also the inspection of the patient's inguinal region, the doctor no-
able to lift the ribs and expand the chest. In this way they also have tices a clearly visible swelling on the right side. The more de-
an inspirational effect (by reversal of punctum fixum and punctum tailed examination consolidates the suspicion that this is a
mobile by resting the arms). hernia. The hernial sac cannot be manually shifted back into
the abdominal cavity. On an ausculatory level bowel sounds
On expiration the elastic restorative forces of the lungs and the are perceptible in the patient's scrotum, indicating that there
thorax as well as gravity have the effect that the chest springs back are intestinal components here. The doctor explains to the pa-
to its initial position, as soon as the inspiratory muscles become tient that intestinal components are trapped in his abdominal
fatigued. Only when breathing is continued via the breathing rest- wall. This is obstructing the transport of the food mass at this
ing position, does contraction of the Mm. intercostales interni point and could explain his symptoms. In the worst case, this
and the M. transversus thoracis cause a further sinking of the ribs. could lead to an intestinal infarct caused by clamping of the
A crucial role for forced expiration is also played by the abdominal blood supply to the intestine. Due to the alarming findings,
the doctor immediately refers the patient to the local hospital.
muscles (› Chap. 3.1.4 ). Their contraction lowers the thorax fur-
ther, narrows the lower thoracic aperture and increases the in- Further diagnostics
tra-abdominal pressure, causing the abdominal organs and the dia- In the subsequent x-ray of the abdomen the level of fluid in
phragm to be pushed upwards at the expense of the intrathoracic the small intestines is noticeable, which indicates a partial or
volume. Therefore the abdominal muscles are the most important complete closure of the intestinal passage (subileus or ileus)
auxiliary muscles for expiration. When the arms are at rest, the due to the inguinal hernia.
M. latissimus dorsi also supports expiration by lowering the ribs.
Therapy and follow-up
The senior surgical consultant conducts emergency surgery 3
hours later in which he confirms an indirect inguinal hernia.
He can move the section of the small intestine back without
having to resect it.
During the morning visit the next day the patient thanks the
doctor for his rapid assistance and asks when he can finally
get back home to support his wife.

90
 3.1 Ventral torso wall

Clinical picture Superficial fascia

The inguinal canal is the most common localisation (approx. The superficial fascia (Fascia abdominis superficialis, SCARPA's
80%) of abdominal wall hernias. A distinction is made be- fascia) is fused with the M. obliquus externus abdominis and its
tween indirect and direct inguinal hernias depending on the aponeurosis. Fibres of the fascia join together with fibres of the M.
hernial ring. Indirect inguinal hernias are the most common obliquus externus abdominis aponeurosis and form the Lig. sus-
abdominal wall hernias in adulthood (approximately two pensorium penis on the upper side of the penis and at the top of
thirds of all hernias) and occur particularly in men. The hernial
the clitoris the Lig. suspensorium clitoridis. They connect these
sac continues via the inguinal canal through the outer inguinal
ring into the scrotum or to the labia majora. Direct inguinal with the lower edge of the symphysis pubica.
hernias (about one third of all hernias) make a direct course The Fascia abdominis superficialis passes cranially continuously to
through the abdominal wall, by penetrating the abdominal the superficial chest wall fascia (Fascia pectoralis) and to the Fascia
wall in the Fossa inguinalis medialis. axillaris; caudally it continues under the Lig. inguinale in the fascia
of the thigh (Fascia lata) and dorsal in the back fascia (Fascia tho-
racolumbalis).
The abdominal wall surrounds the abdominal cavity (peritoneal
cavity, cavitas peritonealis) and the organs of the abdominal cavi- Vascular, lymphatic and nervous systems of the superficial layer
ty (Cavitas abdominalis) in the extraperitoneal space (Spatium Arteries
extraperitoneale). It is cranial to the chest, dorsal to the spine and The arterial blood supply takes place partially segmentally; in some
caudal to the pelvis. It is primarily formed from 4 flat abdominal cases the supply deviates from this (› Fig. 3.12, › Fig. 3.2):
muscles and their tendon plates (aponeuroses), which extend be- • Segmentally
tween the chest and pelvis. Together, they form the abdominal wall – Rr. cutanei laterales of the Aa. intercostales posteriores
and the lateral parts are also referred to as the flanks. The abdomen (VIIth to XIth) reach the skin at the edge of the M. obliquus
wall runs continuously into the pelvic wall. It can be divided into externus abdominis
three layers: • Not segmentally
• Superficial layer – Branches of the Aa. epigastricae superior and inferior to the
– Skin and subcutaneous tissue skin
– General body fascia (Fascia abdominis superficialis) – A. epigastrica superficialis
• Middle layer – A. circumflexa ilium superficialis
– Front, side and back abdominal muscles with aponeuroses – Aa. pudendae externae superficialis et profunda
• Deep layer
– Inner abdominal wall fascia (Fascia abdominis interna) Veins
– Subserosal connective tissue (Tela subserosa) The veins in the subcutis of the abdominal wall form a network
– Parietale peritoneum (Peritoneum parietale) which drains into the
• V. thoracoepigastrica (in the upper section) and into the
Superficial layer • V. epigastrica superficialis (in the lower section).
Cutis The V. thoracoepigastrica leads the blood into the V. axillaris. The
The cutis is elastic and approximately 2 mm thick. The gender-spe- V. epigastrica superficialis drains the blood to the vein cross (Hia-
cific pubic hair (pubes) in men usually extends up to the navel and tus saphenus). The V circumflexa ilium superficialis and the Vv.
in the case of women ends above the mons pubis. The collagen fi- pudendae externae merge here. The Vv. paraumbilicales are con-
brils of skin have a certain alignment (LANGER'S lines), which nected with the Vv. thoracoepigastrica et epigastrica superficialis
need to be taken into account during surgery to avoid extensive and also drain through the abdominal wall to the V. portae hepatis
scars. (› Chap. 7.8.3). Segmentally arranged, the main veins accompa-
nying the arteries carry blood to the Vv. intercostales posteriores
and Vv. epigastricae superior et inferior.
Clinical remarks
Skin overstretching of the abdominal wall or thighs, e.g. in Lymph vessels
the case of obesity or during pregnancy, can evoke stripe-like Regional lymph nodes of the cutis and subcutis (› Fig. 3.19,
tears (stretch marks) in the dermis and visible striae disten- › Fig. 3.5) are:
sae. • Above the navel:
– Nodi lymphoidei pectorales
– Nodi lymphoidei intercostales
Subcutis – Nodi lymphoidei parasternales
In the Tela subcutanea there is gender-specific storage of fat de- • Below the navel:
pending on the nutritional status. The subcutaneous adipose tissue – Nodi lymphoidei inguinales superficiales (Tractus horizon-
is missing in the umbilical area. talis: Nodi lymphoidei superomediales and nodi lymphoidei
The subcutis is a layer of connective tissue particularly below the superolaterales)
umbilicus, which consists of connective tissue membranes and is
stored in the adipose tissue. It is referred to as the Stratum mem- Innervation
branosum (CAMPER's fascia). The connective tissue contains The innervation of the abdominal wall takes place segmentally
large quantities of elastic fibres and is fused with the outer ring of (› Fig. 3.2). The contributing main nerves are branches of the
the rectus sheath (see below). Fibre bundles of CAMPER's fascia • Nn. intercostales VI–XI
extend to the penis root as the Lig. fundiforme (Lig. fundiforme • N. subcostalis
penis) or to the clitoris (Lig. fundiforme clitoridis). • N. iliohypogastricus
• N. ilioinguinalis

91
3 Torso

versus thoracis, 3 muscle layers are differentiated from the hy-

pomere in the abdominal area:
• M. obliquus externus abdominis
• M. obliquus internus abdominis
• M. transversus abdominis
The following also emerge from the hypomere:
Nodi lymphoidei brachiales
• M. rectus abdominis
Nodi lymphoidei pectorales • M. quadratus lumborum
• Pelvic floor muscles and closing muscles of the urethra and anus.

Front (straight) abdominal muscles

M. rectus abdominis
The paired M. rectus abdominis has a straight fibre trend, which is
displaced by 90° with the fibres of the M. transversus abdominis
Nodi lymphoidei (› Fig. 3.20, › Fig. 3.22). It lies paramedially from the pubic
inguinales superficiales bone to the thorax and is embedded in a fibre canal (rectus sheath,
superolaterales (Tractus see below), which is formed by the aponeuroses of the oblique ab-
Nodi lymphoidei horizontalis)
dominal muscles. The M. rectus abdominis muscle has 4–5 muscle
inguinales superficiales
superomediales bellies, which are impressive when there is a low level of subcuta-
neous adipose tissue and well-trained muscles in the form of a ‘six-
Nodi lymphoidei
inguinales superficiales
(Tractus pack’. The muscle parts do not comply with the segmental myo-
verticalis)
inferiores tomes and are separated by 3–4, rarely by 5 Intersectiones tend-
ineae. The inter-sections are individually arranged at different
Fig. 3.19 Superficial lymph vessels and regional lymph nodes of the heights and often also vary between the two sides. They are fused
anterior torso wall.
with the frontal lamina (Lamina anterior) of the rectus sheath. On
the back the branches of the intercostal nerves (T7–12) and sup-
Rr. cutanei anteriores mediales of the intercostal nerves reach the plying blood vessels (Aa./Vv. epigastricae superior et inferior) can
skin beside the linea alba; the corresponding Rr. cutanei anteri- reach the muscle. The muscle is of great significance for the torso
ores laterales reach the subcutis in the area of origin of the M. flexion and plays a role together with the oblique abdominal mus-
obliquus externus abdominis. cles in abdominal pressing and forced expiration.
The R. medialis of the N. iliohypogastricus arrives at the surface
anatomy a little above the Anulus inguinalis superficialis and in- M. pyramidalis
nervates the skin around the annulus and the mons pubis. The ter- The M. pyramidalis is a small triangular-shaped muscle between
minal branch of the N. ilioinguinalis leaves the Canalis inguinalis the aponeuroses of the oblique abdominal muscles or behind the
to innervate the skin above and medial of the Anulus inguinalis su- front lamina of the rectus sheath (› Fig. 3.20). It spans the Linea
perficialis and the mons pubis. In addition, its branches innervate alba. It is missing in 10–25% of people.
parts of the Labia majora as Rr. labiales anteriores and as Rr. scro-
tales anteriores the front of the scrotum. Lateral (angled) abdominal muscles
Lateral abdominal muscles (Mm. obliquus externus abdominis, M.
Middle layer obliquus internus abdominis, M. transversus abdominis) overlap
The middle layer of the abdominal wall includes the front and lat- each other in 3 layers. The fibres of these muscles run differently.
eral abdominal muscles and their aponeuroses and a group of They cover a large area, but are relatively thin. In the area of the
deeper abdominal muscles. According to their location, the mus- midclavicular line, the muscles pass into their aponeuroses, from
cles are divided into: which the rectus sheath of the right and left side are formed and
• Front (straight) abdominal muscles which interweave into the midline to the Linea alba (see below).
• Lateral (angled) abdominal muscles
• Rear (deep) abdominal muscles M. obliquus externus abdominis
The muscles of the abdominal wall (Mm. abdominis) form togeth- The M. obliquus externus abdominis is the most superficial and
er with their aponeuroses and suffused fascia the actual abdominal largest of the lateral abdominal muscles (› Fig. 3.20, › Table 3.2).
wall, which covers the area between the chest wall and pelvic ring. The muscle has a serrated shape, with the attachments of the M.
Innervation, attachment, origin and function of the muscles are serratus anterior alternating origin line that extends up to the Vth
summarised in › Table 3.2. The fascia, which cover the muscles rib. In the case of trained persons the line is clearly visible on the
outside (Fascia abdominis superficialis) and inside (Fascia trans- side of the thorax (GERDY's line). The course of the muscle fibres
versalis), belong to the superficial or deep layer of the abdominal of the M. obliquus externus abdominis continues over the line on
wall. the M. serratus anterior to cranial. Caudally, on the opposite side
(via an imaginary line through the two rectus sheaths), the muscle
Development fibre course continues to the M. obliquus internus abdominis of the
The abdominal muscles emerge from the ventral dermomyotome, opposite side and thus forms a slanted muscle loop. This explains
which divides in the 5th week into a larger ventral group of mesen- the strong force effect of the M. obliquus externus abdominis in
chymal cells (hypomere) and a smaller dorsal group (epimere). The torso diffraction, torso rotation and when throwing (M. serratus
epimere becomes the indigenous back muscles. Apart from the anterior in continuation on the shoulder girdle). The caudal limit
Mm. scaleni, the prevertebral neck muscles, the infrahyoid mus- of the aponeurosis of the M. obliquus externus abdominis is
cles, the Mm. intercostales, the Mm. subcostales and the M. trans- formed by the inguinal ligament (Lig. inguinale). The aponeurosis

92
 3.1 Ventral torso wall

has a gap for the outflow of the inguinal canal (outer inguinal ring, horizontally and pass laterally from the M. rectus abdominis into a
Anulus inguinalis superficialis) and is involved in the development crescent-shaped line (Linea semilunaris, SPIEGHEL line) into its
of the front lamina of the rectus sheath. aponeurosis. Lower muscle fibres emerging from the inguinal liga-
ment pass over the inguinal canal (› Fig. 3.26). The aponeurosis
M. obliquus internus abdominis combines above the Linea arcuata (› Fig. 3.30) with the posterior
The M. obliquus internus abdominis lies between the M. transver- part of the aponeurosis of the M. obliquus internus abdominis to
us abdominis and M. obliquus externus abdominis (› Fig. 3.20, the rear lamina of the rectus sheath. The part emerging below the
› Fig. 3.21, › Table 3.2). Its muscle fibres radiate from the Spina Linea arcuata from the inguinal ligament of the aponeurosis is
iliaca anterior superior in a fan shape and insert into the Linea alba fused with the M. obliquus internus abdominis (M. complexus)
and the bottom edge of the rib arch. The fibre course continues and runs ventrally to strengthen the front face of the rectus sheath.
here in the Mm. intercostales interni. Thus, the muscle fibres run Some fibres are usually involved in the formation of the M. cremas-
obliquely above the pelvic comb and thus perpendicular to the M. ter. As the Falx inguinalis is the radiating part of the attachment
obliquus externus abdominis. At the height of the Spina iliaca ante- tendon of the M. transversus abdominis it is referred to as the Tu-
rior superior the muscle fibre course is horizontal and below it berculum pubicum. The fibres previously run in an arch shape on
downwards. The descending fibres overlie the spermatic cord and the border to the rectus sheath downwards (transversus sinew arch,
at the same time form the roof of the inguinal canal. Caudal muscle transversus sinew arcade, Tendo conjunctivus) and laterally limit
fibres accompany the spermatic cord as the M. cremaster (Funicu- the Trigonum inguinale (HESSELBACH's triangle, see below).
lus spermaticus, see below). The internus aponeurosis branches
above the Linea arcuata (› Fig. 3.25) in 2 parts: the front portion Rear (deep) abdominal muscles
combines with the aponeurosis of the M. obliquus externus ab- Dorsally, the abdominal wall is formed by 2 pairs of muscles, which
dominis to the front lamina of the rectus sheath; the rear portion lie ventrally of the deep lamina of the Fascia thoracodorsalis and of
combines with the aponeurosis of the M. transversus abdominis to the original area of the M. transversus abdominis:
the rear lamina of the rectus sheath (see below). Below the Linea • M. psoas major
arcuata both parts extend to the front lamina of the rectus sheath. • M. quadratus lumborum
Both muscles form the base of the Fossa lumbalis, a muscular
M. transversus abdominis niche, which extends between the lumbar spine, XIIth rib and iliac
The M. transversus abdominis is the deepest of the lateral abdomi- crest.
nal muscles (› Fig. 3.22, › Table 3.2). Its fibres run approximately­

Ligg. costoxiphoidea M. pectoralis major,

Pars sternocostalis
M. serratus anterior

M. pectoralis major,
Vagina musculi Pars abdominalis
recti abdominis,
Lamina anterior
M. obliquus externus
abdominis
M. rectus abdominis,
Intersectio tendinea
Mm. intercostales
interni
M. rectus abdominis

M. rectus abdominis
M. obliquus externus
abdominis
M. obliquus internus
abdominis,
Aponeurosis
Anulus umbilicalis

M. obliquus externus
abdominis
Linea alba

M. obliquus internus
Spina iliaca abdominis
anterior superior

M. obliquus externus
Fibrae intercrurales abdominis,
Aponeurosis

Anulus inguinalis Crus laterale Funiculus spermaticus;

superficialis Crus mediale M. cremaster Fig. 3.20 Superficial and mid-
dle layer of the abdominal mus-
M. pyramidalis Lig. reflexum cles, Mm. abdominis.
Ventral view.

93
3 Torso

M. serratus anterior M. pectoralis major

M. latissimus dorsi
M. obliquus externus
abdominis

M. obliquus
externus abdominis
Intersectiones
tendineae
Mm. intercostales
externi
Vagina musculi
recti abdominis,
Mm. intercostales
Lamina anterior
interni

Cartilago costalis X
M. rectus abdominis

M. obliquus
externus abdominis
Vagina musculi
recti abdominis,
M. obliquus Lamina anterior
internus abdominis

Spina iliaca anterior

superior Anulus inguinalis
superficialis
Lig. inguinale

Fig. 3.21 Middle layer of the

abdominal muscles, Mm.
Funiculus spermaticus; M. pyramidalis abdominis. Ventral view.
M. cremaster

M. rectus abdominis M. rectus abdominis

Mm. intercostales M. pectoralis major

externi
M. latissimus dorsi
Mm. intercostales
interni Intersectiones
tendineae
Cartilagines costales
M. obliquus externus
abdominis
Costae IX; X

Vagina musculi recti

Vagina musculi recti abdominis,
abdominis, Lamina anterior
Lamina posterior

M. obliquus internus
Linea semilunaris abdominis

M. transversus M. transversus
abdominis abdominis
M. obliquus internus
abdominis Intersectio tendinea

M. obliquus internus M. obliquus internus

abdominis, abdominis
Aponeurosis
Anulus inguinalis
Linea arcuata superficialis,
Crus mediale

Vagina musculi recti

Anulus inguinalis
abdominis,
superficialis,
Lamina anterior
Crus laterale

Fascia transversalis M. pyramidalis

Fig. 3.22 Deep layer of the
Funiculus spermaticus M. rectus abdominis abdominal muscles, Mm.
abdominis. Ventral view.

94
 3.1 Ventral torso wall

Table 3.2 Abdominal muscles.

Innervation Origin Attachment Function

Anterior muscles of the abdominal wall
M. rectus abdominis
Nn. intercostales, • Outer surface of the Vth–VIIth • Os pubis Pull the thorax against the pelvis, abdominal pressing,
N. subcostalis, rib • Symphysis pubica abdominal breathing (expiration)
N. iliohypogastricus • Proc. xiphoideus
• Ligg. costoxiphoideus

M. pyramidalis
N. subcostalis, Os pubis (ventral to the M. rectus Linea alba Tensing of the Linea alba
abdominis)
N. iliohypogastricus

Lateral muscles of the abdominal wall

M. obliquus externus abdominis
Nn. intercostales, Vth–XIIth ribs (outer surface) • Iliac crest • Unilateral contraction: thoracic rotation (synergistically
N. subcostalis • Lig. inguinale (complete) with M. obliquus internus of the contralateral side), later-
• Os pubis al flexion (synergistically with M. internus externus on
• Linea alba the ipsilateral side)
• Bilateral contraction: pulls the thorax against the pelvis,
abdominal pressing, abdominal breathing (expiration)

M. obliquus internus abdominis

Nn. intercostales, • Fascia thoracolumbalis • IXth–XIIth ribs (lower edge) • Unilateral contraction: thoracic rotation (synergistically
N. subcostalis, • Crista iliaca • Linea alba with M. obliquus externus on the contralateral side), lat-
N. iliohypogastricus, • Spinor iliaca anterior superior eral flexion (synergistically with M. obliquus externus on
N. ilioinguinalis • Lig. inguinale (only lateral) the ipsilateral side)
• Bilateral contraction: pulls the thorax against the pelvis,
abdominal pressing, abdominal breathing (expiration)
• M. cremaster: elevation of the testes

M. transversus abdominis
Nn. intercostales, • VIIth–XIIth ribs (inner surface) • Linea alba • Unilateral contraction: torso rotation
N. subcostalis, • Fascia thoracolumbalis • Os pubis • Bilateral contraction: abdominal press, abdominal
N. iliohypogastricus, • Crista iliaca breathing (expiration)
N. ilioinguinalis, • Lig. inguinale (only lateral) • M. cremaster: elevation of the testes
N. genitofemoralis

Posterior (deep) muscles of the abdominal wall

M. quadratus lumborum
N. subcostalis, Rr. musculares of • Crista iliaca • XIIth rib Lateral flexion of the torso, lowering of the ribs (expiration)
the Plexus lumborum • Lig. iliolumbale • Proc. costales of the lumbar
vertebral body

M. psoas major
Rr. musculares of the Plexus lum- Ist–IVth lumbar vertebras (Corpus Trochanter minor (together with • Unilateral contraction: sideways inclination of the torso,
borum and Proc. costalis) M. iliacus) flexion of the hips
• Bilateral contraction: elevation of the torso

M. psoas minor (inconstant)

Rr. musculares of the Plexus lum- • XIIth thoracic vertebral body • Fascia of the M. iliopsoas • Unilateral contraction: sideways inclination of the torso
borum • Ist lumbar body • Arcus iliopectineus • Bilateral contraction: elevation of the torso

Psoas major rear portion. The front part is covered by the Fascia musculi qua-
The M. psoas major belongs functionally to the hip muscles and is drati lumborum, which represents a continuation of the Fascia
discussed there (› Chap. 5.3.4). Its fascia forms a closed funnel-­ transversalis (see below). Medially it passes into the fascia of the
shaped box together with the fascia of the M. iliacus (Fascia ilio- M. psoas major. Cranially, the quadratus fascia is strengthened to a
psoas), which extends from the diaphragm and from the Os ilium tendinous arch, which extends from the Proc. costalis of the Ist
up to the trochanter minor. The Psoas fascia is part of the Fascia lumbar vertebra to the top of the XIIth rib and forms the Lig. ar-
lumbalis and has cranial connections to the fascia on the dia- cuatum laterale (quadratus arcade, outer HALLER's arches).
phragm, where it is involved in the formation of the Lig. arcuatum A contraction of the muscle lowers the XIIth rib. In addition the
mediale (psoas arcade, internal HALLER's arches). muscle stabilises the XIIth rib during the contraction of the dia-
phragm and is therefore also important for inspiration. The muscle
M. quadratus lumborum shows a large number of muscle spindles. This indicates a fine reg-
The M. quadratus lumborum is located adjacent to the vertebral ulated muscle tension from spinal reflexes, as it is often found in
column on the deep lamina (Lamina profunda) of the Fascia thora- support motor functions.
columbalis (› Fig. 3.23, › Table 3.2). It consists of a front and a

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3 Torso

Foramen venae cavae Pars sternalis diaphragmatis

Pars costalis diaphragmatis

M. transversus abdominis

Oesophagus, Pars abdominalis

Centrum tendineum
Hiatus oesophageus
Pars costalis
diaphragmatis Hiatus aorticus

Truncus coeliacus
Pars lumbalis
diaphragmatis, Pars abdominalis aortae
Crus dextrum
Vertebrae lumbales III; IV
Lig. arcuatum mediale
Fascia transversalis
Lig. arcuatum laterale
Crista iliaca

(M. psoas minor) (M. psoas minor),

Tendo
M. transversus abdominis
M. psoas major

M. quadratus lumborum M. iliacus

M. psoas major Promontorium

Lacuna vasorum
M. iliacus
A. femoralis
Peritoneum parietale
V. femoralis
Fig. 3.23 Diaphragm (Diaphrag-
Rectum Lig. inguinale* ma) and abdominal muscles
(Mm. abdominis). Ventral view.
Pecten ossis pubis Vesica urinaria * FALLOPIAN ligament or
POUPART's ligament

Functions of the abdominal muscles Vascular, lymphatic and nervous systems of the middle layer
Functionally the lateral abdominal muscles form through their op- Arteries
posite fibre course via the midline belt-shaped muscle loops in 4 • The arteries have a segmental arrangement and run along the
levels around the abdominal cavity and brace it. The muscle loops side of the abdominal wall ventrally. The Aa. intercostales VI–
are of functional importance in the selective contraction of differ- XI leave the corresponding ICS at the rib arch and pass between
ent muscles parts in the lateral flexion or the forward bending of the the Mm. obliquus internus abdominis et transversus abdominis
torso (ventral flexion). They also play a major role in torso rotation forward below to the rectus sheath (› Fig. 3.2). On their way
(torsion) and therefore when throwing. Simultaneous contraction they emit branches to the M. obliquus externus abdominis. The
of all abdominal muscles leads to an intra-abdominal pressure in- terminal branches pass through the aponeuroses of the abdomi-
crease (abdominal pressing), which has different functions depend- nal muscles to the side into the rectus sheath and supply the M.
ing on whether the glottis is opened or closed: rectus abdominis. Here they anastomose with the Aa. epigastri-
• In the case of a closed glottis the abdominal pressing supports cae superiores et inferiores.
micturition and/or defaecation (after surgical removal of the lar- • The A. epigastrica superior is the continuation of the A. thorac-
ynx patients can no longer retain air in the lungs by arbitrarily ica interna. They are usually connected within the rectus sheath
closing the glottis and have to manually close the artificially pro- on the back or side of the M. rectus abdominis with the A. epi-
duced exit of their trachea in the throat area [tracheostoma] gastrica inferior.
during abdominal pressing). The abdominal pressing is also es- • The A. epigastrica inferior exits from the A. iliaca externa
sential during parturition and to support contractions during shortly before it enters the Lacuna vasorum and runs on the Lig.
the expulsion phase. interfoveolare (see below) in a cranial direction to the rectus
• In the case of an open glottis the abdominal pressing can help to sheath. On the rear surface of the abdominal wall it emits, to-
expel inspired air and thus to increase the volume of a vocal gether with its associated vein, the Plica umbilicalis lateralis
sound. In addition, the simultaneous contraction of all abdomi- (epigastrica). After entering the rectus sheath it runs on the back
nal muscles when the glottis is open causes the diaphragm to of the M. rectus abdominis further cranially and connects with
bulge into the thorax, the lungs become compressed and as such the A. epigastrica superior approximately at the height of the
exhalation is accelerated (forced expiration). centre of the rectus sheath. In its course the following emerge
from the A. epigastrica inferior:
– A. cremasterica (in men): it supplies the M. cremaster.
– A. ligamenti teretis uteri (in women): it supplies the Lig.
teres uteri.

96
 3.1 Ventral torso wall

– R. pubicus: it extends to the pubic bone. – Nodi lymphoidei iliaci communes

– R. obturatorius: it normally forms an anastomosis with the R. – Nodi lymphoidei lumbales.
pubicus of the A. obturatoria. The lymph of the abdominal wall flows into lymph vessels that ac-
• Another branch for blood supply to the abdominal wall muscu- company the Vasa epigastrica and which drain into the
lature in the lower section (› Fig. 3.41) is the A. circumflexa – Nodi lymphoidei epigastrici inferiores
ilium profunda. It extends with a R. ascendens between the M. – Nodi lymphoidei parasternales.
obliquus internus and the M. transversus abdominis and con-
nects here with the Aa. lumbales, of the A. iliolumbalis and the Innervation
A. epigastrica inferior. The innervation of the middle layer of the abdominal wall takes
place via (› Fig. 3.24):
• Nn. intercostales V–XI: they run together with the intercostal
Clinical remarks vessels between the M. obliquus internus abdominis and m.
A Corona mortis (lat. wreath of death) is an ectopic origin of transversus abdominis. Their branches innervate the lateral ab-
the A. obturatoria from the A. epigastrica inferior. In this case, dominal muscles and after penetration of the rectus sheath the
a powerful R. obturatorius of the A. epigastrica inferior replac- M. rectus abdominis.
es the unformed A. obturatoria. This common vessel variation • N. subcostalis: it runs like the Nn. intercostales V–XI and in-
(up to 30%) used to frequently lead to fatal bleeding in sur-
nervates the lateral abdominal muscles and the M. rectus ab-
gery on the groin (predominantly in leg hernias).
dominis. It is also involved in the innervation of the M. quadra-
tus lumborum and the M. pyramidalis.
• N. iliohypogastricus: the muscle branch of the N. iliohypogas-
Veins tricus extends between the M. obliquus internus abdominis and
The abovementioned arteries are accompanied by ordered veins M. transversus abdominis, which it also innervates, medially
running segmentally (Vv. intercostales VI–XI, Vv. epigastrica su- and also innervates the M. rectus abdominis and the M. pyrami-
perior, Vv. epigastrica inferior) (› Fig. 3.2, › Fig. 3.14). The Vv. dalis.
epigastricae superiores drain into the Vv. thoracicae internae; the • N. ilioinguinalis: it extends on the top inside edge of the Os ili-
Vv. epigastricae inferiores pass into the v. iliaca externa. um between M. obliquus internus abdominis and M. transversus
abdominis while emitting muscle branches medially. At the level
Lymph vessels of the Spina iliaca anterior superior it penetrates the M. obliquus
The lymph of the middle and deep layers of the lateral abdominal internus abdominis and runs parallel to the Lig. inguinale cau-
wall drain into the dally covered by the external aponeuroses. In men, the nerve

Lig. arcuatum laterale Pars lumbalis diaphragmatis,

Crus dextrum
M. quadratus lumborum
N. subcostalis
N. subcostalis
N. iliohypogastricus
N. ilioinguinalis N. iliohypogastricus
M. psoas major
M. obliquus N. ilioinguinalis
externus abdominis
M. obliquus Plexus lumbalis
internus abdominis
M. transversus Truncus
abdominis sympathicus

N. cutaneus
femoris lateralis N. femoralis
N. femoralis
Truncus
N. genitofemoralis,
lumbosacralis
R. femoralis
N. genitofemoralis,
N. genitofemoralis
R. genitalis
N. obturatorius
N. obturatorius
N. cutaneus
femoris lateralis
N. cutaneus
N. genitofemoralis, femoris lateralis
Rr. femorales
N. femoralis,
Rr. cutanei anteriores R. genitalis N. genito-
R. femoralis femoralis
Lamina cribrosa
V. saphena magna Plexus sacralis
N. genitofemoralis, Rr. genitales Lacuna vasorum Fig. 3.24 Nerve branches for
Funiculus spermaticus N. obturatorius, R. anterior innervation of abdominal wall
muscles. Ventral view.

97
3 Torso

joins the Funiculus spermaticus, in women it runs with the Lig. Table 3.3 Structure of the rectus sheath.
teres uteri. In the area of the Anulus inguinalis superficialis it
Above Linea/Zona arcuata Below Linea/Zona arcuata
leaves the inguinal canal and divides into its terminal branches
(Nn. scrotales anteriores or Nn. labiales anteriores). Lamina anterior
• N. genitofemoralis: its R. genitalis extends over the Fossa ingui- Aponeurosis of the M. obliquus exter- Aponeurosis of the M. obliquus exter-
nalis lateralis to the inguinal canal. Shortly before entering, it nus abdominis nus abdominis
emits muscle branches to the M. transversus abdominis and in- Anterior lamina of the aponeurosis of Anterior lamina of the aponeurosis of
nervates the M. cremaster in the inguinal canal (see below). the M. obliquus internus abdominis the M. obliquus internus abdominis
Posterior lamina of the aponeurosis of
NOTE the M. obliquus internus abdominis
Rapid stroking of the abdominal skin of the relaxed patient, lying Aponeurosis of the M. transversus
on his/her back with a pointed object (tip of the reflex hammer, abdominis
rods and back of the fingernail) from lateral to medial triggers the
abdominal skin reflex of the equilateral abdominal muscles. This Lamina posterior
belongs to the physiological foreign reflexes. An examination is Posterior lamina of the aponeurosis of
conducted on both sides below the ribs, at the height of the navel the M. obliquus internus abdominis
and above the groin. Absence can provide important clinical evi-
Aponeurosis of the M. transversus
dence (e.g. on a pyramid tract lesion). abdominis
Fascia transversalis Fascia transversalis

Clinical remarks Parietal peritoneum Parietal peritoneum

The Nn. ilioinguinalis and iliohypogastricus from the Plexus

lumbalis break through the M. transversus abdominis dorsal Clinical remarks
to the kidneys and then run ventrally between the M. transver-
sus abdominis and M. obliquus internus abdominis. Damage The area of the abdominal wall is frequently the site of forma-
to the nerves during dorsal surgical access to the retroperito- tion of hernias. They are characterised by:
neal space (e.g. kidneys, adrenal glands) can cause postoper- • A hernial sac (bulge of the Peritoneum parietale)
ative pain in the groin area or lead to an abdominal wall weak- • A hernial ring or hernial canal (preformed or acquired gap in
ness on the affected side. the abdominal wall)
For the treatment of pain or in the context of inguinal hernia • A hernial content (e. g. intestinal components, internal or-
surgery, the N. ilioinguinalis medial of the Spina iliaca anterior gans)
superior can be blocked using infiltration anaesthesia. Be- The hernial sac pushes through the hernial ring or hernial ca-
cause of its close proximity, the N. iliohypogastricus it often nal to the outside and can contain hernial contents. Approxi-
simultaneously blocked. mately 10% of all hernias are scar hernias following surgery or
via the abdominal wall. The incisions are often quite large to
attain good access and optimal visibility into the abdominal
cavity and to be able to display the contents. The most com-
mon incision is the central craniocaudal incision from the
Rectus sheath Proc. xiphoideus up to the Symphysis pubica in the area of the
The paired rectus sheath (Vagina musculi recti abdominis) is a Linea alba. It enables large-scale access to the entire abdomi-
connective tissue guide tube, in which the M. rectus abdominis and nal cavity contents with exploratory laparotomy; however, lap-
the M. pyramidalis are located. It is formed by the lateral abdomi- arotomy has receded into the background in favour of a far
nal muscles and the abdominal wall fascia (› Fig. 3.20, › Fig. 3.21, less invasive laparoscopy. In laparoscopy the abdominal wall
› Fig. 3.22). The tube consists of a front (Lamina anterior) and a is only cut in a few points to be in a position to inspect the
stomach contents by means of optics that are introduced
rear lamina (Lamina posterior). Slightly below the navel (Linea through small abdominal wall cuts. Using inserted instru-
arcuata, Linea semicircularis, DOUGLAS' line, it is sometimes not ments it is now possible, e.g. to remove the gall bladder (cho-
a clear line but a transition zone, Zona arcuata) the structure lecystectomy) or the appendix. The patient can also be dis-
changes (› Fig. 3.22). Above the Linea arcuata, the Lamina ante­ charged much earlier, and the rate of complications (e.g. de-
rior of the rectus sheath is formed from the aponeurosis of the veloping a post-operative incisional hernia) is significantly
M. obliquus externus abdominis and the front lamina of the apo- lower.
Rarely a SPIGELIAN hernia can occur between the lateral mar-
neurosis of the M. obliquus internus abdominis; below the Linea/
gin of the Linea arcuata and Linea semilunaris.
Zona arcuata the rear lamina of the internus aponeuroses and the
transversus aponeuroses are involved in the formation of the Lami-
na anterior of the rectus sheath (› Table 3.3, › Fig. 3.25). The
Lamina posterior above the Linea/Zona arcuata consists of the rear Linea alba
lamina of the aponeurosis of the M. obliquus internus abdominis, The interdependence of the tight connective tissue of all aponeuro-
M. transversus abdominis, Fascia transversalis and Peritoneum pa- ses of the flat stomach muscles of both sides in the median plane
rietale; below the Linea/Zona arcuata only the Fascia transversalis forms the Linea alba. It is 1–3 cm wide and runs from the Proc.
and the Peritoneum parietale are involved (› Table 3.3, › Fig. xiphoideus up to the Symphysis pubica, where it enters via the tri-
3.25). The medial edge of the rectus sheath is formed by the Linea angular Adminiculum lineae albae (Lig. triangulare) at the Lig. pu-
alba (see below); the lateral edge, which represents the transition bicum superius. It is slightly wider only around the navel, where it
zone of the lateral abdominal muscles in their aponeuroses, is the is interrupted by the umbilical port. It is significantly narrower be-
Linea semilunaris (› Fig. 3.22). The transversus fascia between low the navel.
Linea arcuata and lateral edge of the rectus sheath is referred to
clinically as SPIEGHEL fascia.

98
 3.1 Ventral torso wall

M. rectus abdominis
Lig. falciforme
Tela subcutanea, Linea alba A.; Vv. epigastrica(e) superior(es)
Panniculus adiposus M. obliquus externus abdominis, Aponeurosis
Vagina musculi recti abdominis, Lamina anterior
Vagina musculi
recti abdominis M. obliquus internus abdominis
M. obliquus externus abdominis
V. paraumbilicalis Lig. teres M. transversus
hepatis abdominis, Mm. intercostales
Aponeurosis
M. transversus abdominis
Umbilicus

M. rectus abdominis

Anulus umbilicalis Fascia transversalis

M. obliquus externus
abdominis
Plica umbilicalis mediana; M. obliquus internus
Lig. umbilicale medianum (Chorda urachi) abdominis
Vagina musculi recti abdominis, M. transversus
Lamina anterior M. rectus abdominis abdominis

A.; Vv. epigastrica(e)

inferior(es)

Chorda arteriae umbilicalis M. pyramidalis

Plica umbilicalis medialis Plica umbilicalis lateralis M. obliquus internus abdominis

M. obliquus externus abdominis
M. transversus abdominis

Fig. 3.25 Structure of the rectus sheath, Vagina musculi recti abdominis. Horizontal section; Caudal view.

Clinical remarks Development

Between the 3rd and 4th week, the entodermal germinal layer bulg-
A Diastasis recti abdominis is the separation of the two Mm.
recti abdominis by more than 2 cm in the area of the Linea es inwards and forms the central gut (precursor of the small intes-
alba. It can be either congenital or acquired and occurs more tines). Initially, the connection between the midgut and yolk sac is
often in women and above the Linea arcuata than below: still large, but increasingly becomes a narrow tube (yolk sac stalk
• Causes of acquired Diastasis recti abdominis are pregnancy Ductus vitellinus, Ductus omphaloentericus, body stalk). The at-
and birth (in particular multiple births, strong pressing), tachment point of the amnion is reduced around the Ductus vitelli-
obesity and chronic constipation. With increasing enlarge- nus at the ventral embryo surface to a narrow oval area (umbilical
ment of the Diastasis recti, the abdominal muscles become
ring) and also the connection between the intra-embryonic and
increasingly insufficient and it also predisposes to abdomi-
nal wall hernias (see below). extra-embryonic coelom will soon be only a narrow connection,
• The physiological Diastasis recti abdominis in a normal which circularly surrounds the yolk sac stalk. The navel and the
pregnancy (from the 5th month of pregnancy), which occurs umbilical cord (contains extra-embryonic coelom = navel coelom,
in nearly every pregnant woman and gradually regresses af- yolk corridor, system for navel vessels and allantoin) have evolved.
ter birth, should be differentiated from those pathological In the first instance, the amnion supplies the epithelial surface of
forms of Diastasis recti that do not recede. Regression exer- the umbilical cord. Due to its good blood supply via the A. mesen-
cises can be beneficial here.
terica superior, the midgut grows relatively quickly in the abdomi-
The abdominal wall in abdominal cavity operations can be
opened along the Linea alba without causing any major bleed- nal cavity. The maturing liver and mesonephros are already there.
ing (median laparotomy). The space is not sufficient and the midgut deviates depending on
the path of least resistance into the navel coelom (the evolving um-
bilical cord). A developmental umbilical hernia occurs (the term
physiological umbilical hernia is inaccurate and should not be used
Umbilicus for this purpose). This process takes place in the 6th-10th week. In
Structure of the abdominal wall doing so, the gut is not only displaced to the umbilical cord, but it
Around the navel (Umbilicus) in adults, there is a special structure also rotates through 90° counter-clockwise around the A. mesen-
around the abdominal wall: the outer skin is fused above the um- terica superior. At the end of the 10th week the gut can be brought
bilical papilla (Papilla umbilicalis, an opening in the Linea alba) back, because in the meantime the abdominal cavity has become
with the Fascia umbilicalis (a consolidation of the Fascia transver- sufficiently large. The extra-embryonic coelom and the yolk sac
salis) directly with the Peritoneum parietale. At this point, since obliterate completely. During the foetal period the strong Aa. um-
the subcutaneous adipose tissue is missing, there is an umbilical bilicales and the V. umbilicalis run through the navel. Both arter-
recess. The umbilical recess is surrounded by circularly running ies are fused to the navel ring here; the V. umbilicalis is, in contrast,
connective tissue fibres of the Linea alba, which form the easily only loosely connected with the navel ring. After birth, and separa-
palpable navel ring (Anulus umbilicalis). tion of the umbilical cord, rapid obliteration and accretion take

99
3 Torso

place; the remnants of the severed umbilical vessels form a firm Vascular, lymphatic and nervous systems of the deep layer
closure of the navel together with the navel ring and the skin. Vessel supply lymph drainage and innervation correspond to the
middle layer of the abdominal wall.
Clinical remarks Inguinal region
If the gut does not completely shift back into the abdominal The groin (inguinal region, Regio inguinalis) includes the transi-
cavity at the end of the 10th week, this results in an omphalo- tional area between the abdominal wall and thigh. This includes
cele (congenital omphalocele). This is an inhibition malfor- not only the inguinal ligament (Lig. inguinale), but also the osteofi-
mation with an incidence of 1:5000. The abdominal wall lies brous canal lying beneath the inguinal ligament, which is separated
outside a bladder surrounded by an amnion, which contains
by a connective tissue separation of the inguinal ligament (Arcus
bowel loops, mesentery and branches of the A. mesenterica
superior (internal organs such as the liver or spleen are rarely iliopectineus) into a medial access site for vessels (Lacuna vaso-
included). rum) and a lateral access site for muscles (Lacuna musculorum).
In contrast to an omphalocele a congenital umbilical hernia is
covered by skin. The hernial ring is the not yet formed umbili- Inguinal ligament
cal papilla. Acquired umbilical hernias occur in adults due to The inguinal ligament (Lig. inguinale) is made of firm collage-
the separation of the connective tissue from the umbilical nous connective tissue and spans between the Spina iliaca anterior
papilla in pronounced hyperextension of the abdominal wall
superior and Tuberculum pubicum (› Fig. 3.26, also › Chap.
(pregnancy, obesity). The hernial ring is, in this case, the navel
ring. 5.10.1, › Fig. 5.71). It forms the floor of the inguinal canal (see be-
low). Covering skin and inguinal ligament are fused mainly by
tight Retinacula cutis; subcutaneous fat tissue is extensively lack-
ing, so that the Lig. inguinale is easily palpable. The Lig. inguinale
Deep layer is not a ligament in the true sense, but a fusion of different fibrous
The deep layer comprises the inner lining of the abdominal wall. It structures:
involves: • Lower section of the aponeurose of the M. obliquus externus ab-
• Fascia transversalis dominis
• Peritoneum parietale • Lower section of the fused aponeuroses of the M. obliquus inter-
nus abdominis and M. transversus abdominis
Fascia transversalis • Fascia transversalis (medial)
The Fascia transversalis is not only a rough muscle fascia on the in- • Fascia iliopsoas (lateral)
ner surface of the muscle part of the M. transversalis but also cov- • Fascia lata (caudal)
ers all muscles and structures that limit the abdominal wall. There- At the medial margin of the inguinal ligament a small part of the
fore, we speak of the Fascia abdominis interna. Dorsally, the Mm. fibres from the inferior margin of the inguinal ligament extends in
quadratus lumborum et psoas major are covered by the Fascia a downward curve to the Os pubis. This fibre content, the Lig. la-
transversalis. In addition, it extends over the lumbar spine and par- cunare (› Fig. 5.71 ), medially limits the Lacuna vasorum. The
ticipates ventrally in the establishment of the rectus sheath. Here it fixing of the Lig. lacunare on Pecten ossis pubis is referred to as the
is fused above the Linea arcuata with the aponeurosis of the M. Llig. pectineum. The abovementioned Arcus iliopectineus is a
transversus abdominis; below it the transversus aponeuroses and curved connective tissue structure and part of the Fascia iliaca. It
Fascia transversalis are separate. The transversus aponeuroses con- spans between the Lig. inguinale and Eminentia iliopubica and de-
nects below the Linea arcuata with the aponeuroses of M. obliquus marcates the Lacuna musculorum from the Lacuna vasorum
internus abdominis and M. obliquus externus abdominis and run (› Chap. 5.10.1, › Fig. 5.71 for penetrating structures).
in front of the M. rectus abdominis. The Fascia transversalis runs
further caudally and, together with the Peritoneum parietale forms Inguinal canal
the rear lamina of the rectus sheath in this area. Around the navel The inguinal canal (Canalis inguinalis) is approx. 4–5 cm long
the Fascia transversalis is reinforced to the Fascia umbilicalis. Cra- and penetrates through the abdominal wall at an oblique angle
nially, the Fascia transversalis continues into the Fascia diaphrag- from the top externally to the bottom internally. In men, the sper-
matica; caudally, it is secured to the Lig. inguinale and passes into matic cord runs through the inguinal canal; in women the Lig.
the Fascia iliaca. At the inner inguinal ring (see below) the Fascia teres uteri together with lymph vessels passes from the tube angle
transversalis bulges into the inguinal canal and runs as the Fascia on both sides of the Labia majora via the inguinal canal. The struc-
spermatica interna enveloping the spermatic cord to the testes. tures penetrating the canal normally fill the canal completely and
are usually connected with it via loose connective tissue. Entry and
Peritoneum parietale exit points for the inguinal canal are:
The peritoneum is a serous skin, which ensures the smooth sliding • Internal inguinal ring (Anulus inguinalis profundus): it is vis-
of the organs in the abdominal cavity. It is divided into a visceral ible as a deepening on the inside of the abdominal wall, in the
lamina (Peritoneum viscerale), which covers the abdominal or- Fossa inguinalis lateralis (see below). Its medial border is
gans, and a parietal lamina (Peritoneum parietale), which covers strengthened by the Lig. interfoveolare (sickle-shaped reinforce-
the front and side abdominal cavity wall. It is divided from the Fas- ment of the Fascia transversalis) and by the muscle fibres of the
cia transversalis by a Tela subserosa, which is developed to a dif- M. transversus abdominis (M. interfoveolaris). More muscle fi-
fering degree depending on the region. Above the navel (especially bres of the M. transversus abdominis also wind around the inner
Linea alba) and around the navel the Tela subserosa is so thin that inguinal ring, which is referred to as the transversus loop.
the Peritoneum parietale and Fascia transversalis are connected al- • Outer inguinal ring (Anulus inguinalis superficialis): it enters
most immoveably. through the aponeurosis of the M. obliquus externus abdominis.
At this point, the aponeurosis forms 2 connective tissue legs

100
 3.1 Ventral torso wall

M. transversus abdominis Anulus inguinalis

profundus
M. obliquus internus abdominis

M. obliquus externus
abdominis, Aponeurosis
A.; Vv. epigastrica(e)
inferior(es)
N. ilioinguinalis

Fascia transversalis Fascia transversalis

A. ductus deferentis
N. ilioinguinalis

Ductus deferens
Anulus inguinalis
N. genitofemoralis, superficialis
R. genitalis

Plexus pampiniformis Lig. reflexum

M. cremaster
N. genitofemoralis,
R. genitalis Fig. 3.26 Walls and contents of
Lig. inguinale
the inguinal canal (Canalis
Fascia spermatica externa inguinalis), right. Ventral view.
[S010-17]

(Crus mediale and Crus laterale), which are held together at the Covering of the spermatic cord and the scrotum
top with other connective tissue fibres of the M. obliquus exter- The spermatic cord (Funiculus spermaticus) and testicles (testis) lie
nus abdominis (Fibrae intercrurales). Below the legs are held to- in a pouch of the abdominal wall which extends into the scrotum
gether by a trench-type tendon plate (Lig. reflexum). caused by the descensus testis. The spermatic cord and scrotum are
The walls of the inguinal canal are formed (› Fig. 3.26): therefore constructed in the same way as the abdominal wall. In this
• Above: under the edge of the M. obliquus internus abdominis process the following structures become separated (› Fig. 3.28):
and M. transversus abdominis and its fused aponeuroses; the • Fascia spermatica externa: this is a continuation of the lower
roof is laterally structured from muscle fibres, medially from portion of the aponeurosis of the M. obliquus externus abdomi-
connective tissue nis on the Funiculus spermaticus.
• Bottom: Lig. inguinale and medial Lig. reflexum • Fascia cremasterica with M. cremaster: the M. cremaster with
• Front: aponeurosis of the M. obliquus externus abdominis with its fascia forms a separation of the lower portion of the M.
Fibrae intercrurales
• Rear: Fascia transversalis, subserous connective tissue and Peri-
toneum parietale, reinforced by the Lig. interfoveolare with the Testis
M. interfoveolaris; hence, a muscle-free triangle is formed when Peritoneum Fascia transversalis M. transversus
parietale abdominis
viewed from the inside (Trigonum inguinale, HESSELBACH's Gubernaculum
testis
triangle) M. obliquus internus
abdominis

Development M. obliquus externus

Spermatogenesis requires a lower temperature than the average abdominis

body temperature of approximately 37 °C. Therefore, the testes shift

during the foetal period outside the abdominal cavity. For this pur-
pose, the testes migrate along the lower Gubernaculum testis under (Proc. vaginalis peritonei)
the Peritoneum parietale at the side of the body wall into the scro-
tum downwards and partially take the abdominal wall layers with
them (› Fig. 3.27). The Peritoneum parietale forms a pouch in the
inguinal canal (Proc. vaginalis peritonei), reaching down to the
scrotum and ending above the testes. With the exception of a rem-
nant in the testis region (Tunica vaginalis testis), the Proc. vaginalis
peritonei obliterates shortly after birth.

Clinical remarks
Disorders of Descensus testis are frequent (approximately 3% Fascia spermatica
of all newborns). The testicles can lie in the abdominal cavity interna
or in the inguinal canal (testicular retention, cryptorchidism, M. cremaster
ectopic testis) and fertility problems and an increased risk of
malignant degeneration may occur. The Descensus testis into (Proc. vaginalis peritonei) Fascia spermatica externa
the scrotum is a sign of foetal maturity at birth.
Fig. 3.27 Descensus testis from the 7th week (postconception) until
delivery.

101
3 Torso

Peritoneum parietale Lig. umbilicale medianum M. rectus abdominis

(Chorda urachi)
Fascia transversalis Chorda arteriae umbilicalis
A. epigastrica A. epigastrica inferior
M. transversus inferior
abdominis 3 1 2
2 3
1
M. obliquus internus
abdominis

M. obliquus externus
abdominis
Anulus inguinalis
(Fascia superficialis) superficialis
M. obliquus externus
abdominis, Aponeurosis (Proc. vaginalis
peritonei persistens)
Anulus inguinalis
superficialis Septum scroti

Fascia spermatica externa

Fascia cremasterica; M. cremaster

Fascia spermatica interna

Ductus deferens

Epididymis 1 Fossa supravesicalis

2 Fossa inguinalis medialis
Testis (Cavitas serosa scroti) 3 Fossa inguinalis lateralis

Fig. 3.28 Structure of the abdominal wall and the sheaths of the spermatic cord (Funiculus spermaticus) and testes (Testis). Schematic pre-
sentation. [L240]

obliquus internus abdominis. Often lower muscle fibres of the two thirds of all hernias) and occur primarily in men. During
m. transversus abdominis also participate in this. this process, the hernial sac in the Fossa inguinalis lateralis
• Fascia spermatica interna: this continues the Fascia transversa- passes through the Anulus inguinalis profundus into the
lis and envelopes the Funiculus spermaticus. ­inguinal canal or completely through the inguinal canal up
• Vestigium processus vaginalis: this relates to a Proc. vaginalis into the scrotum or the Labia majora (› Fig. 3.29). The hernial
ring is identical to the inner inguinal ring and lies lateral to
peritonei, which is obliterated with the exception of a remnant
the Vasa epigastrica inferiora. Since these vessels in the
in the testicular region (Tunica vaginalis testis with Lamina pari- ­surgical site are easy to identify, they are referred to as lateral
etalis = Periorchium and Lamina visceralis = Epiorchium). inguinal hernias (Herniae inguinales laterales). Indirect herni-
The content of the Funiculus spermaticus, the structure of the Tu- as can also occur innately. In this case the Proc. vaginalis
nica dartos, the blood supply, the lymph drainage and the innerva- testis is not closed, but persists (Proc. vaginalis peritonei
tion of the testes and the scrotum are outlined in › Chap. 8.5. persistens › Fig. 3.28). There is an open connection
­between the abdominal cavity and Cavitas serosa scroti,
M. cremaster through which the hernia content can advance into the
­scrotum. In general, however, indirect hernias are acquired.
The M. cremaster is innervated by the R. genitalis of the N. geni- • Direct inguinal hernia (about one third of all hernias) pene-
tofemoralis and emerges from the lower fibres of the M. obliquus in- trate through the muscle-free trigonum inguinale (HESSEL-
ternus abdominis and usually from fibres of the M. transversus ab- BACH’s triangle, › Fig. 3.31) into the Fossa inguinalis medi-
dominis (› Fig. 3.21, › Fig. 3.26). Some muscle fibres originate at alis which is a weak spot, because the abdominal wall here
the front lamina of the rectus sheath. The fibres are positioned in only consists of the Fascia transversalis and Peritoneum pa-
men as single muscle fibres that surround the Funiculus spermaticus rietale. Because the hernial ring lies medial of the Vasa epi-
between the Fascia spermatica externa and Fascia spermatica interna gastrica inferiora, one also talks about medial inguinal her-
nias (Herniae inguinales mediales, › Fig. 3.29).
to the scrotum. In women they join the Lig. teres uteri. Side hernias (approx. 10% of all hernias) are more frequent in
women. The hernial ring is in contrast to inguinal hernias be-
NOTE neath the Lig. inguinale either in the Lacuna vasorum (more
Stroking of the inside of the thigh triggers a contraction of the M. frequently) or the Lacuna musculorum (less frequently).
cremaster (cremasteric reflex) . This causes elevation of the testi-
cles on the same lamina. The cremasteric reflex is one of the physi-
ological extrinsic reflex actions. Afferent fibres run in the R. femora-
lis of the N. genitofemoralis and the efferent fibres in the R. genital- NOTE
is of the N. genitofemoralis. Preferred points for abdominal wall hernias are in the inguinal ca-
nal (80%), the side channel (10%), the navel (5%), the Linea alba
(5%), the Linea semilunaris, the Canalis obturatorius and the Trigo-
Clinical remarks num lumbale (the latter 3 together under 1%). In the case of ingui-
nal hernias, a distinction is made between direct and indirect in-
The inguinal canal is a predilection site for hernias (Inguinal guinal hernias. Indirect inguinal hernias are the most common ab-
hernias). A distinction is made between indirect and direct dominal wall hernias in adulthood (approximately two thirds of all
inguinal hernias depending on the hernial ring: hernias) and are more common in men. The hernial sac follows the
• Indirect inguinal hernias (canal hernias) are the most com- course of the inguinal canal. Direct inguinal hernia (about one third
mon abdominal wall hernias in adulthood (approximately of all hernias) break through the abdominal wall directly into the
Fossa inguinalis medialis, i.e. not through the inner inguinal ring.

102
 3.1 Ventral torso wall

Peritoneum parietale A. epigastrica inferior A. epigastrica inferior

3 Anulus inguinalis superficialis 2
Fascia transversalis Anulus inguinalis
3 superficialis
1
M. transversus abdominis 1 M. obliquus
externus abdominis
M. obliquus internus abdominis
Fascia spermatica
externa
(Fascia superficialis)
Fascia
transversalis
*
***
**
**
Ductus deferens
*
(Proc. vaginalis peritonei),
Ductus deferens
Peritoneum parietale
Fascia spermatica interna
Fascia spermatica interna
Fascia cremasterica;
Fascia cremasterica; M. cremaster M. cremaster 1 Fossa supravesicalis
2 Fossa inguinalis medialis
Fascia spermatica externa (Cavitas serosa scroti) 3 Fossa inguinalis lateralis

Fig. 3.29 Hernias, schematic presentation. Left image: lateral, indirect hernia; right image: medial, direct hernia; [L240]
* Intestinal loop in the hernial sac, ** peritoneal space, *** newly formed peritoneal hernia sac. [L240]

Inner outline of the abdominal wall ale, which emerged from the obliteration of the former A. um-
The abdominal wall has on its inside a distinctive inner outline of bilicalis. In some cases, the A. umbilicalis can still be preserved.
folds and recesses, all of which are covered by the Peritoneum pari- • Plica umbilicalis lateralis (paired): this arises from the course
etale (› Fig. 3.30, › Fig. 3.31). Behind the symphysis the bladder of the Vasa epigastric inferiora, coming from the Vasa iliaca ex-
body (Corpus vesicae) protrudes. When moderately filled it has a terna and passing to the back wall of the rectus sheath, and thus
transversus furrow (Plica vesicalis transversa). In addition, the fol- has no connection to the navel. In the lower section of the Plica
lowing folds can be defined on the inside of the abdominal wall: umbilicalis lateralis, the Fascia transversalis is reinforced by the
• Plica umbilicalis mediana (unpaired): this runs from the vertex Lig. interfoveolare (HESSELBACH’s ligament) (› Fig. 3.30,
of the bladder to the navel and contains the Lig. umbilicale me- › Fig. 3.31) and by the M. interfoveolaris. Both structures are
dianum, which has emerged from the obliteration of the former divisions of the M. transversus abdominis and limit the muscle-­
urachus, which runs from the bladder to the navel (original uri- free triangle (Trigonum inguinale, ­HESSELBACH’s triangle)
nary passage). (› Fig. 3.30, › Fig. 3.31).
• Plica umbilicalis medialis (paired): this runs from the lateral Between the folds and lateral to the Plica umbilicalis lateralis the
bladder wall to the navel and contains the Lig. umbilicale later- following recesses can be defined (› Fig. 3.30):

Lig. falciforme (hepatis) Chorda arteriae umbilicalis

Linea arcuata M. rectus abdominis

Plica umbilicalis mediana A.; V. epigastrica inferior

Plica umbilicalis medialis Anulus inguinalis profundus

Plica umbilicalis lateralis N. cutaneus femoris lateralis

M. iliopsoas Lacuna musculorum

A.; V. femoralis N. femoralis

Fossa inguinalis lateralis Arcus iliopectineus

Fossa inguinalis medialis Lacuna vasorum

Ductus deferens Vasa testicularia

Ureter N. obturatorius; A.; V. obturatoria

Fossa supravesicalis Lig. interfoveolare*

Vesica urinaria Trigonum inguinale**

Fig. 3.30 Anterior abdominal wall. View from the inside; The Peritoneum parietale and Fascia transversalis have been removed on the right
side of the body; * HESSELBACH’s ligament, ** HESSELBACH’s triangle.

103
3 Torso

M. transversus abdominis, Linea (zona) arcuata

aponeurosis (= Linea semicircularis) Fascia transversalis

M. rectus abdominis

Fascia transversalis (cutting edge)

Fascia on the interfoveolar muscle

Fascia transversalis

Lig. interfoveolare
(HESSELBACH's ligament)

Tendo conjunctivus
(transversal tendon arcade)

Fossa inguinalis lateralis

Anulus inguinalis profundus

Lig. inguinale

Funiculus spermaticus

Trigonum inguinale Fig. 3.31 Anterior abdominal

(HESSELBACH's triangle) wall. View from the inside; right
side; Peritoneum parietale and
Lig. lacunare Fascia transversalis have been
partially removed; presentation
Adminiculum Symphysis Linea alba Os pubis Falx inguinalis
lineae albae pubica of HESSELBACH's ligament and
HESSELBACH's triangle. [L127]

• Fossa supravesicalis (paired): it is located between the Plica 3.2 Dorsal torso wall
umbilicalis mediana and Plica umbilicalis medialis. Friedrich Paulsen, Jens Waschke
• Fossa inguinalis medialis (pair, medial inguinal recess): It is
­located between the Plica umbilicalis medialis and Plica umbili-
calis lateralis in the area of the muscle-free triangle 3.2.1 General structure
(HESSELBACH’s triangle) (› Fig. 3.30, › Fig. 3.31).
• Fossa inguinalis lateralis (pair, lateral inguinal recess): It is lo- Depending on fitness, the back outline is basically formed by the
cated laterally to the Plica umbilicalis lateralis. The inner ingui- back muscles on the surface, the M. trapezius, Mm. rhomboidei,
nal ring (Anulus inguinalis profundus) lies within it. In addition, M. latissimus dorsi and M. teres major. The expansion of the back
the structures involved in the development of the spermatic cord area ranges from the Linea nuchalis superior at the Os occipitale to
run together below the Peritoneum parietale. At the Anulus in- the Os coccygis along the spine and laterally to the dorsally visible
guinalis profundus the Fascia transversalis lowers into the ingui- part of the thoracic and abdominal wall.
nal canal and becomes the Fascia spermatica interna.
In addition to the 5 lower abdominal wall folds an upper fold on Surface anatomy
the inner abdominal wall extends from the navel to the liver. It Lines and palpable bone points are used for guidance and for
contains the Lig. teres hepatis, which represents the obliterated V. height localisation.
umbilicalis (› Fig. 3.30).
Orientation lines
Vertically running orientation lines on the dorsal abdominal wall
Clinical remarks are (› Fig. 1.6):
The technique formerly commonly practiced for inguinal hernia • Linea mediana posterior (via the spinous processes)
surgery (SHOULDICE’s technique) doubling of the Fascia trans- • Linea paravertebralis (via the vertebral transverse processes)
versalis fascia in the HESSELBACH's triangle for reinforcement • Linea scapularis (through the Angulus inferior of the Scapula
of the rear wall of the inguinal canal is now almost a thing of the with relaxed hanging arms)
past. It has been replaced by minimally invasive techniques
such as the TEPP (total extraperitoneal patch plastic) or the
TAPP procedure (transabdominal preperitoneal hernioplasty). Palpable bone points
As part of the TEPP an endoscopy (in contrast to TAPP) is con- Palpable bone points on the dorsal abdominal wall are:
ducted on the abdominal wall through 2–3 incisions. Within the • Spina scapulae (lies on both sides just under the skin, and can be
framework of the operation a thin plastic mesh is laid between traced laterally to the acromion); a horizontal line between the
the layers of the abdominal wall (behind the M. transversus and two spinae scapulae is at the height of the spinous process of the
under the Peritoneum parietale). The advantage of this surgical IIIrd thoracic vertebra
procedure is the immediate ability to sustain pressure, which
• Angulus superior scapulae (moves when the arms are moved)
generally makes it possible to do even intense sport within 1
week. Surgery is open, the LICHTENSTEIN’s operation is general- • Margo medialis scapulae (moves when the arms are moved)
ly used in which a mesh is also inserted. Due to the good re- • Angulus inferior scapulae (moves when the arms are moved)
sults and the excellent compatibility of the meshes, these are • Vertebra prominens (spinous process of the VIIth cervical verte-
used substantially today in operative inguinal hernia surgery. bra)
• Ribs

104
 3.2 Dorsal torso wall

• Crista iliaca • The start of the Crena ani

• Spina iliaca posterior superior
• Tuber ischiadicum
• Os sacrum
Clinical remarks
• Procc. spinosi In obstetrics, the shape of the MICHAELIS rhomboid can pro-
vide an insight into possible deformation of the bony pelvis.
Surface relief
The skin on the back has a rough corium and is therefore relatively
thick. In the Regio vertebralis the surface outline is defined by the Spinal regions
back groove and the laterally lying autochthonous back muscles The neck section of the spinal region is referred to as the neck re-
(› Chap. 3.2.2). The Fascia thoracolumbalis lies lumbarly above gion (Regio cervicalis posterior, Regio colli, Regio nuchae) (› Fig.
the autochthonous back muscles (› Chap. 3.2.2). The superficial 1.4b). The muscles of this area are discussed in › Chap. 3.2.2,
back muscles define the outline laterally up to the neck area, as al- blood supply and topographic aspects in › Chap. 10. Other re-
ready mentioned above. Where the Regio vertebralis passes into gions of the dorsal abdominal wall are the Regiones vertebralis,
the Regio sacralis, the sacral triangle is formed in men and the scapularis, infrascapularis, lumbalis, sacralis et glutealis (› Fig.
­MICHAELIS rhomboid (Venus rhomboid) in women. The sacral 1.4b). There are 2 weak points in the Regio lumbalis (› Fig. 3.33):
triangle and Venus rhomboid are created from palpable bone points • The upper lumbar triangle (Trigonum lumbale superius,
lying directly under the skin without underlying muscles or subcu- ­GRYNFELT triangle, Trigonum lumbale fibrosum, spatium
taneous fatty tissue. The points resemble groove-like indentations. tendineum lumbale) has the following limits:
– Cranial: the XIIth rib
Sacral triangle – Lateral: M. obliquus internus abdominis
The sacral triangle (› Fig. 3.32) is formed by: – Medial: autochthonous back muscles
• The two Spinae iliacae posteriores superiores – Base: original aponeurosis of the M. transversus abdominis
• the start of the Crena ani (vertical gap between the buttocks, – Coverage: M. serratus posterior inferior, M. latissimus dorsi
anal groove) • The lower lumbar triangle (Trigonum lumbale inferius, PETIT
triangle) has the following limits:
MICHAELIS’ rhomboid – Medial: edge of the M. latissimus dorsi
The MICHAELIS’ rhomboid (› Fig. 3.32) is formed by: – Lateral: rear edge of the M. obliquus externus abdominis
• The dimple-shaped indentation of skin above the spinous pro- – Caudal: Crista iliaca
cess of the IVth or Vth lumbar vertebra – Base: original aponeurosis of the M. transversus abdominis
• The two Spinae iliacae posteriores superiores and Fascia transversalis with Peritoneum parietale

Clinical remarks
The Regio lumbalis is the operative access route to the kid-
neys. In the lumbal triangles (GRYNFELT’s or PETIT’s triangle)
GRYNFELT’s hernias (rare) or PETIT lumbal hernias can arise.
Because the bones in the Regio sacralis lie at several points
just under the skin (without subcutis), pressure sores can eas-
ily arise in the case of bed-ridden patients at these points (de-
cubitus).

3.2.2 Back muscles

Overview
All muscles on the dorsal side of the torso are referred to as back
muscles (Mm. dorsi). This also includes the muscles of the throat
Vertebra lumbalis IV, area, which topographically lie in the Regio cervicalis posterior
proc. spinosus
and thus at the neck, but due to their course systematically corre-
Crista iliaca spond with the back muscles.
Spina iliaca
MICHAELIS rhomboid posterior The back muscles form 2 layers that differ developmentally and
(venus diamond; superior functionally:
red + grey
Sacral triangle
• The deep back muscles are already created on the dorsal side of
triangle)
(red triangle) the torso. Therefore they are referred to as primary or autoch-
thonous (= local ) back muscles (Mm. dorsi proprii). They are
Os sacrum
innervated by the R. posterior of the spinal nerves, are used for
the correction and extension of the torso and are functionally
Crena ani
Os coccygis collectively known as ‘M. erector spinae’.
• In contrast, the superficial back muscles develop not at the back
Fig. 3.32 Tactile and visible bone points of the MICHAELIS rhomboid but on the ventral torso wall, the arm position or arise from the
and the sacral triangle. Dorsal view. [L126] material for the formation of the soft tissues of the head and only

105
3 Torso

M. trapezius
M. splenius capitis M. sternocleidomastoideus
M. levator scapulae

M. rhomboideus minor
M. splenius cervicis

Fascia deltoidea
M. trapezius

M. rhomboideus
major

M. serratus posterior M. teres major

superior
M. infraspinatus,
Fascia infraspinata
Costae
Scapula, Angulus inferior
M. latissimus dorsi
M. erector spinae

M. serratus anterior
M. latissimus dorsi

M. serratus posterior inferior

Fascia thoracolumbalis

M. obliquus externus
M. obliquus externus abdominis
abdominis
Fig. 3.33 Deep layer of the tor-
M. obliquus internus abdominis;
so arm and torso shoulder gir-
(Trigonum lumbale superius) (Trigonum lumbale inferius) dle muscles. Dorsal view. The M.
trapezius has been removed on
the right side of the body, the
M. obliquus internus abdominis Crista iliaca
Mm. rhomboidei and the M.
latissimus dorsi from the left
side of the body.

shift to the back during the development as secondary back cial back muscles. A further distinction is made in systems. The de-
muscles. They are innervated according to their original territo- scription of the systems essentially relays the course of muscles,
ry from the R. anterior of the spinal nerves, from the Plexus bra- from which the function (see below) can be derived from the indi-
chialis or the N. accessorius [XI]. Most superficial back muscles vidual muscle groups (› Fig. 3.34). The abdominal muscles and
are used mainly for the upper extremities and are therefore func- the M. erector spinae together act as a functional unit (bow-
tional parts of the shoulder and shoulder girdle muscles. string-arch principle).

NOTE Medial tract

The back muscles are divided into two layers: The medial tract (› Table 3.4) is located near the mid-axis, deep
• The primary (= autochthonous) back muscles lie deep and are in- and the muscles act via short lever arms. It consists of two systems
nervated by the R. posterior of the spinal nerves. They are used (› Fig. 3.34):
for the correction and extension of the torso (M. erector spinae). • spinal system (M. spinalis and Mm. interspinales, › Fig. 3.35,
• The secondary (= immigrant) back muscles lie superficially and
› Fig. 3.36, › Fig. 3.37, › Fig. 3.39)
are innervated by the Rr. anterior of the spinal nerves, from the
Plexus brachialis or the cranial nerves. They are used for the • transversospinal system (M. semispinalis, Mm. multifidi, Mm.
movement of the upper extremity and the ribs. rotatores, › Fig. 3.35, › Fig. 3.36, › Fig. 3.39)
The deep neck muscles assume a special position (Mm. suboccipi-
Both the deep and the superficial back muscles can be divided into tales) (see below).
systems that are useful for understanding the function of individu- In the area of the head joints, the medial tract of the M. erector spi-
al muscle groups. nae has been reshaped during evolution to ensure as free and close-
ly controlled movement of the head as possible. Here, four pairs of
Autochthonous (deep) back muscles muscles are differentiated that are referred to collectively as deep
The deep back muscles are referred to collectively as M. erector neck muscles or dorsal muscles of the short head joint muscles
spinae (M. erector trunci). The M. erector spinae extends from the (Mm. suboccipitales) (› Fig. 3.37, › Fig. 3.38, › Table 3.5):
pelvis to the occiput (› Fig. 3.34, › Fig. 3.35) and fills the trench • M. rectus capitis posterior major
formed by the skeleton formed between the spinous processes and • M. rectus capitis posterior minor
the ribs or the rib equivalents. It can be structurally and function- • M. obliquus capitis superior
ally divided into a medial and a lateral tract which lie in their own • M. obliquus capitis inferior
fascial tubes. The tracts are separated by an envelope system of taut
connective tissue, from the Fascia thoracolumbalis, to the superfi-

106
 3.2 Dorsal torso wall

Tract Straight system Oblique system Tract

Lateral M. longissimus M. splenius* Lateral

-capitis -capitis
-cervicis -cervicis
-thoracis

M. semispinalis** Medial
Lateral M. iliocostalis -capitis
-cervicis -cervicis
-thoracis
-lumborum

M. multifidus** Medial
-cervicis
Medial M. spinalis
-thoracis
-capitis
-lumborum
-cervicis
-thoracis

Mm. rotatores longi** Medial

Lateral Mm. inter- -cervicis
transversarii -thoracis
posteriores -lumborum

Medial Mm. interspinales Mm. rotatores breves** Medial

-cervicis -cervicis
-thoracis -thoracis
-lumborum -lumborum

Fig. 3.34 Autochthonous (deep)

back muscles; orientation
Fascia
scheme of the muscle groups;
thoracolumbalis * Spinotransversal,
** Transversospinal.

Table 3.4 Autochthonous muscles of the back, medial tract.

Innervation Origin Attachment Function

Spinal system
Mm. interspinales (lumborum, thoracis [inconstant], cervicis)
Rr. posteriores of the Nn. spi- Procc. spinosi in the median level Procc. spinosi in the median Support for the extension, stabilization and fine tuning of the
nales level motion segments
M. spinalis (thoracis, cervicis, capitis [inconstant])
Rr. posteriores of the Nn. spi- Procc. spinosi lateral to the medi- Procc. spinosi lateral to the medi- • Unilaterally active: support of the lateral inclination of the spine
nales an plane an plane, superior nuchal line • Bilaterally active: extension of the spine

Transversospinal system
Mm. rotatores breves et longi (lumborum [inconstant], thoracis, cervicis [inconstant]), pull to the next or skip a segment
Rr. posteriores of the Nn. spi- Procc. mamillares of the lumbar Procc. spinosi of the next high- • Unilaterally active: low lateral inclination and rotation to the
nales spine, Procc. transversi of the tho- est (breve) or second highest contralateral side
racic and cervical vertebrae (longi) vertebra • Bilaterally active: low extension, stabilisation of the mobile
segments

Mm. multifidi (lumborum [particularly strong], thoracis, cervicis), skip 2–3 segments
Rr. posteriores of the Nn. spi- Facies dorsalis of the Os sacrum, Procc. spinosi • Unilaterally active: rotation of the vertebral column to the con-
nales Crista iliaca, Procc. mamillares of tralateral side and support of lateral inclination
the lumbar vertebrae, Procc. trans- • Bilaterally active: extension and tension as well as stabilisa-
versi of the thoracic vertebrae, tion of the spinal column
Procc. articulares of the cervical
vertebrae

M. semispinalis (thoracis, cervicis, capitis), skip 4–7 segments

Rr. posteriores of the Nn. spi- • Procc. transversi of the thoracic Procc. spinosi, Linea nuchalis • Unilaterally active: rotating the head, the cervical spine and
nales spine and cervical spine superior thoracic spine to the contralateral side, lateral inclination of the
• M. semispinalis capitis super- head, cervical spine and thoracic spine to the ipsilateral side
imposes the other sections • Bilaterally active: extension of the head and spine, tension
and stabilisation of the cervical spine and thoracic spine

107
3 Torso

M. semispinalis capitis Lig. nuchae

M. splenius capitis
M. splenius capitis
M. sternocleidomastoideus
M. splenius cervicis
M. longissimus capitis
M. scalenus posterior

M. splenius cervicis

M. trapezius
M. longissimus
cervicis
M. serratus
posterior
M. levator scapulae
superior

M. semispinalis cervicis
M. teres major
M. iliocostalis cervicis

M. rhomboideus
M. infraspinatus, major
Fascia infraspinata

M. spinalis thoracis M. latissimus dorsi

M. iliocostalis thoracis M. iliocostalis

thoracis
M. iliocostalis lumborum

M. serratus anterior
M. obliquus externus
abdominis
M. serratus posterior inferior
M. longissimus thoracis

Fascia thoracolumbalis
M. obliquus internus abdominis
Fig. 3.35 Autochthonous back
M. longissimus thoracis M. erector spinae muscles; superficial layer. Dor-
sal view.

M. rectus capitis posterior major, M. obliquus capitis superior and • Intertransversal system (Mm. intertransversarii)
M. obliquus capitis inferior form the deep neck triangle (Vertebra- • Mm. levatores costarum
lis triangle).
Apart from the deep neck muscles that form the dorsal group of Functions
Mm. suboccipitales, 2 more muscle pairs belong to the short head The autochthonous back muscles, apart from the passive musculo-
joint muscles (Mm. suboccipitales, › Chap. 10.2.2, › Tab. 10.8, skeletal system (bone, discs, joints, ligaments), are of vital impor-
› Fig. 10.8): tance for the movement and the posture of the spine, of the torso
• M. rectus capitis anterior and the head as active components of a standing and walking per-
• M. rectus capitis lateralis (› Fig. 3.37) son (› Fig. 3.46):
They form the ventral group. All 6 muscle pairs together make up • Straightening of the torso (M. erector spinae)
their insertion of the Axis, Atlas and Os occipitale. In contrast to • Stretching (both sides) and lateral flexion (one-sided) of the
the dorsal group the ventral group is innervated by Rr. anteriores torso
of the spinal nerves. Together with the dorsal group they influence • Rotation of the torso
the fine tuning of the head in the atlantooccipital joints. Apart • Proprioception: location of body position in the room (especial-
from the deep neck muscles, however, further muscles of the ly Mm. suboccipitales)
M. erector spinae and parts of the shoulder girdle muscles are in- The participation of the individual muscle systems can be deduced
volved in the movement of the head. from their course:
• Bilateral contraction always causes stretching
Lateral tract • Straight median muscles (spinal system) can only stretch
The lateral tract not only lies lateral to the medial tract, but also • Straight lateral muscles (intertransversal system) can only lean
partially overlaps it. The muscles are aligned laterocranially and the to the side
individual muscles are much longer in relation to the muscles of • Oblique muscles are used for rotation:
the medial tract (longer lever arms). The lateral tract can be divid- – Muscles, which run laterally, rotate in the same direction (spi-
ed into 4 muscle systems (› Table 3.6, › Fig. 3.34, › Fig. 3.35, notransversal system)
› Fig. 3.36, › Fig. 3.37, › Fig. 3.38): – Muscles that run medially, rotate in the opposite direction
• Sacrospinal system (M. longissimus, M. iliocostalis) (transversospinal system).
• Spinotransversal system (M. splenius)

108
 3.2 Dorsal torso wall

M. rectus capitis posterior minor M. obliquus capitis superior

M. semispinalis capitis M. splenius capitis

M. rectus capitis posterior major

M. longissimus capitis
Atlas, Tuberculum posterius
I M. digastricus, Venter posterior
Atlas, Proc. transversus
II
Mm. intertransversarii posteriores cervicis
M. obliquus capitis inferior

M. semispinalis capitis Ligg. intertransversaria

Mm. multifidi VII Ligg. interspinalia; Lig. supraspinale

I
M. semispinalis cervicis
Mm. rotatores thoracis breves
Mm. interspinales cervicis
Mm. intertransversarii thoracis
M. spinalis capitis
Mm. rotatores thoracis longi
Mm. levatores costarum breves
Lig. costotransversarium superius
M. semispinalis thoracis

Mm. intercostales externi, Fascia Lig. intertransversarium

Mm. levatores costarum breves Membrana intercostalis interna

Mm. levatores costarum longi

XII M. quadratus lumborum, Fascia
Mm. intertransversarii thoracis
I Mm. intertransversarii mediales lumborum
Costa XII
M. transversus abdominis
Fascia thoracolumbalis
Mm. interspinales lumborum
M. obliquus internus abdominis

Mm. intertransversarii laterales Ligg. intertransversaria

lumborum V
Lig. iliolumbale
Fascia transversalis

M. obliquus externus abdominis Spina iliaca posterior superior

Mm. multifidi Lig. sacrotuberale

Fig. 3.36 Autochthonous back muscles, deep layer, and neck muscles (Mm. suboccipitales). Dorsal view.

Table 3.5 Deep neck muscles, dorsal group of short cranial joint muscles (M. suboccipitales).

Innervation Origin Attachment Function

M. rectus capitis posterior major
R. posterior of the Ist spinal Proc. spinosus of the Axis Middle third of the Linea nucha- • Unilaterally active: rotates and tilts the head slightly to the
nerve (N. suboccipitalis) lis inferior ipsilateral side, fine tuning of the head in the atlantooccipi-
tal joint
• Bilaterally active: slight extension of the cranial joints
M. rectus capitis posterior minor
R. posterior of the Ist spinal Tuberculum posterius of the Medial below the Linea nuchalis • Unilaterally active: rotates and tilts the head to the ipsilater-
nerve (N. suboccipitalis) Arcus posterior of the Atlas inferior al side, fine tuning of the head in the atlantooccipital joint
• Bilaterally active: extension of the cranial joints
M. obliquus capitis superior
R. posterior of the Ist spinal Proc. transversus of the Atlas Lateral third of the Linea nucha- • Unilaterally active: tilts the head to the ipsilateral side, fine
nerve (N. suboccipitalis) lis inferior tuning of the head in the cranial joints
• Bilaterally active: extension of the cranial joints
M. obliquus capitis inferior
R. posterior of the Ist spinal Proc. spinosus of the Axis Proc. transversus of the Atlas • Unilaterally active: rotates and tilts the head to the ipsilater-
nerve (N. suboccipitalis) al side, fine tuning of the head in the cranial joints
• Bilaterally active: extension of the cranial joints

109
3 Torso

M. rectus capitis
posterior minor
M. rectus capitis M. obliquus
lateralis capitis superior

Mm. intertransversarii M. rectus capitis

posteriores laterales posterior major
cervicis M. obliquus
Mm. intertransversarii
posteriores laterales capitis inferior
Mm. interspinales
cervicis cervicis

a b

Fig. 3.37 Short neck and head joint muscles. a Short neck muscles. b Short head joint muscles (Mm. suboccipitales). [L126]

M. trapezius M. semispinalis capitis

M. rectus capitis posterior major

M. rectus capitis posterior minor
Atlas, Arcus posterior

Atlas, Tuberculum posterius

M. obliquus
capitis superior

M. splenius capitis
M. splenius capitis

M. semispinalis capitis M. obliquus

capitis inferior

M. splenius cervicis Proc. mastoideus

M. longissimus capitis
M. longissimus capitis
M. digastricus,
Venter posterior
Axis, Proc. spinosus
Proc. styloideus

Mm. interspinales cervicis M. splenius cervicis

M. semispinalis capitis
M. longissimus cervicis

M. longissimus capitis
M. iliocostalis cervicis
Mm. multifidi

M. semispinalis cervicis

Fig. 3.38 Neck muscles (Mm.

M. semispinalis thoracis Lig. supraspinale suboccipitales) and back mus-
cles (Mm. dorsi). Dorsal view.

Due to their cross-section the M. longissimus , the M. iliocostalis • M. longissimus capitis

and the M. spinalis are particularly responsible for straightening • M. splenius capitis
the torso and are therefore also strictly speaking referred to by Ter- These muscles sometimes have contrary functions, except for the
minologia Anatomica as M. erector spinae. The short muscles (Mm. extension on unilateral contraction! The Mm. suboccipitales are
interspinales and inter-transversarii, Mm. rotatores, Mm. leva- responsible for fine tuning of head movements because they per-
tores costarum) are used primarily for stabilisation of the individ- ceive proprioceptive functions due to the large number of muscle
ual movement segments of the spinal column. spindles and also mostly only skip one vertebral segment (excep-
The exact courses are only important for muscles that lead to the tion: M. rectus capitis posterior major).
head:
• Mm. suboccipitales
• M. spinalis and m. semispinalis capitis

110
 3.2 Dorsal torso wall

Table 3.6 Autochthonous muscles of the back, lateral tract.

Innervation Origin Attachment Function

Sacrospinal system

M. iliocostalis (lumborum, thoracis, cervicis)

Rr. posteriores of the Nn. spi- Facies dorsalis of the Os sacrum, Crista ilia- Procc. costales of the upper lumbar spine, • Unilaterally active: lateral flexion and
nales ca, Crista sacralis lateralis, Procc. spinosi of Angulus costae of the Ist–XIIth ribs, Tuber- rotation of the vertebral column to the
the lumbar vertebrae, Lamina superficialis cula posteriora of the IIIrd–VIth cervical ipsilateral side
of the Fascia thoracolumbalis, medial from vertebrae • Bilaterally active: extension and tension
the Angulus costae of the IIIrd–XIIth ribs of the spinal column, expiration (by low-
ering the ribs)

M. longissimus (thoracis, cervicis, capitis)

Rr. posteriores of the Nn. spi- Facies dorsalis of the Os sacrum, Crista Procc. transversi of the thoracic and cervi- • Unilaterally active: lateral flexion and
nales sacralis lateralis, Crista iliaca, Lamina cal vertebrae, Angulus costae, Tubercula rotation of the head and spine to the
superficialis of the Fascia thoracolumbalis, posteriora of the IInd–VIIth cervical verte- ipsilateral side
Procc. spinosi of the lumbar vertebrae, brae, Proc. mastoideus • Bilaterally active: extension of cervical
Procc. transversi and Procc. articulares of spine and head, spinal tension
the thoracic and cervical vertebrae

Intertransversal system, Mm. intertransversarii (lumborum, cervicis)

Rr. posteriores (and anteri- Tuberculum posterius of the Procc. trans- Tuberculum posterius of the Procc. trans- • Unilaterally active: support of lateral flex-
ores) of the Nn. spinales versi of the Ist to IVth cervical vertebrae, versi of the IInd–Vth cervical vertebrae, ion
Procc. accessorii of the Ist–IVth lumbar ver- Procc. accessorii and Procc. mamillares of • Bilaterally active: low extension
tebra the IInd–Vth lumbar vertebrae

Spinotransversal system, M. splenius (cervicis, capitis)

Rr. posteriores (and anteri- Procc. spinosi of the IIIrd–VIIth cervical ver- Proc. mastoideus and lateral portion of the • Unilaterally active: lateral flexion and
ores) of the Nn. spinales tebrae and the Ist–IVth thoracic vertebrae Linea nuchalis superior, Procc. transversi of rotation of the cervical spine and head to
the Ist-IIIrd cervical vertebrae the ipsilateral side, tension of the cervi-
cal spine
• Bilaterally active: extension of cervical
spine and head

Mm. levatores costarum

Rr. posteriores (and anteri- Procc. transversi of the thoracic vertebrae Next lower (breve) and second lowest (lon- • Unilaterally active: rotation of the verte-
ores) of the Nn. spinales gi) rib (lateral from Angulus costae) bral column to the contralateral side and
lateral flexion to the ipsilateral side
• Bilaterally active: extension of the spine
and elevation of the ribs (inspiration)

Fascia thoracolumbalis is also the origin for the following abdominal muscles, secondary
The Fascia thoracolumbalis consists of 2 sheets (› Fig. 3.39, back muscles and hip muscles:
› Fig. 3.40): • Superficial lamina:
• Superficial lamina (Lamina superficialis): originates at the rear – M. latissimus dorsi
of the sacrum and the spinous processes of the spine – M. serratus posterior inferior
• Deep lamina (Lamina profunda): connects the Crista iliaca via – M. gluteus maximus
the Procc. costales of the lumbar vertebra with the XIIth rib; the • Deep lamina:
coarse section between the ribs process of the Ist lumbar verte- – M. obliquus internus abdominis
bra and XIIth rib is referred to as lumbocostal ligament. – M. transversus abdominis
The Fascia thoracolumbalis together with the spinal column forms This enables the thoracolumbar fascia to interact with these muscle
an osteofibrous canal, in which the autochthonous muscles are groups in the movement of the torso and extremities.
embedded (› Fig. 3.39, › Fig. 3.40). The Fascia thoracolumbalis
Clinical remarks
Lateral tract Medial tract
In the case of pathologically increased tone (spasticity) in the
Lamina Processus
spinosus
muscles, that lead to the head, a muscular twisted neck (Torti-
Fascia thoraco- superficialis
collis spasmodicus) may occur with rotation of the head. This
lumbalis Lamina
profunda
is treated, among other things, by interrupting synaptic trans-
mission to the muscular end plate with an injection of botuli-
num toxin. Primarily the two strongest and most superficial
M. latissimus dorsi muscles (M. splenius capitis and M. semispinalis capitis)
come into question; however, since they rotate the head to
Processus
costalis
opposite sides and the M. splenius is also very thin, it must be
ensured according to the symptoms that only one of the two
M. obliquus M. transversus muscles is affected.
internus abdominis abdominis
The muscular twisted neck belongs to the group of myogelos-
es (muscle tension). This consists of circumscribed palpable,
Fig. 3.39 Fascia thoracolumbalis and autochthonous back muscles;
scheme. [L126]

111
3 Torso

Lig. longitudinale anterius

M. psoas major Cauda equina

Pediculus arcus vertebrae Arcus
Ren Lamina arcus vertebrae vertebrae

Plexus lumbalis
Mm. transversospinales**
Proc. costalis
M. erector spinae*
M. quadratus
lumborum

Costa XII

M. obliquus internus Fig. 3.40 Autochthonous back

abdominis (Lamina profunda) Fascia thoraco- muscles and Fascia thoracolum-
(Lamina superficialis) lumbalis balis. Transversal section at the
M. latissimus dorsi level of the IInd lumbar verte-
Proc. spinosus bra; caudal view; * lateral tract,
** medial tract.

mostly pressure pain thickenings of a muscle with contractile • Posterior branch: supplies the back muscles but also the skin,
muscle bundles, such as nodes or swellings, which are com-
the vertebrae and the spinal canal with spinal cord and spinal
mon in chronic pain conditions of the back.
cord membranes. It leads to the Rr. spinales and is divided into
the R. cutaneus medialis and the R. cutaneus lateralis.
• Collateral branch: supplies the intercostal muscles and together
Superficial muscles of the back with the Aa. intercostales it is anastomosed with the Aa. inter-
The superficial back muscles are used for the movement of the costales anteriores (see below).
arms and the ribs. According to their course, they can be divided • Lateral cutaneous branch: supplies the skin in the area of the
into three systems: axillary line and divides into an anterior and posterior branch.
• Spinohumeral system: M. latissimus dorsi The anterior branches of the Rr. cutanei laterales of the Aa. inter-
• Spinoscapular system: M. trapezius, Mm. rhomboidei, M. leva- costales posteriores II–IV supply the mammary glands as the Rr.
tor scapulae mammarii laterales.
• Spinocostal system: Mm. serrati posteriores superior et inferior
Course and function of the muscles are explained in more detail Branches of the Aorta abdominalis
in the upper extremities (› Chap. 4.3.4) or have already been The branches of the Aorta abdominalis supply the back muscles
­discussed for the ventral torso wall (spinocostal system) and the skin of the back with blood, partially the lower portion of
(› Chap. 3.1.2, › Table 3.1, › Fig. 3.33). the abdominal muscles and are involved in the blood supply of the
vertebral canal in the lumbar region and the diaphragm (› Fig.
3.41). Central branches are 4 paired Aa. lumbales, which leave the
3.2.3 Vascular, lymphatic and nervous systems of aorta on their rear wall and pass to the abdominal wall at the level
the dorsal torso wall of the I–IV lumbar vertebrae behind the M. psoas and the M. qua-
dratus lumborum. Here they pass between the M. obliquus inter-
Arteries nus abdominis and the M. transversus abdominis and anastomoses
The dorsal torso wall is supplied with blood, to a large extent di- with the Aa. intercostales posteriores, A. epigastrica inferior, A. il-
rectly from the aorta but also from branches of the Aa. subclavia et iolumbalis and the A. circumflexa ilium profunda. From each
axillaris (throat area) as well as the Aa. iliacae externa et femoralis A. lumbalis originates a
via anastomoses with the ventral torso wall arteries. The blood sup- • Posterior branch: this supplies, analogue to the posterior
ply to the neck muscles is discussed in › Chap. 10.4. branch, the Aorta thoracica (see above), the back muscles, also
the skin, the vertebra and the spinal canal with Cauda equina
Branches of the Aorta thoracica and spinal cord membranes. The Rr. spinales arises from it and
The branches of the Aorta thoracica (Pars thoracica aortae) show divides into the main branches R. cutaneus medialis and the R.
the typical segmental classification (therefore also referred to as cutaneus lateralis.
chest segment arteries) and supply the intercostal muscles, the up- At the level of the diaphragm the paired A. phrenica inferior aris-
per part of the stomach muscles, the skin at the side and back chest es on the anterior side of the aorta at the height of the aortic hiatus.
wall and join the blood supply of the mammary gland (› Fig. 3.13). It branches off on the underside of the diaphragm and anastomoses
From the Aorta thoracica, the paired Aa. intercostales posteriores with the lower intercostal arteries and visceral arteries.
emerge. The 3rd–11th arteries originate directly from the thoracic
aorta and the 1st and 2nd arteries from the A. intercostalis supre- Veins
ma of the Truncus costocervicalis of the A. subclavia. The intercos- The venous drainage of the dorsal torso wall is divided into 3 sys-
tal arteries course in the respective ICS on the bottom edge of the tems as in the ventral torso wall:
rib in the Sulcus costalis. The 12th chest segment artery still runs • Epifascial venous system
under the XIIth rib, but no longer in an ICS. It is therefore called • Subfascial venous system
the A. subcostalis. Branches of the intercostal arteries are respec- • Venous system of the spine
tively (› Fig. 3.13): The course of the veins can be extremely variable, particularly in
the epifascial and subfascial venous systems.

112
 3.2 Dorsal torso wall

A. vertebralis

A. thoracica interna

Truncus costocervicalis

A. carotis communis
A. subclavia

A. thoracica superior

Rr. acromialis, Pars thoracica aortae

clavicularis and deltoideus [Aorta thoracica]
A. thoracoacromialis

A. thoracodorsalis

A. thoracica lateralis Aa. intercostales anteriores

and posteriores
A. thoracica interna

A. epigastrica superior

Aorta abdominalis
A. lumbalis

A. epigastrica inferior A. iliaca communis

A. iliaca interna A. sacralis mediana

A. iliaca externa

A. circumflexa ilium profunda

A. profunda femoris Fig. 3.41 Arteries of the torso

wall. Anterior view. [L266]

Epifascial venous system • V. hemiazygos: drains into the A. subclavior azygos, V. cava in-
The epifascial veins lie in the subcutis and form a densely ramified ferior, V. illiaca communis and V. illiaca externor.
network on the dorsal torso wall. The lumen diameter varies consid- • V. hemiazygos accessoria: Supplies blood to the V. azygos and
erably from person to person, and in contrast with the ventral torso the A. subclavior.
wall, where there are larger vein stems with their own terminology,
there is no terminology for these veins at the dorsal torso wall. Venous system of the spine
The veins of the spine are referred to in their entirety as Vv. colum-
Subfascial venous system nae vertebralis. They can be divided into an outer and inner ve-
The subfascial venous system is similar to the arteries, which are nous network (› Fig. 3.65). They are discussed in › Chap. 3.3.2.
accompanied by these veins; however, there are exceptions on the
dorsal torso wall. The azygos system (› Fig. 3.16) is here, consist- Lymph vessels
ing of the V. azygos, V. hemiazygos and the V. hemiazygos accesso- Epifascial lymph vessels above the navel drain into the axillary
ria. The following belong to the subfascial venous system of the lymph nodes (Nodi lymphoidei axillares); epifascial lymph vessels
dorsal torso wall: below this drain into the superficial inguinal lymph nodes (Nodi
• Vv. intercostales posteriores: They receive blood from the inter- lymphoidei inguinales superficiales), Nodi lymphoidei supero-
costal muscles and the overlying skin of the dorsal torso wall and medialis and superolateralis of the superficial inguinal Lymph
from the back muscles (R. dorsalis) and the vertebral canal (R. nodes.
intervertebralis, R. spinalis). The upper intercostal veins (II–III) Subfascial lymph vessels on the inside of the dorsal torso wall drain
drain to the right via the V. intercostalis superior dextra into the into the Nodi lymphoidei intercostalis lying paravertebrally,
V. azygos and to the left via the left superior intercostal vein into which also take up the lymph of the Pleura parietalis in this area.
the V. left innominate vein. The lower intercostal veins (IV–XI) With the Aorta abdominalis there is also a lymph discharge to the
drain to the right into the V. azygos, left into the V. hemiazygos Nodi lymphoidei lumbales and along the A. iliaca externa to the
and the V. hemiazygos accessoria. Nodi lymphoidei iliaci externi.
• Vv. lumbales (I–IV): they drain the blood of the posterior ab-
dominal wall into the Vilumbalis ascendens and from there into Innervation
the V. iliaca communis. The 3rd and 4th lumbar veins usually The dorsal torso wall is innervated segmentally from the branches
flow directly into the V. cava inferior. of the thoracic and lumbar spinal nerves (› Fig. 3.42).
• V. azygos: this leads the blood up into the V. cava superior and The Rr. posteriores of the Nn. spinales thoracici and lumbales
down into the V. cava inferior. each divide into a R. mediales and a R. laterales (› Fig. 3.43).

113
3 Torso

Radix posterior

Radix anterior Ganglion sensorium nervi spinalis

R. posterior
Truncus nervi spinalis
N. intercostalis

R. cutaneus lateralis
N. intercostalis
R. communicans

Ganglion trunci
sympathici
R. communicans
N. splanchnicus
major

R. cutaneus anterior Rr. meningei Ganglion trunci sympathici

Nn. spinales:
Nn. cervicales Fig. 3.42 Construction principle
Nn. thoracici of spinal nerve (N. spinalis) and
Nn. lumbales
Nn. sacrales
spinal cord segment, exempli-
N. coccygeus fied by two thoracic nerves (Nn.
thoracici). Anterior oblique view.

They innervate the autochthonous back muscles and the overlying VII–XI and is involved in the innervation of the M. rectus abdo-
skin. The lateral cutaneous branches are well developed in the low- mini.
er back and, depending on the location are referred to as Rr. cuta- In the axillary line each intercostal nerve emits a R. cutaneus latera-
nei posteriores or Nn. clunium superiores. lis and in the front sternal line a R. cutaneus anterior to the skin.
The Rr. anteriores (ventrales) of the Nn. spinales thoracici (in- Depending on the region to be innervated, the branches are called:
tercostales) are the intercostal nerves (they are shown here com- • Rr. cutanei laterales pectorales
pletely because of their origin in the area of the dorsal torso wall, • Rr. cutanei anteriores pectorales
although they innervate the ventral torso wall). They innervate the • Rr. mammarii laterales
intercostal and abdominal muscles and the Mm. serrati posteriores • Rr. mammarii mediales
superior et inferior. Their sensitive branches are used for the inner- • Rr. cutanei lateralis abdominis
vation of the Pleura parietalis and Peritoneum parietale: • Rr. cutanei anterieores abdominis
• N. intercostalis I is part of the brachial plexus. The Rr. cutanei laterales of the (1st, 2nd and 3rd) intercostal nerve
• Nn. intercostales II–VI run in the ICS up to the sternum. extend as the N. or Nn. intercostobrachiales on the medial side of
• Nn. intercostales VII–XI run partly in the ICS, then leave and run the arm and combine here with the N. cutaneus brachii medialis
almost near to the midline. In the process they cross the attach- (› Chap. 4.6.1).
ment area of the diaphragm and run between the M. obliquus in- The Rr. cutanei anteriores of the 1st (and 2nd) Intercostal nerves
ternus abdominis and the M. transversus abdominis up to the rec- are missing. The skin is innervated here by the Nn. supraclavicu-
tus sheath, enter this and innervate the M. rectus abdominis. lares from the Plexus cervicalis.
• The 12th intercostal nerve runs under the XIIth rib and is called
the N. subcostalis. It has the same course as the Nn. intercostalis
Clinical remarks
Truncus sympathicus, Medulla spinalis Due to the segmental sensory innervation of the skin of the
ganglion trunci sympathici torso wall, nipples (T5), navel (T10) and the inguinal region
Corpus vertebrae (L1) are used as reference points for height localisation.
R. communicans
Pain in the chest wall can be projected into the arm via the Nn.
Radix anterior
R. meningeus intercostobrachiales (e.g. when mammary carcinoma metas-
Radix posterior tases are present in the axillary lymph nodes that grow into
Ganglion sensorium the nerves).
nervi spinalis Foramen
intervertebrale
Truncus nervi
spinalis Canalis vertebralis

N. intercostalis Arcus vertebrae 3.3 Spine, spinal cord and thorax

Costa
Bernhard Hirt, Friedrich Paulsen
Proc. spinosus

R. posterior Mm. dorsi The vertebral column (Columna vertebralis), together with the axial
R. lateralis
skeleton, is located at the back of the torso and is thus eccentric, car-
rying the weight of the head, the upper extremities, the torso and the
R. medialis
thoracic and abdominal viscera and transferring it to the pelvic girdle.
(R. cutaneus (R. cutaneus The chest wall skeleton is connected by a joint system with the spine.
lateralis) medialis)
The special structure of the free (presacral) spine with generally 24
Fig. 3.43 Spinal nerve (N. spinalis) in the thoracic region. Caudal individually moving vertebrae and 23 intervertebral discs (Disci in-
view. tervertebrales) as well as the ligaments of the spine provide excellent

114
 3.3 Spine, spinal cord and thorax

power transfer during free movement. The weight is transferred • In the case of wedge-shaped vertebrae (hemivertebrae) the
caudally via the sacrum (Os sacrum), which is integrated into the front surface of the vertebral body is lower than the rear sur-
pelvic girdle to which the coccyx (Os coccygis) is connected. face. This occurs when two cartilage centres appear instead
The spinal cord is located in the vertebral canal (Canalis vertebra- of just one. Wedge-shaped vertebrae change the spinal form
(kyphosisation) and the spinal static.
lis); the spinal nerve branches enter and exit via the intervertebral
• In adults if two vertebrae fuse under degeneration of the in-
foramina (Foramina intervertebralia). The dorsal root ganglia are tervertebral disc, block vertebrae are created.
also found here. If single or multiple vertebral arches do not fuse together, the
result is a divided, dorsally open spine (Spina bifida):
• In the simplest form, the fissure formation lies under the
3.3.1 Embryology skin and is not externally visible (Spina bifida occulta).
• If the neural folds are also open to the outside, it is called
rachischisis (Spina bifida aperta).
Development of the axis organs and somites
• If the spinal cord is also affected, this can be associated
On the 16th day of development the Chorda dorsalis as a rod- with paralysis in the affected area and below.
shaped structure in the median plane of the middle germ layer SCHEUERMANN’s disease (Scheuermann’s disease, adoles-
(mesoderm). It is located in the axial plane as a support rod and cent kyphosis, juvenile kyphosis, osteochondritis deformans
releases inductive messengers, which cause the paraxial mesoderm juvenilis dorsi) is an etiologically unclear (probably inherited)
(› Chap. 2.6.2) to differentiate (see below). Parallel to this, the spinal disease (probably giving rise to disorders in the ring
neural tube is formed. The notochord and neural tube are referred apophyses/growth zones) that form in children and adoles-
cents aged between 11 and 17 years. Boys are much more
to as the axis organs. The close relationship between the spine and
likely to be affected. In this case, the front part of the vertebral
the spinal cord is thus already created. Through consolidation of body (especially on the lower thoracic spine) is decreased, the
the paraxial mesoderm in the following period (up to the 5th week) top and base plates are irregularly outlined, SCHMORL’s carti-
42–44 pairs of somites are created (syn.: original segments), which lage nodes can be found on the end and base plates and the
are positioned beside the axis organ like a string of pearls. This vertebral body is extended on the ventral side. Those affected
structure of the mesoderm in somites is the basis of the segmental suffer from back pain, stooping, movement restrictions and
structure of the body (metamerism). overloading of adjacent spinal sections. Physiotherapy, sport
and a spinal support (by orthoses) are used for treatment.
Differentiation of somites
The cells of the somites differentiate sequentially into sclerotomes,
myotomes and dermatomes. Vertebrae, parts of the intervertebral
discs and the ligaments develop from the sclerotomes. For this 3.3.2 Spine
purpose, the somite cells migrate medially to the Chorda dorsalis
and to the neural tube. The vertebral bodies differentiate in the cra- The spine accounts for two fifths of the size of a human. A quarter
nial and caudal halves of two neighbouring somites. Thus, the ver- of the vertebral column length is attributable to the intervertebral
tebral body positions are located between the somites and the posi- discs (Disci intervertebrales).
tions of the intervertebral discs each lie in the middle of the so-
mites. The vertebral arch positions arise from two neighbouring Structure and form
paraxial somite parts lying beside the Chorda dorsalis. Sections
The initially centrally located Chorda dorsalis in the vertebral The vertebral column (Columna vertebralis, › Fig. 3.44) is divid-
­system becomes degenerated. As a relic of the notochord the only ed into 5 sections. The sections differ in the number of vertebrae,
thing remaining is the gelatinous core of the intervertebral discs and in the rotation and tilting of the vertebrae in relation to each
(Nucleus pulposus). other. The 24 presacral vertebrae are divided into
The initially organised 42–44 somite pairs are distributed in the – 7 cervical vertebrae (Vertebrae cervicales),
course of development. – 12 thoracic vertebrae (Vertebrae thoracicae) and
• The cranial 4½ somites evolve to parts of the occipital bone. – 5 lumbar vertebrae (Vertebrae lumbales).
• The coccyx evolves from 3–5 vertebral positions. The following are immovable
• The caudal 5–7 somites regress. • 5 synostotically fused vertebrae called the sacrum (Os sacrum)
From the 6th embryonic week the cartilaginous reconstruction of and the
mesenchymal precursor tissue occurs based on cartilage centres in • coccyx consisting of 3–5 fused vertebrae (Os coccygis).
the area of the vertebral body and the arch roots. Ossification (en- The boundary between the lumbar spine and the sacrum is the
dochondral ossification) begins in the 4th foetal month with the Promontorium.
formation of bone cores in the vertebral bodies and the vertebral
arches. In neonates the vertebral bodies are usually already ossified. NOTE
In 5–6 % of the population there is a transition vertebra in form of
a sacralisation. In the process, lumbar vertebra V is fused with the
Clinical remarks sacrum and there are only 23 presacral vertebrae. A sacralisation is
very often associated with the cervical ribs. There is also a predis-
Vertebral malformations can be associated with pathological
position for a slipped disc in the segment lying above.
vertebral body shapes:
Another form of a transition vertebra is lumbalisation, which is
• The fusion of 2 or more vertebral bodies in the context of de-
slightly less common than the sacralisation. In the process, the
velopment leads to a dysontogenetic block vertebra. Verte-
sacral vertebra I is not fused with the rest of the sacrum to a bone,
bral fusion occurs on the cervical spine, e.g. in the case of
but remains as a free vertebra. In this case there are 25 presacral
KLIPPEL–FEIL’s syndrome (congenital cervical vertebrae syn-
vertebrae.
ostosis) with characteristic shoulder blade elevation and
deep hairline.

115
3 Torso

Atlas

Vertebrae Axis
cervicales
I–VII Cervicales ordosis

Vertebra prominens

Vertebrae
thoracicae Thoracicae kyphosis
I–XII
Disci intervertebrales

Foramina intervertebralia

Vertebrae
lumbales
I–V

Lumbales lordosis

Promontorium

Os sacrum

Sacralis kyphosis

Os coccygis
a b c

Fig. 3.44 Vertebral column (Columna vertebralis). a ventral view. b dorsal view. c lateral left view.

Curvatures ment remains difficult even today; however, almost everyone

The spine has physiological curvatures in the sagittal plane (› Fig. has a minimal level of scoliosis, because most people’s legs
3.44), which give it its double-S-shape. These are not yet in exis- differ slightly in length. Degenerative or inflammatory chang-
tence in neonates. Only a flat kyphotic curve in the thoracic spine, es, developmental disorders or compression fractures of the
and in the sacrum and coccyx are dominant. The curvature in the spine may result in a hyperkyphosis of the upper thoracic
spine and the formation of a round back.
throat and lumbar regions are formed with the burden on the spine
through raising the head, sitting and standing upright in the 1st
year of life and beyond. The cervical and lumbar spine are ventrally
bent and convex which is referred to as lordosis (cervical lordosis, Vertebrae and their connections
lumbar lordosis), the thoracic spine and Os sacrum/Oscoccygis are Basic form of a vertebra
bent ventrally and concave, which is referred to as kyphosis (tho- Each free presacral vertebra, › Fig. 3.45) consists of:
racic kyphosis, sacral kyphosis). The curvature of the spine in • Vertebral body (Corpus vertebrae)
adults is not exactly transferable to the various sections of the • Vertebral arch (Arcus vertebrae)
spine; therefore, cervical lordosis refers to the cervical vertebrae I– • Vertebral arch processes (Procc. arcus vertebrae)
VI and thoracic kyphosis to the VI cervical to IX thoracic vertebrae The exception is in the first two cervical vertebra (Atlas and Axis).
and lumbar lordosis from the IX thoracic to the V lumbar vertebra. All other vertebrae of the freely movable spine are structured in
this way, but show characteristic shape and position variations in
their structure in the various sections of the spine.
Clinical remarks
Excessive curvature of the spine in the frontal plane is referred Vertebral bodies
to as scoliosis and is always pathological. This growth defor- The vertebral body (› Fig. 3.45) has cranially and caudally a
mity of the spine results in a fixed lateral curvature. In the tho- transverse oriented surface (Facies intervertebralis), which is sur-
racic spine a scoliosis in conjunction with a fixed twisting (tor- rounded in a circular form by a border rim (Epiphysis anularis).
sion) of individual vertebrae and rib-vertebrae joints (rotation
The border rim is made of dense bone in the same way as the side
of axial organs) also leads to a deformity of the rib cage with
hump formation (Gibbus), which can no longer be compensat- wall of the vertebral body. The central area is also made up of com-
ed on a muscular level. This often has an impact on the pul- pact bone but only a thin layer, so that it directly connects with the
monary and circulatory function. Scoliosis has been a well- underlying cancellous bone of the vertebral body. The vertebral
known orthopaedic condition since ancient times but its treat- body surface is covered by hyaline cartilage; cranially it is referred
to as a cover plate and caudally as a ground or base plate. The top

116
 3.3 Spine, spinal cord and thorax

Epiphysis vertebrale). The vertebral foramen of all vertebrae form in their

anularis entirety the vertebral canal (Canalis vertebralis), which contains
the marginal ligaments, the spinal cord and the spinal meninges.
Corpus
vertebrae
Vertebral arch processes
Pediculus Between the pedicle and the arch plate (lamina) a laterally facing
Proc. arcus vertebral arch process is located on both sides (transverse process,
vertebrae
articularis
superior
Arcus Proc. transversus). On each side one articular process protrudes up
vertebrae
Lamina
arcus
and down, respectively, (Procc. articulares superior et inferior) for
Proc. vertebrae flexible connection with the above and underlying vertebrae or
trans- bones. The pedicle is constricted at the top and bottom in the lateral
versus
view (Incisurae vertebrales superiores et inferiores). Through the
Proc. articularis Proc. spinosus corresponding upper and lower constrictions of the pediculi of ad-
inferior
jacent vertebrae, the vertebral arch foramina are created (Foramina
intervertebralia), which enter and exit through the spinal nerve
Fig. 3.45 Structural elements of a vertebra, schematic. Posterior
oblique view. [L126]
roots and contain the portions of the spinal ganglia.

and bottom plates are solidly connected with the adjacent interver-
Clinical remarks
tebral disc (disc, Discus intervertebralis, see below). Clinicians often use the short forms lamina and pedicle. The
term lateral mass, which is frequently used for all vertebrae,
for the region of the joint and transverse process between the
Clinical remarks arch root and the arch plate is incorrect. The lateral masses
are exclusively structures of the first cervical vertebrae (Atlas,
In Germany approximately 6 million adults suffer from osteo-
see below).
porosis (bone loss) and 80% are women. Osteoporosis is a
In spinal surgery the removal of the vertebral arch plate plays
systemic disease of aging of the skeleton, which changes the
a significant role (laminectomy, e.g. in the operative treatment
cancellous bone architecture and makes the bones suscepti-
of a disc prolapse, see below). Screws that are introduced into
ble to fractures. It is characterised by a decrease in bone
the vertebral arch root to stabilise the spine, are called pedi-
mass, whereby less bone is formed than degraded. In particu-
cle screws.
lar, very spongiose constructed skeletal elements, such as the
A spondylolysis is a lateral cleft in the vertebral arch that leads
vertebral body are affected, as the conversion rate in ancel-
to the separation of the inferior articular process from the rear
lous bone (approximately 28%) is significantly higher than in
part of the arch and of the spinal process from the rest of the
compact bone (approx. 4%). Risk factors for osteoporosis are
vertebral parts. They can occur as a congenital defect or as ac-
family history, white skin colour, age, oestrogen deficiency,
quired stress fracture of the lamina. The bony separation of the
vitamin D deficiency, low calcium intake, smoking, excessive
isthmus (› Fig. 3.60) can cause vertebral slippage (spondylo-
alcohol intake and an inactive life style. The most common
listhesis). The latter is an instability of the spine, in which the
cause is oestrogen deficiency after menopause (as with men
upper portion of the spine slides forward with the slipped verte-
in old age). In this process the bone loss increases as oestro-
bra over the underlying vertebral body. In most cases, spondy-
gen inhibits the osteoclast activity. A lack of oestrogen means
lolisthesis is an incidental finding but it can be accompanied by
that too many osteoclasts are created and live for too long. In
nerve and spinal cord involvement up to failure symptoms.
the vertebral bodies, particularly the cancellous bone trabecu-
lae, there is thinning and consequently microfractures. Verti-
cal cancellous bone trabeculae heal together again via sec-
ondary fracture healing (via callus), because the fracture ends
Mobile segments of the spinal column
adjoin each other. Horizontal fracture ends are pressed apart
by the forces acting on the vertebral bodies and can no longer
The term mobile segment refers to two neighbouring vertebrae
grow together. They are degraded. At some point, the vertebra with their connections and the ligamentous and muscular struc-
can no longer withstand the physical stress acting on it and tures. The entire vertebral column is therefore made up of various
collapses (sinter down). This can occur completely or only af- mobile segments. The range of movement within a mobile segment
fect the front or rear part, so that deformation of the axial skel- is not particularly large. The sum of all mobile segments leads to an
eton (with reduction in body height) and deficits can be the extraordinarily large range of movement of the vertebral column
result. New drugs against osteoporosis intervene in the bone (› Fig. 3.46) in the various movements.
metabolism, e.g. antibodies against the membrane compo-
nent protein RANKL on osteoblasts or against the osteocyte
protein sclerostin. The previously conducted postmenopausal NOTE
oestrogen treatment has been abandoned due to adverse side The intervertebral discs act as connections between the vertebrae
effects (e.g. a significantly increased risk of breast cancer). (Disci intervertebrales) and the vertebral arch joints (Articulationes
zygapophyseales).

Intervertebral discs
Vertebral arches The spine has 23 intervertebral discs (Disci intervertebrales), lo­
The vertebral arches (Arcus vertebrae, › Fig. 3.45) are located cated between the vertebral bodies (› Fig. 3.47) and in healthy
dorsally on the vertebrae and on both sides consists of 2 units: adults they account for approximately one quarter of the total length
• Pedicle of the vertebral arch (Pediculus arcus vertebrae) of the spine. Skull and atlas as well as atlas and axis (the first two
• Lamina of the vertebral arch (Lamina arcus vertebrae) cervical vertebrae) are linked by true joints (diarthroses). There are
The vertebral arch plates of both sides meet in the spinal process no intervertebral discs here. The intervertebral discs connect the top
(Proc. spinosus) and thus form the vertebral foramen (Foramen and base plates of adjacent vertebral bodies and are tightly connected

117
3 Torso

Extension Nucleus pulposus

Proc. articularis
superior
Anulus
Flexion
fibrosus

Cervical
spine
Cervical
spine Thoracic

Proc. costalis
spine

Thoracic spin
e

ine
Lumbar
Corpus Proc. articularis
inferior
sp spine
bar
Lum vertebrae
250°

Lamellae of the
Lig. longitudinale Anulus fibrosus
anterius

Lu
mb 240°
ine
Fig. 3.47 Structure of the Disci intervertebrales. Anterior oblique
sp
view. [L266]
ar
sp ar
ine mb
Lu
Thoracic Thoracic

• Internal zone: consists of wider lamellae made of fibrous carti-

spine spine

Cervical
spine
Cervical
spine
lage (type I and type II collagen), which are also arranged in the
shape of a herringbone pattern.
• Transition zone: the inner zone passes into the Nucleus pulpo-
Rotation sus without any clear demarcation and as a transition zone con-
sists of loose connective tissue.
The Nucleus pulposus borders cranially and caudally with the car-
tilage plates of the vertebral body and laterally on the Anulus fibro-
sus. It consists primarily of an extracellular matrix with a high pro-
portion of proteoglycans and a correspondingly high water-bind-
ing capacity.

Cervical Cervical Function

The water-binding capacity of the Nucleus pulposus leads to a uni-
Th spine spine
e
or in
ac sp
ic ic
Lum
bar
sp
spin e
in
Th
or
ac
bar
spin
e
form source pressure, which is aligned against the base and top plates
Lum
of two adjacent vertebrae and is released laterally (axial pressure
e

150° load). In this way the fibres of the Anulus fibrosus are always kept un-
der tension. The Nucleus pulposus acts like a centrally-loaded water
Lateral tilt
cushion, which distributes the physical pressure evenly on the top and
base plates of the vertebral body. The grid-like interwoven fibres of
Fig. 3.46 Range of movement of the spinal sections (equivalent to the Anulus fibrosus hold the Nucleus pulposus in position and make
neutral-null method). [L126] it impossible for the vertebrae to shift against each other when the in-
tervertebral disc is intact. The fibres of the Anulus fibrosus, convert
with these by collagen fibres. The thickness of the intervertebral discs eccentrically acting pressure and shear forces on the Nucleus pulpo-
increases from cranial to caudal corresponding to the mechanical sus into tensile forces on the marginal edge of the vertebral body.
load. The height of each individual intervertebral disc is subject to a
daily time fluctuation due to pressure-dependent fluid volume dis- Nutrition
turbances in the extracellular spaces (this means that in the morning The outer zone of the Anulus fibrosus is supplied with vessels in
after sleep one can be 2.5 cm taller than in the evening). the case of healthy and young intervertebral discs, but this ceases
with age. The other zones are avascular. The tissue of the interver-
Structure tebral discs is bradytrophic, has a low metabolic activity and can
A Discus intervertebralis (› Fig. 3.47) consists of an outer fibrous hardly regenerate. Nutrition is carried out using convection of nu-
ring (Anulus fibrosus) and an inner jelly-like core (Nucleus pulpo- trients from the blood vessels of the vertebral body and the periph-
sus). The Anulus fibrosus is further divided into an external zone, eral zone of the Anulus fibrosus. Convection is expedited by the
an internal zone and a transition zone. fluid displacement that take place throughout the day.
• External zone: consists of dense connective tissue arranged in
lamellae made of collagen fibrils which run in opposition, in the NOTE
form of a herringbone pattern (rhombic lattice scissors grid, Ve- In old age a large part of the proteoglycans of the intervertebral
netian scissors) (in particular type I collagen), which is anchored discs is lost. The reasons for this have not been conclusively estab-
to the bony edge of the vertebral body. Between the collagen fi- lished. As a result, the water retention capacity in the Anulus fibro-
brils there are large quantities of proteoglycans (approximately sus decreases by 20%. This can be compensated by muscle train-
ing. If this compensation is missing, degenerative changes occur
66%), which form a functional unit with the collagen fibrils. that can lead to complaints.
There are also numerous elastic fibres.

118
 3.3 Spine, spinal cord and thorax

Clinical remarks (diarthrosis) with the corresponding inferior articular process

(Proc. articularis inferius) of the overlying vertebra. The shape,
With age, the water-binding capacity of the Anulus fibrosus
size and position of the joint facets (Facies articulares superior et
and Nucleus pulposus continuously decreases. Small tears
appear in the Anulus fibrosus (chondrosis). This can be de- inferior) are regionally different and are distinctive structural fea-
tected radiologically by a reduction in height and functionally tures of the individual spinal sections (› Fig. 3.49).
by an instability with increased mobility in the motion seg- Within a mobile segment the two vertebral arch joints absorb pres-
ment. The height of the disc is reduced and its mechanical sure forces in this way and have an important kinematic function
buffer function diminished. This results in the top and base in the movement control of the individual regions of the spine. The
plates of the vertebral body being stressed to a greater level, function of this is closely linked to the spatial position of the artic-
which can be expressed radiologically as sclerotisation (in-
ular surfaces.
creased radiation density, osteochondrosis). In addition,
spondylophytes (bony marginal spikes) can form on the verte-
bral bodies. NOTE
If this type of predamaged intervertebral disc is overstressed, The Articulationes zygapophysiales are often referred to as facet
the Anulus fibrosus can rupture and the jelly-like centre can joints due to the shape and position of the joint facets in the vari-
penetrate at different points through the now discontinuous ous sections of the spine.
Anulus fibrosus (so-called slipped disc):
• Most common is a laterodorsal prolapse (› Fig. 3.48),
which restricts the intervertebral foramen and compresses Clinical remarks
the spinal nerve root of the corresponding segment. The re-
sult is a so-called spinal radicular syndrome with back pain An irritation (mostly chronic) of the facet joints (Articulationes
(lumbago), possibly referred pain in the arms (brachialgia) zygapophyseales) leads to pain, which is referred to as facet
or legs (ischialgia) and sensory disturbances or muscle pa- syndrome or facet joint syndrome. It is the most common
resis in the innervation area of the affected spinal nerve; cause of back pain, which in turn is the most common reason
however, a prolapse can also be asymptomatic. Due to the to seek medical consultation in Germany. The cause of the
high complication rate there is a strict indication for surgery. pain is degenerative changes (osteoarthritis, spondyloarthro-
• A mediodorsal disc prolapse can also compress the spinal sis) in one or in most cases in several adjacent facet joints.
cord at a corresponding height (› Fig. 3.48). This situation The lumbar spine is most often affected because here the
is an emergency, because the spinal cord has to be rapidly stress of the body weight coupled with high mobility is at a
relieved. high level. Obesity is an additional important factor. Charac-
Degeneratively linked slipped discs are most common in the teristically, there is pain at the height of the affected joints or
lumbar and cervical spine. The segments S1, L5 and L4 are somewhat below them radiating to the legs. Within the frame-
most often affected. The slipped discs arise in the cervical work of the joint changes the nerves innervated in the joints
spine after rupture of the intervertebral discs, which lie in the are also stimulated (facet joint nerves), which are branches of
uncovertebral joints (see below). the corresponding spinal nerve roots. The symptoms corre-
spond to a root stimulus symptom (radiculopathy), but with-
out the sensation disorders typical for a radicular syndrome.
These are sometimes referred to as pseudoradicular pain.
Vertebral arch joints
The vertebrae are connected on both sides under each other via
vertebral arch joints (Articulationes zygapophysiales). Dorsal of
the vertebral bodies and intervertebral discs, the upper articular Ligaments of the vertebral column
process (Proc. articularis superius) of a vertebra forms a true joint The spine has strong ligaments. The ligaments extend between the
spinal vertebrae or over larger sections. A distinction is made be-
tween vertebral body ligaments and vertebral arch ligaments.
mediodorsal prolapse
(constriction of the vertebral canal) Nucleus pulposus
Laterodorsal prolapse Vertebral body ligaments
Anulus fibrosus
(compression of the The vertebral bodies are connected ventrally and dorsally via a lon-
N. spinalis N. spinalis) gitudinal ligament:
• Lig. longitudinale anterius
• Lig. longitudinale posterius
The Lig. longitudinale anterius (› Fig. 3.50, › Fig. 3.51) extends
from the anterior atlas arch to the Os sacrum and ends there as the
Lig. sacrococcygeum. The ventral superficial fibre components of
the ligament extend over several vertebral bodies; the dorsal, deep
fibre components connect the bony edges between two adjacent
vertebrae. A connection to the intervertebral discs does not exist.
The ligament becomes broader from cranial to caudal.
Ganglion spinale
Dura mater The Lig. longitudinale posterius (› Fig. 3.50, › Fig. 3.51) ex-
spinalis Radix anterior
tends from the Os occipitale to the Os sacrum, limits the vertebral
Radix posterior canal at the front and lies on the back of the vertebral body. Over-
Spatium epidurale
Medulla spinalis all, it is narrower than the Lig. longitudinale anterius and ends as
deep Lig. sacrococcygeum posterius profundum in the sacral canal.
The fibres, which run at the front, each spread over the interverte-
Fig. 3.48 Disc prolapse. [L266] bral discs and are fused with them.

119
3 Torso

Facies articularis
45° 80° superior
45°

20°

Fig. 3.49 Position of the verte-

Facies articularis inferior
bral arch joints at the cervical,
HW BW LW
thoracic and lumbar vertebrae.
[L126]

Fovea costalis inferior

Fovea costalis superior
Lig. costo-
Pediculus arcus vertebrae
transversarium
Costa

Discus Arcus vertebrae

intervertebralis
Lig. longitudinale
Lig. longitudinale posterius
anterius
Vertebra thoracica XII,
Corpus vertebrae

Discus
intervertebralis
Fig. 3.50 Ligmaments of the
spine. a Lig. longitudinale ante-
Lig. capitis rius (using the example of the
costae radiatum
lower thoracic spine). b Lig. lon-
gitudinale posterius (using the
a b example of the lower thoracic
and upper lumbar spine).

Clinical remarks pass into the Lig. supraspinale. They limit ventral flexion and
In the case of BECHTEREW's DISEASE (Spondylitis anky- also the sliding movement of the vertebrae.
losans), a genetically caused painful, inflammatory rheumat- • Lig. supraspinale: the ligament consists of long fibres and con-
ic disease, there is increasing ossification of all ligament nects the tips of multiple Proc. spinosi. Cranially, it passes into
structures, particularly of the spine. In the early stages, often the Lig. nuchae. It limits the ventral flexion of the spine.
only the sacroiliac joints are affected. Later, the spine is like
• Lig. nuchae: The Lig. nuchae is a sagittally situated, thin, rough
a fixed rod and the back has the appearance of being
‘smoothly ironed’, the chest wall excursions are significantly plate of connective tissue between the Protuberantior occipitalis
reduced with reduced respiratory capacity. The occiput wall externa and the Proc. spinosus of the VIIth cervical vertebra
distance when standing is significantly increased. (Vertebra prominens, see below). It is fused in the area of the
neck groove with the general body fascia.
• Ligg. intertransversaria: The ligaments connect adjacent Procc.
transversi of the thoracic spine and Proc. accessori of the lumbar
Vertebral arch ligaments spine and limit lateral flexion and rotation.
The vertebral arches are also very well secured by ligaments
(› Fig. 3.51). These include: Characteristics of the individual regions of the spine
• Lig. flava: They join the Laminae arcus vertebrale and form the According to the regional differences in the movement of the spi­
posterior limit of the Foramina intervertebralior and the lateral nal sections, there is a difference between the form of the vertebral
and posterior limitation of the vertebral canal. The Ligg. flava bodies, of the spinal processes, the transverses process and the joint
have a very high proportion of elastic fibres (hence the yellow processes.
colour) and help the autochthonous back muscles (see below) Based on these characteristics, individual vertebrae can be assigned
when holding the spine straight. In the process they act against a to the respective spinal section. The specific structure of the indi-
front-facing force. vidual mobile segments lead to differences of mobility in the indi-
• Ligg. interspinalia: They join adjacent spinal processes (Procc. vidual spinal regions. These are measured according to the neu-
spinosi) and are closely connected to the tendons of the autoch- tral-null method.
thonous back muscles. At the tip of the spinal processes they

120
 3.3 Spine, spinal cord and thorax

Epiphysis anularis* Proc. articularis superior

Foramen intervertebrale
Lig. flavum
Lig. longitudinale anterius
Lig. supraspinale
Facies intervertebralis

** Lig. interspinale
Discus Anulus fibrosus
intervertebralis Nucleus pulposus
Fascia
thoracolumbalis

(Foramen venae basivertebralis)

Fig. 3.51 Lumbar mobile seg-
Pediculus arcus vertebrae ment with ligaments of the
Proc. spinosus
Lig. longitudinale posterius spine. Median section; left view.
Lamina arcus vertebrae
* also: marginal ridge,
Proc. articularis inferior ** hyaline cartilaginous covering
on the base plate

NOTE
The objectification of movement restrictions can be performed via
the Fingertip-to-Floor (FTF) test and function tests according to OTT
(thoracic spine) and SCHOBER (lumbar spine). Condylus occipitalis
• The FTF measures the distance between the finger tips and the
floor when bent forwards with straight legs. A young person should Foramen magnum
always reach the floor (finger floor distance = 0).
• In the test according to SCHOBER (› Fig. 3.52) a mark is made on
the skin at the spinal process of S1 and 10 cm cranial of this point.
At maximum flexion (forward flexion) the markings typically deviate (Crista occipitalis
5 cm apart, in the retroflexion the distance is reduced by 1–2 cm. externa)
• In the test according to OTT (› Fig. 3.52) a mark is made on the
skin above the Proc. spinosus process of the VIIth cervical vertebra Fig. 3.53 Section with the Os occipitale and the condyles for the
(Vertebra prominens) and a further 30 cm caudal of this point. At upper cranial joint. The condyles of the skull are located at the front
the maximum flexion markings typically deviate 3–4 cm apart. lateral to the Foramen magnum.
The mobility of the spine is e.g. in the case of ankylosing spondyli-
tis (BECHTEREW's disease) limited. The convex and slightly rostrally converging joint surfaces for ar-
ticulation with the first cervical vertebra (Condyli occipitales skull
Craniocervical junction conyles, skull condyles) are located at the side of the Foramen mag-
The Os occipitale and the first two cervical vertebra (atlas and axis) num in the two Partes laterales ossis occipitalis (› Fig. 3.53). Both
are connected to one another via a total of 5 joints and facilitate hinge ligaments (Lig. alaria) begin rostromedial of the Condyli oc-
the freedom of movement of the head in 3 axes. In principle, the cipitales. In the median the Faciculus Longitudinalis inserts at the
mobile segments differ in their morphological structure from those anterior margin of the Foramen magnum, the superior longitudi-
of the lower sections. nal bundle and the widely spread Membrana tectoria (› Fig.
3.56).
Os occipitale
The unpaired occipital bone (Os occipitale) consists of 3 units (Pars Atlas
basilaris, Partes laterales and Squamor occipitalis, › Fig. 9.10). The atlas (Ist cervical vertebra, › Fig. 3.54) has no vertebral body,
instead an anterior atlas arch (Arcus anterior atlantis) connects
two lateral masses (Massae laterales), on which the upper and lower
OTT joint surfaces (Facies articulares superior et inferior) for articula-
CVII tion with the skull condyles and the axis can be found (IInd cervi-
cal vertebra), as well as the transverse process with the Foramen
SCHOBER OTT transversarium for the passage of the A. vertebralis. At the front
cm 30 +
0
+5 8c the anterior atlas arch has a Tuberculum anterius. The posterior
SI atlas arch (Arcus posterior atlantis) has a trench for the A. verte-
1

bralis (Sulcus arteriae vertebralis) and a posterior tubercle (Tuber-

SCHOBER
culum posterius). A spinous process is missing.

Clinical remarks
Especially in motor vehicle accidents, there may be isolated
fractures of the atlas arches which is now happening less fre-
quently due to the improved protective devices in cars (air
bags). They have to be differentiated from atlas variants (e.g.
Fig. 3.52 Objective assessment of movement restrictions of the lum- Canalis arteriae vertebralis) or malformations (e.g. fusion of
bar spine (method according to SCHOBER) and the thoracic spine
(OTT sign).

121
3 Torso

atlas and occipital bone = atlas assimilation) as well as fre- Cranial joints
quently occurring cleft formations in the region of the verte- A differentiation is made between 2 cranial joints (› Fig. 3.56,
bral arch. › Fig. 3.57, › Fig. 3.58):
• Upper cranial joint (Articulatio atlantooccipitalis): connects the
skull with the atlas
Axis • Lower cranial joint (Articulatio atlantoaxialis): connects the at-
The axis (IInd cervical vertebra, › Fig. 3.55) has a vertebral body las and axis and is divided into the following:
which has a massive tooth-shaped projection, the Dens axis. From – Articulatio antlantoaxialis mediana (unpaired)
an evolutionary perspective the Dens axis is the former vertebral – Articulatio antlantoaxilialis lateralis (paired)
body of the Atlas. From the top of the dens axis (Apex dentis) the All of these joints are true joints (diarthroses) without interverte-
Lig. apicis dentis originates (› Fig. 3.56) and from the lateral ar- bral discs.
eas the Ligg. alaria arise laterally and wing-shaped. On the ventral In the Articulatio atlantooccipitalis the Condyli occipitales artic-
side there is a joint surface at the Dens axis (Facies articularis ante- ulate with the Facies articulares superiores atlantis (› Fig. 3.57).
rior) for articulation with the anterior vertebral arch of the Atlas, The upper articular surfaces of the atlas can be designed individu-
on the dorsal side there is an area (Facies articularis posterior) by ally and intervariably and also have biconvex joint surfaces. The
which Lig. transversum atlantis holds the Dens axis in position. joint capsule is wide (› Fig. 3.56b) and reinforced on both sides
The axis has a vertebral arch, which laterally supports the connec- by a lateral ligament (Lig. atlantooccipitale laterale).
tion from the vertebral body on the lower edge of the dens axis of 2 In the Articulatio atlantooccipitalis the atlas and the axis are
upper articular processes (Procc. articulares superiores) to the connected via 3 individual joints:
atlas and below 2 articular processes (Procc. articulares inferi- • The Articulatio atlantoaxialis mediana has 2 joint surfaces for
ores) for the articulation with the IIIrd cervical vertebra. In addi- the Dens axis. In the anterior joint chamber the Facies articularis
tion, the axis has a Proc. transversus. The Foramen transversari- anterior of the Dens axis articulates with the Fovea dentis of the
um for the vertebral artery, which is slightly slanted from lower in- anterior atlas arch (› Fig. 3.58). In the posterior joint chamber
side to upper outside, lies in this. the Facies articularis posterior of the Dens axis articulates with
the Lig. transversum atlantis (› Fig. 3.58), which originates on
both sides at the Massae laterales atlantis and crosses over the
Clinical remarks root and the main body of the Dens axis.
In road accidents, dens fractures can occur or a fracture of the • The Articulatio atlantoaxialis lateralis are made up of joint
arch root (Hangman's fracture) with the risk of cervical cord connections between the Facies articularis inferior atlantis cau-
compression. These fractures are very difficult to diagnose dal of the Massa lateralis atlantis and the Facies articularis supe-
and can occur even in young children. rior axis on both sides (› Fig. 3.56, › Fig. 3.57). Both joint
surfaces are convex and thus incongruent.

Arcus anterior atlantis Tuberculum anterius

Tuberculum anterius Fovea dentis
Foramen vertebrale Arcus anterior atlantis

Facies articularis Massa lateralis Massa lateralis Massa lateralis atlantis

superior atlantis atlantis Facies articularis inferior
Proc.
transversus
Proc.
Foramen transversus
transversarium Sulcus arteriae Foramen
vertebralis vertebrale Foramen
* transversarium
Arcus posterior
a Tuberculum posterius atlantis b Tuberculum posterius Arcus posterior atlantis

Fig. 3.54 I. Cervical vertebra, atlas. a cranial view. b caudal view. * variant: Canalis arteriae vertebralis

Apex dentis Apex dentis

Facies articularis anterior Facies articularis posterior
Dens axis
Proc. articularis superior Proc. articularis superior
Corpus vertebrae
Corpus vertebrae
Proc.
Tuberculum anterius transversus Foramen transversarium
Proc.
transversus
Tuberculum posterius Foramen
transversarium Foramen vertebrale
Proc.
articularis inferior Arcus vertebrae
Proc. articularis inferior Arcus vertebrae
Proc. spinosus
a b Proc. spinosus

Fig. 3.55 II. Cervical vertebrae, axis. a ventral view. b dorsal view.

122
 3.3 Spine, spinal cord and thorax

Cutting edge of the Lig. alarium

Lig. cruciforme atlantis Membrana tectoria
Articulatio
Lig. apicis dentis Lig. trans- Fasciculi atlantooccipitalis
versum longitudinales
Os occipitale Ligg. alaria atlantis

Articulatio
atlantooccipitalis,
capsula articularis

Capsulae
articulares Articulatio atlanto-
axialis lateralis,
Dens axis capsula articularis
Articulatio atlanto-
axialis lateralis
Axis, corpus
Membrana tectoria
a b (downwards)

Fig. 3.56 Cranial joints with deep ligaments. Dorsal view. a Upper and lower cranial joint, joint capsules, Lig. cruciforme atlantis. b Ligg. alaria
and Lig. apicis dentis.

Ligaments the anterior Atlas arch. In the area of the joint surface, the liga-
The stability of the craniocervical junction is ensured by an elabo- ment is made of fibrous tissue. A Fasciculus longitudinalis su-
rate ligament back-up, which still allows maximum freedom of perior runs in the vertical direction from the front edge of the
movement. A multi-layer structure of the ligament structures pre- Foramen magnum to the Lig. transversum atlantis; a Fasciculus
vents dislocation of the vertebral bodies, ensuring the integrity of longitudinalis inferior comes from the rear surface of the axis
the vertebral canal with the structures important for the vital func- body and radiates caudally into the Lig. transversum atlantis.
tions of the Medulla oblongata and the cervical cord: The Lig. cruciforme atlantis inhibits the forward inclination of
• Membrane atlantooccipitalis anterior (› Fig. 3.57, › Fig. the head with both units.
3.58): This passes as a continuation of the Lig. longitudinale an- • Ligg. alaria (› Fig. 3.56a): The wing ligaments extend to the
terius extending from the anterior atlas arch to the underside of side from the Dens axis to the medial edge of the Foramen mag-
the occipital bone in front of the Foramen magnum and inhibits num and limit the rotation in the Articulatio atlantoaxialis me-
extension of the head. diana as well as the forward inclination of the head.
• Membranor atlantooccipitalis posterior (› Fig. 3.58): This • Lig. apicis dentis (› Fig. 3.56a, › Fig. 3.58): Extends from the
moves from the posterior atlas arch to the dorsal margin of the Apex dentis to the anterior edge of the foramen magnum and
Foramen magnum and inhibits flexion of the head. inhibits forward inclination of the head.
• Membrana tectoria (› Fig. 3.56b, › Fig. 3.58): This continues
the Lig. longitudinale posterior and runs from the posterior edge
of the axis body to the anterior edge of the foramen magnum
Clinical remarks
and to the Clivus. It limits the forward tilt of the head. In the case of a cervical fracture the Lig. transversum atlantis
• Lig. cruciforme atlantis (› Fig. 3.56b, › Fig. 3.58): The liga- or the Lig. cruciforme atlantis tear. The Dens axis tilts dorsally
ment consists of several units that cross in their fibre d
­ irection. into the vertebral canal and presses on the Medulla oblonga-
The Lig. transversum atlantis extends between the two Massae ta, in which the respiratory and circulatory centres are located,
and on the spinal cord. This results in immediate death.
laterales of the atlas, runs behind the Facies articularis posterior
of the dens axis and as such holds the Dens axis in position at

Os occipitale, Pars basilaris Membrana atlantooccipitalis anterior

Os occipitale, Pars lateralis Os occipitale, Pars lateralis

Articulatio atlantooccipitalis Capsula articularis

Atlas

Articulatio atlantoaxialis lateralis Lig. longitudinale anterius

Axis
Discus intervertebralis
Fig. 3.57 Cranial joints with lig-
Vertebra cervicalis III Vertebra cervicalis III, Corpus vertebrae aments and upper cervical
spine.

123
3 Torso

Occasionally, a missing or incomplete formation of the Dens mobility results from the interaction with the other mobile seg-
axis may cause an atlantoaxial subluxation. Injury to the liga- ments in the cervical spine.
ments of the cranial joints can cause atlantoaxial instability. The upper cranial joint is a ellipsoid joint, which enables the nod-
Such injuries are often overlooked in clinical practice, as the ding movements of the head around a transversal axis of a total of
patient reactively shows increased muscle tension (protection
20–35°. Around a sagittal axis, minor side movements of 10–15°
spasm). Symptoms of such atlantoaxial instabilities are often
intermittent circulatory disorders of the vertebral arteries, the are possible.
A. carotis interna and the V. jugularis with a dazed feeling, diz- The lower cranial joint is a hinge joint and its vertical axis runs
ziness, visual disturbances (Mouches volantes = seeing through the Dens axis. It allows rotational movements of a total of
stars), headache and nausea. 35–55° and a small nodding movement.

IIIrd–VIIth cervical vertebrae

NOTE Characteristics
The cranial joints are at the height of the oropharynx. When the One can only refer to characteristic cervical vertebrae (Vertebrae
mouth is open and a finger is inserted as far as the pharyngeal cervicales) for the IIIrd–VIIth cervical vertebrae, because only
wall, this lies at the height of the atlantoaxial joint. these 5 are similarly structured (› Fig. 3.59). The overall relatively
small vertebrae have an approximately rectangular shape. Special
features of the cervical vertebrae are:
Mechanisms • The margins of the cervical vertebrae each have an upturned
Together, the two cranial joints act like a ball joint, which enables process with sagittal alignment (Proc. uncinatus; syn.: Uncus
all-round movements of the head; however, the overall extent of corporis). When viewed from the front it looks as if the lateral
edges of the vertebral body cover plates are bent upwards
Os occipitale
(› Fig. 3.59a).
Membrana
• The transverse process consists of a posterior part (Tuberculum
atlantooccipitalis posterius), the actual transverse process and a front portion
anterior (Tuberculum anterius), which corresponds to the rib rudiment
Lig. trans- Lig. apicis dentis (› Fig. 3.59b). The transversus process has a lateral-directed
versum atlantis deepening for the course of spinal nerve branches (Sulcus nervi
Membrana tectoria
Arcus anterior spinalis) and the IIIrd–VIth cervical vertebrae usually have a
atlantis
Membrana atlanto- Foramen transversarium for the passage of the A. vertebralis.
occipitalis posterior • The articular processes are flat and incline approximately 45° to
Articulatio the rear (› Fig. 3.59b).
atlantoaxialis M. rectus capitis
mediana posterior minor • The spinal process of the vertebral bodies III–VI are short and
Dens axis Dura mater bifurcated (bipartite, › Fig. 3.59b).
• The Tuberculum anterius of the VIth cervical vertebra is palpa-
ble from ventral (Tuberculum caroticum).
• The interspinous process of the VIIth cervical vertebra is long
and well palpable (Vertebra prominens) from the outside.
Lig. longi-
tudinale
anterius Uncovertebral joints
Lig. nuchae
Around the 10th year of life, at the upper spine (IIIrd–VIth cervical
Discus inter- Foramen Lig. interspinale vertebrae) there is a physiological fissure formation in the lateral
vertebralis intervertebrale portions of the Disci intervertebralis. This creates new joint-like
Lig. longitudinale posterius connective tissue structures, which are referred to as uncovertebral
joints (Hemiarthroses uncovertebrales, VON LUSCHKA’s joints)
Fig. 3.58 Cervico-occipital transition region with intermediate atlan- (› Fig. 3.60). The cleft formation often continues to the Nucleus
toaxial joint and ligamentous apparatus. Median sagittal section, left pulposus, so that the intervertebral disc is virtually halved horizon-
view.

Foramen Uncus corporis

transversarium [Proc. uncinatus]
Corpus Facies articularis
Tuberculum anterius
vertebrae superior Proc. articularis
superior
Uncus corporis Sulcus n. Proc. transversus
Proc. articularis [Proc. uncinatus] spinalis Facies articularis
superior superior
Proc. Corpus
Tuberculum spinosus vertebrae
posterius

Tuberculum Foramen
Tuberculum Sulcus n. vertebrale Proc. articularis Sulcus n. Foramen
Corpus posterius
anterius spinalis inferior spinalis transversarium
vertebrae
a b Proc. spinosus c

Fig. 3.59 Cervical vertebra. a Ventral view. b Dorsal view. c Right lateral view. [L266]

124
 3.3 Spine, spinal cord and thorax

Nucleus pulposus Clinical remarks

*
** In advanced age there are often degenerative changes of the
Uncus corporis cervical vertebrae, which are manifested as osteochondrosis
[Proc. uncinatus] vertebralis expressed as formation of dorsal osteophytes and
Anulus fibrosus
can lead to narrowing of the vertebral canal with spinal cord
compression.
Osteoarthritis of the vertebral joints and degenerative chang-
Pediculus arcus vertebrae es in the uncovertebral joints are also frequently associated
Corpus vertebrae
with osteophyte formation and can restrict the Foramina inter-
vertebralis and Foramina transversalia. Possible consequenc-
es are a spinal nerve symptom or pressure on the A. vertebra-
** lis and the sympathetic nerve system.
N. spinalis,
Ganglion sensorium
nervi spinalis

A. vertebralis Thoracic vertebrae

Characteristics
Fig. 3.60 Uncovertebral joints; * hyaline cartilaginous coverages of The vertebral bodies of the thoracic spine (Vertebrae thoracicae,
the end plates; ** so-called uncovertebral cleft. › Fig. 3.61) are dorsally indented, so that the base and top plates
have a heart shape. They are lower ventrally than dorsally and thus
tally. This creates structure loosening, which is compensated by the enable thoracic kyphosis. As a special feature, the Ist–IXth thoracic
strong ligaments. On the lower cervical spine the uncovertebral vertebral body dorsolaterally have cranial and caudal joint surfaces
joints are usually only weakly developed. (Foveae costales superior et inferior). An Fovea costalis inferior
It is discussed that these joints allow ventral and dorsal move- always forms a common joint cavity with a Fovea costalis superior
ments, while lateral movements are restricted; however, the func- facet of the underlying vertebra for a rib head (Articulatio capitis
tion has not been conclusively clarified. costae, rib head joint, › Chapter 3.3.4). The Xth and XIth thoracic
vertebral body only have a Fovea costalis. In the case of the XIIth
Mechanisms thoracic vertebral body, the Fovea costalis posterior lies centrally
In the cervical spine below the cranial joints, anteflexion and dorsal on the vertebral body. The transverse processes are inclined to-
flexion as well as lateral flexion and rotational movements to a cer- wards dorsolateral and the Ist–Xth vertebral bodies have joint sur-
tain extent are possible. Overall, the cervical spine is very flexible faces (Foveae costales processus transversi) for connection to the
(› Fig. 3.46). costotransverse joints (Articulationes costotransversariae,
› Chapter 3.3.4). The upper articular processes (Procc. articu-
lares superiores) are directed dorsally and the lower (Procc. artic-

Procc. articulares superiores

Corpus vertebrae Proc. transversus

Arcus vertebrae
Proc. spinosus
a

Epiphysis anularis* Corpus vertebrae, Facies intervertebralis Proc. articularis superior

Fovea costalis superior
Fovea costalis superior Articulatio capitis costae
Proc. transversus Corpus vertebrae
Pediculus arcus Caput costae
vertebrae Fovea costalis
Collum costae
processus transversi
Foramen vertebrale
Foramen costotransversarium
Proc. articularis
Costa ** Fovea costalis inferior
[Zygapophysis] superior
Incisura vertebralis inferior
Fovea costalis c Proc. articularis inferior
processus transversi
Tuberculum costae Proc. spinosus
Proc. transversus
Proc. spinosus Lamina arcus Articulatio
b vertebrae costotransversaria

Fig. 3.61 Thoracic vertebra. a Ventral view; * marginal ridge. b Dorsal view. c Right lateral view; ** region of the vertebral arch between the
superior and inferior joint extension (so-called isthmus = interarticular portion).

125
3 Torso

Proc. articularis superior Facies intervertebralis superior*

Proc. costalis

Corpus vertebrae Facies intervertebralis

inferior**

Facies articularis Proc. articularis inferior

inferior
a

Epiphysis anularis
Corpus vertebrae, Facies Incisura vertebralis superior Facies intervertebralis*
intervertebralis superior*
Proc. articularis
Pediculus arcus superior
vertebrae Foramen vertebrale
Proc. costalis

Proc. spinosus
Proc. costalis Proc. accessorius Corpus
vertebrae

Proc. articularis superior

Proc. mamillaris Incisura vertebralis
inferior
Lamina arcus vertebrae Proc. spinosus
Proc. articularis Facies articularis
b c inferior inferior

Fig. 3.62 Lumbar vertebra. a Ventral view. b Dorsal view; * cover plate, ** base plate. c Right lateral view. [L266]

ulares inferiores) ventrally. The joint surfaces are located approxi- ables extension and flexion and brakes rotational movements. Due to
mately in the frontal plane (› Fig. 3.49). The spinous processes are the condylar position of the joint processes, the rotary motion takes
long and aligned caudally. They overlap like roof tiles and protect place between the lumbar vertebral vein and the sacrum. A lateral
the Canalis vertebralis (› Fig. 3.44c). flexion is extensively possible in the lumbar spine (› Fig. 3.46).

Mechanisms Sacrum
The vertebrae are connected to the chest wall. In spite of the larger The sacrum (Os sacrum; › Fig. 3.63) is composed of 5 sacral ver-
number of vertebrae, the thoracic spine is less mobile than the oth- tebrae that in adolescence are still connected via cartilage and later
er sections of the spine. Slight ventral flexion and dorsal flexion fuse synostotically; however, in later life disc tissue can still be
movements and lateral flexion and rotational motions are possible found between the synostotically connected former vertebral bod-
(› Fig. 3.46). ies. The sacrum is connected to the two hip bones (Ossa coxae) via
the Articulationes sacroiliacae and shows significant gender differ-
Lumbar vertebrae ences (› Table 3.7). The base (Basis ossis sacri) is connected via a
Characteristics large intervertebral disc to the lumbar vertebral vein. The front
The vertebral bodies of the lumbar spine (Vertebrae lumbales, edge of the sacrum base bulges ventrally into the lumbosacral tran-
› Fig. 3.62) are large; the transverse diameter is larger than the sition and into the pelvis (Promontorium). On the front surface
sagittal, the base and top plates are ventrally retracted into a kidney (Facies pelvica) the original borders of the sacral vertebrae can be
shape. They are higher ventrally than dorsally and thus enable lum- recognised as Lineae transversae (› Fig. 3.63a). The Foramina
bar lordosis. The long and laterally oriented processes are referred intervertebralia has merged to bony channels, which have 4 open-
to as Proc. costalis (rib process). The actual transverse processes ings at the front (Foramina sacralia anteriora) for the ventral spi-
lie as rudiments at the base of the Procc. costales and are called nal nerve branches. Dorsally, (Facies dorsalis) multiple longitudi-
Procc. accessorii. The articular processes are aligned dorsally. The nally running strips are present (› Fig. 3.63b):
Proc. articularis superior dorsally bears a hump (Proc. mamillar- • Crista sacralis mediana (unpaired): they are located in the area
is). With the exception of the lumbar vertebral vein the joint sur- of the former spinous process.
faces are aligned in the sagittal plane (› Fig. 3.49). The spinous • Crista sacralis medialis (paired): located in the area of the for-
processes are almost straight and aligned dorsally. mer articular process.
• Crista sacralis lateralis (paired): located in the area of the for-
NOTE mer transverse process.
In clinical terms both the Procc. costales as well as the Procc. ac-
cessorii of the lumbar vertebrae are often summarised as Procc. Table 3.7 Gender differences of the sacrum (Os sacrum).
transversi in the analogy to the other spinal sections.
Form Women Men
Length Shorter Longer
Mechanisms Expression Wider Narrower
The sagittal position of the joint surfaces of the Articulationes zyga-
Curvature Weaker Stronger
pophyseales in the upper 4 mobile segments of the lumbar spine en-

126
 3.3 Spine, spinal cord and thorax

Proc. articularis superior Promontorium Basis

ossis sacri

Basis ossis
sacri Ala
Pars ossis sacri
lateralis
Pars
Ala ossis sacri
lateralis
Crista sacralis medialis
Proc. articularis superior (intermedia)
Promontorium
Canalis sacralis Crista sacralis mediana

Lineae transversae Foramina sacralia c

anteriora

a Apex ossis sacri

Canalis sacralis Proc. articularis superior Pars lateralis

Canalis sacralis
Proc. articularis Basis ossis sacri
superior Tuberositas ossis sacri Foramina sacralia
posteriora
Promontorium
Facies Crista sacralis
Crista sacralis mediana
auricularis lateralis (intermedia) Facies pelvica

Sometimes remnants
Crista sacralis medialis of ligament disc tissue,
Hiatus sacralis often incomplete fusion
Crista sacralis of the sacral vertebrae
mediana d
Foramina sacralia Apex ossis sacri
posteriora

Hiatus sacralis
Cornu sacrale
b Apex ossis sacri

Fig. 3.63 Sacrum, Os sacrum. a Ventral view. b Dorsal view. c View from above. d Mediosagittal section.

Caudally to the Crista sacralis mediana is the access to the sacral lage to the sacrum. In younger people there can also be an interver-
canal (Canalis sacralis), in form of the Hiatus sacralis. The Fora­ tebral disc.
mina sacralia posteriora are the exit points of the dorsal spinal
nerve branches. The region at the side of the rear openings is re- Vascular, lymphatic and nervous systems
ferred to as the Pars lateralis. On their lateral surface are the Facies Arteries
auricularis which are the joint surfaces for articulation and the Tu- Cervical spine
berositas ossis sacri for fibrous connection with the Os ilium of the The mobile segments of the cervical spine are supplied with blood
hip bone (sacroiliac joint, Articulatio iliosacralis, › Chap. 5.2.3). via the branches of the A. carotis externa (A. occipitalis) and the
A. subclavia (A. vertebralis, A. cervicalis profunda from the Trun-
Coccyx cus costocervicalis, A. transversa colli from the Truncus thyrocer-
The coccyx (Os coccygis; › Fig. 3.64) is normally constructed of vicalis).
3–5 rudimentary vertebrae. Only the two coccygeal horns (Cornua The A. vertebralis arises on the rear wall of the A. subclavia. It is
coccygea) of the Ist coccygeal vertebra as rudiments of the upper divided into 4 sections:
articular process enable the origin as vertebrae to be recognised. • Pars prevertebralis: Course on the M. longus colli to the Foramen
The Cornua coccygea can articulate with rudiments of the left and transversarium of VIth cervical vertebra (approx. 90% of cases).
right lower articular processes of the sacral vertebral vein (Articu- Also a shorter distance to the VIIth cervical vertebra (approxi-
latio sacrococcygea). The coccyx is otherwise connected by carti- mately 2% of cases; then the VIIth cervical vertebra also has Fo-

Cornu
coccygeum Cornu Vertebra coccygea I
coccygeum

Vertebra coccygea I

Vertebra coccygea II
Vertebrae coccygeae II–IV
Vertebrae coccygeae III–V
a b Fig. 3.64 Coccyx, Os coccygis.
a Ventral view. b Dorsal view.

127
3 Torso

ramina transversaria) or a longer distance with entry into the Vth, canal, and supply the meninges (Rr. spinales) and the spinal
IVth or IIIrd cervical vertebrae is possible (› Fig. 10.14). cord (Rr. radiculares). Rr. musculares run to the deep neck
• Pars transversaria: Course through the Foramina transversaria, muscles.
accompanied by the Plexus venosus of the V. vertebralis and the • Pars atlantica, Pars intracranialis: Chap. 11.1.5.
Plexus vertebralis (sympathetic nerve network around the A. In the posterior cranial fossa the right and left A. vertebralis con-
vertebralis). From the Pars transversaria segmental branches nect to the A. basilaris on the clivus. Further details of the A. verte-
emit through the Foramina intervertebralia into the vertebral bralis are presented in Chap. 11.1.5.

A. lumbalis Aorta

R. ventralis

R. dorsalis

R. cutaneus medialis

R. cutaneus lateralis

A. lumbalis

R. cutaneus medialis R. spinalis

R. cutaneus
lateralis
a

Lig. longitudinale posterius

(V. basivertebralis)
Plexus venosus vertebralis
Plexus venosus vertebralis
externus anterior
internus anterior

Plexus venosus vertebralis V. lumbalis ascendens

internus posterior

(V. intervertebralis)

Plexus venosus vertebralis

externus posterior

Discus intervertebralis, Anulus fibrosus

Lig. longitudinale anterius

Lig. longitudinale posterius R. meningeus

Ganglion trunci sympathici
Capsula articularis
R. communicans albus

(R. medialis) R. communicans griseus

Truncus nervi spinalis Fig. 3.65 Vascular, lymphatic
(R. lateralis) and nervous systems of the spi-
R. anterior
Ganglion sensorium nervi spinalis nal canal. Right oblique view.
c R. posterior a Arteries [L266]. b Veins.
c Nerves.

128
 3.3 Spine, spinal cord and thorax

NOTE On the thoracic and lumbar spine the vein networks drain via the
During operations on the throat area it is always to be expected
that the A. vertebralis shows a ‘high entry’ into the cervical verte-
Vv. intercostales posteriores or Vv. lumbales into the azygos system
brae and thus can run as a strong arterial vessel outside the cervi- (Vv. azygos, hemiazygos et hemiazygos accessoria, › Fig. 3.16) and
cal vertebrae. via the vein networks of the pelvis into the V. iliaca interna.

Innervation of the vertebral arch joints

Thoracic and lumbar vertebral column The innervation of the joint capsule of the vertebral arch joints
A strictly segmental arterial supply is at the height of the thoracic takes place from the Rr. mediales of the Rr. posteriores of the spinal
and lumbar spine. Eleven paired Aa. intercostales posteriores, the nerves (› Fig. 3.65c).
paired A. subcostalis and 4 paired Aa. lumbales exit as segmental
branches from the Aorta thoracica or the Aorta abdominalis to
supply the adjacent vertebrae with blood (› Fig. 3.13). 3.3.3 Spinal cord site
The arteries each emit a R. dorsalis from which a R. spinalis pass-
es through the Foramen intervertebrale of the corresponding mo- Spinal canal
bile segment and enters the vertebral canal (› Fig. 3.65a). The seg- The vertebral canal (also spinal canal; Canalis vertebralis) extends
mental spinal arteries anastomose at different heights in the verte- from the Foramen magnum of the Os occipitale to the Hiatus sacra-
bral canal via ascending and descending branches. The posterior lis of the sacrum. It follows the curvature of the spine in the presacral
artery branches each reach the arch plates (laminae) and the spino- area and at the height of sacrum is referred to as the sacral canal.
sus processes from the inside. The terminal branches of the Rr. In the presacral, free part of the spine, the vertebral canal is limit-
posteriores are the Rr. cutanei mediales and Rr. cutanei laterales, ed ventrally by the vertebral bodies, the intervertebral discs and the
which run parallel with the dorsal spinal nerve branches of the posteriorly attached Lig. longitudinale posterius (› Fig. 3.51). Lat-
same name, supply blood to the posterior bony structures from the erally and dorsally it is limited by the vertebral arches and the con-
outside and their end branches penetrate the dorsal back muscles necting Ligg. flava and the Lig. interspinale. The intvertebral formi-
and supply the skin. na (Foramina intervertebralia) lie laterally between the individual
vertebrae.
Sacrum and coccyx The caudal section of the vertebral canal is the sacral canal (Cana-
The supply of the sacrum takes place via the A. sacralis mediana lis sacralis, › Fig. 3.63), which is bordered on all sides by bone
running along the ventral side from the abdominal aorta (› Fig. and is covered with offshoots of the Lig. longitudinale posterius. It
3.41) and via the lateral sacral arteries (Aa. sacrales laterales) from ends at variable heights in the Hiatus sacralis. The Foramina sacra-
the A. iliaca interna. The lateral sacral arteries emit Rr. spinales lia anteriora connect the sacral canal with the pelvic space and the
into the Foramina sacralia pelvina and reach the coccyx as termi- Foramina sacralia dorsalia with the sacral region.
nal branches.

Veins
Clinical remarks
The venous drainage from the spine and the spinal cord takes place A narrowing of the vertebral canal is referred to as a spinal ca-
via venous networks (› Fig. 3.65b). The veins are valveless and nal stenosis. The cause is often bony projections (spondylo-
have connections to the veins in the skull and the azygos system. phytes) of the vertebral body or the intervertebral joints,
They can be divided into an outer and inner venous network: which emerge during degenerative changes of the spine. The
patients report radicularly radiating pain of the affected seg-
• Outer venous system:
ments. The pain often increases when walking. In this case it
– The Plexus venosus vertebralis externus anterior is to the is known as a claudicatio spinalis.
side and in front of the vertebral body and includes veins that
come from the lateral surface of the vertebral body and the
neighbouring ligaments.
– The Plexus venosus vertebralis externus posterior is to the Spinal meninges
side and behind the arch roots and the spinous processes. It Hard spinal meninges
takes up the blood from these, the neighbouring ligaments, The hard meninges (Dura mater encephali) passes into the hard
the autochthonous back muscles and the skin on the back. spinal meninges at the Foramen magnum (Dura mater spinalis).
• Inner venous system: At the craniocervical junction the Dura mater spinalis is firmly
– The Plexus venosus vertebralis internus anterior is located connected via the periosteum to the bony wall of the foramen mag-
on the rear of the vertebral body in the vertebral canal lateral- num and of the vertebral canal. Below the axis, there are only a few
ly to the Lig. longitudinale posterius and take blood from the connections between the Dura mater spinalis and the vertebral
vertebral bodies, which is supplied from the Vv. basiverte- arches (› Fig. 3.66a). Lateral bulges of the Dura mater spinalis ex-
brales (a horizontally running vein network in the cancellous tend into the Foramina intervertebralia. The dural sac usually ends
bone of the vertebral body). It also drains blood from the spi- caudally at the height of the IInd sacral vertebrae and from there
nal cord (Vv. spinales anteriores). goes over into the thin offshoots of the Filum terminale (also
– The Plexus venosus vertebralis internus posterior is located › Chap. 12.6.2).
on the inside of the vertebral arches and drains the blood
from the vertebral arches and the neighbouring ligaments, as Soft spinal meninges
well as from the spinal cord (Vv. spinales posteriores). The two soft meninges (Leptomeninx encephali, consisting of the
The outer and inner venous systems are connected with abundant Arachnoidea mater encephali and Pia mater encephali) continu-
anastomoses. In the craniocervical junction there is a link between ously pass into the soft spinal meninges, (Leptomeninx spinalis).
extracranial and intracranial veins. In the throat area the venous The outer lamina of the Arachnoidea mater spinalis attaches to
plexuses drain into the V. vertebralis and the V. cervicalis profunda. the inner surface of the Dura mater spinalis (› Fig. 3.66b). The

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3 Torso

Truncus nervi spinalis, R. communicans

Truncus nervi spinalis, R. anterior
Epineurium Ganglion sensorium nervi spinalis
Truncus nervi spinalis, R. posterior Dura mater spinalis
Ganglion sensorium nervi spinalis
N. spinalis, Radix anterior
Truncus nervi spinalis, R. meningeus
Lig. denticulatum
Spatium subarachnoideum
N. spinalis, Radix posterior
(Spatium subdurale)
Pia mater spinalis
Dura mater spinalis
Spatium epidurale; Plexus venosus
vertebralis internus posterior
a Periosteum Arachnoidea mater spinalis

Lig. longitudinale posterius

Filum terminale
Plexus venosus vertebralis internus anterior
Truncus nervi spinalis, R. meningeus
Cauda equina

Ganglion trunci sympathici

N. spinalis, Radix anterior
Truncus nervi spinalis, R. communicans

Truncus nervi spinalis, R. anterior Ganglion sensorium nervi spinalis

Truncus nervi spinalis, R. posterior N. spinalis, Radix posterior

R. lateralis Arachnoidea mater spinalis
R. medialis (Spatium subdurale)
Spatium subarachnoideum Dura mater spinalis
Pia mater spinalis Spatium epidurale
b Lig. flavum Periosteum

Fig. 3.66 Content of the spinal canal (Canalis vertebralis); cranial view. a Cross-section at the height of the cervical vertebral vein. b Cross-sec-
tion at the height of the IIIrd lumbar vertebra.

subarachnoid space is between the Arachnoid mater spinalis and Clinical remarks
Pia mater spinalis (Spatium subarachnoideum), which shows
continuity with the intracranial subarachnoid space and contains Through a puncture of the subarachnoid space Liquor cerebro-
the Liquor cerebrospinalis. spinalis can be removed for research purposes, or medication
can be administered in the fluid space. In most cases, the Cis-
The Pia mater spinalis is firmly attached to the spinal cord and the terna lumbalis (in the area of the Cauda equina) is punctured
spinal nerve roots (› Fig. 3.66). The spinal cord and the spinal for this (lumbar puncture). It lies caudally to the spinal cord
nerve roots, the spinal ganglion and the Truncus nervi spinalis are below the IInd lumbar vertebra, usually between the spinous
surrounded by Liquor cerebrospinalis. The subarachnoid space is processes L3/L4 or L4/L5 and has the advantage that the spi-
traversed by thin trabeculae of the Arachnoidea spinalis. The Lig. nal nerve roots in the subarachnoid space can avoid the punc-
denticulatum extends laterally as a loose connective tissue plate ture needle and injury to the spinal cord can be excluded. The
through the subarachnoid space into the Foramina intervertebralia puncture needle is inserted through the Ligg. supraspinale et
interspinale, the epidural space, the Dura mater, and the
(› Fig. 3.67a). There it separates and stabilises the two spinal Arachnoidea until the needle enters the subarachnoid space.
nerve roots. Alternatively, a suboccipital puncture is also possible, in
Extensions of the subarachnoid space are referred to as cisterns: which the Cisterna cerebellomedullaris is punctured at the
• At the craniocervical junction there is a posterior extension of craniocervical junction (more often in children).
the subarachnoid space due to the attachment of the Dura mater
spinalis on the wall of the vertebral canal (Cisterna rebello­
medullaris, › Chap. 11.4.4).
• Caudally to the spinal cord are the spinal nerve roots (Cauda Spinal cord
equina) in the cerebrospinal fluid-filled subarachnoid space The spinal cord (Medulla spinalis) lies protected, surrounded by
(› Fig. 3.67b). This area is also referred to as the Cisterna lum- the spinal cord meninges within the vertebral canal (› Fig. 3.66a).
balis. It does not fill the vertebral canal completely, so that the dural sac
lies in the loose connective tissue of the epidural space. The caudal
end of the spinal cord is referred to as the Conus medullaris (also
› Chap. 12.6.2). The growth in length of the spinal cord lags be-
hind compared to the length growth of the axial skeleton. In neo-

130
 3.3 Spine, spinal cord and thorax

Dura mater spinalis

Arachnoidea mater spinalis
N. spinalis, Fila radicularia
A. spinalis anterior, R. radicularis anterior
Proc. articularis superior

Lig. denticulatum
Truncus nervi spinalis, R. posterior
Ganglion sensorium nervi spinalis Truncus nervi spinalis, R. anterior
Arcus vertebrae Spatium subarachnoideum

Rr. spinales Arachnoidea mater spinalis

(A. intercostalis posterior)
R. meningeus
Fovea costalis processus transversi
Plexus venosus vertebralis
internus anterior
R. interganglionaris
Lig. longitudinale posterius
Truncus sympathicus;
Rr. communicantes Corpus vertebrae

a Ganglion trunci sympathici Lig. longitudinale anterius

Spatium epidurale Vertebra lumbalis II, Proc. costalis

Lig. flavum
Ganglion sensorium
nervi spinalis M. quadratus lumborum
N. spinalis
R. anterior Plexus venosus vertebralis
R. posterior internus posterior

Rr. dorsales (A.; V. lumbalis) Dura mater spinalis

Radices anterior et posterior Arachnoidea mater spinalis

V. spinalis posterior Pia mater spinalis

Lig. intertransversarium
Cauda equina
Proc. articularis superior
R. anterior
M. intertransversarius
Radix anterior lateralis lumborum
Radix posterior M. intertransversarius
Dura mater spinalis medialis lumborum

Arachnoidea mater spinalis Lig. iliolumbale

Os sacrum, Pars lateralis
Spatium epidurale; Plexus venosus
vertebralis internus anterior Os sacrum, Proc. articularis superior
b (Spatium subdurale) Pia mater spinalis Spatium subarachnoideum

Fig. 3.67 Opened spinal canal. a Thoracic spine with spinal cord (Medulla spinalis) and sympathetic trunk (Truncus sympathicus); ventral
view. b Lumbar spine with Cauda equina; dorsal view.

nates the spinal cord ends at the height of the IIIrd lumbar verte- and sacral spinal cord, which partially run over a long distance
bra, in adults it is usually between the Ist and IInd lumbar verte- caudally to the Conus medullaris in the subarachnoid space, are
brae. amalgamated as the Cauda equina (horse tail). The almost vertical
In the area of the entry and exit points of the spinal nerve roots for course of the caudal spinal nerve roots changes direction when it
the extremities, the spinal cord is thickened: enters into the horizontally aligned intervertebral foramina
• Intumescentia cervicalis: between the IIIrd cervical vertebra (› Fig. 3.67).
and the IIIrd thoracic vertebra with the spinal nerve roots for the
Plexus cervicalis and the Plexus brachialis Intervertebral foramina
• Intumescentia lumbosacralis: between the Xth thoracic verte- Bony and ligamentary borders
bra and the Ist lumbar vertebra with the spinal nerve roots for The intervertebral foramina (Foramina intervertebralia) are
the Plexus lumbosacralis formed in the presacral section of the spine by contractions (Inci-
surae vertebrales inferior et superior), which are created between
Spinal nerve roots adjacent vertebrae dorsal to the vertebral bodies and the interverte-
Lateral to the spinal cord, the entry and exit points of the spinal bral disc and ventral of the vertebral arch joints in the area of the Pe-
nerve roots are located (Radices anteriores et posteriores, › Fig. diculi arcus vertebrae (› Fig. 3.51). Since the Foramina interverte-
3.66, › Fig. 3.67). Because the spinal cord grows more slowly than bralia are formed by 2 articulated interconnected vertebrae, the di-
the axial skeleton, the spinal nerve roots run in the subarachnoid ameter of the Foramina changes during movement in the respective
space at the height of the cervical spine almost horizontally to the motion segment. At the lumbar spine, the foramina intervertebralia
intervertebral foramina, while they steeply extend caudally at the are limited dorsally by the Ligg. flava (› Fig. 3.51, › Fig. 3.68).
height of the lumbar spine. The spinal nerve roots of the lumbar

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3 Torso

R. meningeus Radix anterior Radix posterior

R. anterior Truncus nervi spinalis (L3)
Spatium
R. communicans subarachnoideum
R. posterior
Lig. flavum

Discus intervertebralis,
Anulus fibrosus

a b

Fig. 3.68 Foramen intervertebrale using the example of the lumbar spine; left view. a Content of the Foramen intervertebrale. b Sagittal sec-
tion at the height of the Foramen intervertebrale. [S010-17]

Contents closes the thoracic cavity (Cavitas thoracis). Functionally the chest
The intervertebral foramina are each 7–10 mm deep and can there- forms a stable protective enclosure for vital organs, such as the
fore be considered as connecting canals between the vertebral ca- heart and lungs; it is the attachment point for many muscles (in-
nal and the paravertebral region. Each Foramen intervertebrale cluding the diaphragm) and enables breathing through the mov-
contains: able ribs.
• the posterior spinal nerve root (Radix posterior) with the spinal The upper chest opening (Apertura thoracis superior) is limited
ganglion (Ganglion spinale) by the first thoracic vertebra, both first ribs and the Manubrium
• the anterior spinal nerve root (Radix anterior), which usually sterni. The lower chest opening (Apertura thoracis inferior) is sig-
consists of several bundles nificantly greater than the upper. It is limited by the XIIth thoracic
• the retrograde R. meningeus for the innervation of the meninges vertebra, in each case by the XIIth ribs, the cartilaginous ends of
• the R. spinalis of the segment artery the Xth and XIth ribs and the cartilaginous costal arch (Angulus
• Connecting veins for connection between the Plexus venosus infrasternalis) as well as the Proc. xiphoideus of the sternum.
vertebralis internus and Plexus venosus vertebralis externus. The shape of the thorax goes through age and gender-specific
The Radix posterior, Radix anterior and R. meningeus are located changes and also displays individual differences. In newborns the
as parts of the spinal segment in the subarachnoid space and are thorax is still bell-shaped and the ribs are almost horizontally
sheathed by hard meninges. The R. spinalis of the segment artery aligned. Therefore, an infant breathes far more abdominally. With
and the connecting veins lie in the epidural space of the Foramen the growth in length, the course of the ribs becomes more cres-
intervertebrale, embedded in loose connective tissue. Outside of cent-shaped. This is the mechanical prerequisite for more efficient
the Foramen intervertebrale is the merging point of the spinal thoracic breathing.
roots to the spinal nerve stem (Truncus nervi spinalis).
Ribs
Normally there are 12 rib pairs (Costae). Most of the ribs in young
Clinical remarks adults are formed from a larger bony and a smaller cartilaginous
An osteophyte formation in arthrosis of the vertebral arch portion. A differentiation is made depending on whether the ribs
joints (Osteochondrosis vertebralis) or the uncovertebral have contact to the sternum or to the cartilaginous costal arch or
joints (on the cervical spine) can constrict the Foramina inter- have no contact with the sternum or rib arch (› Fig. 3.70):
vertebralia and as such damage the spinal nerve roots or the • True ribs (Costale verae, ribs I–VII), their rib cartilage is di-
spinal nerve stem. Patients complain in most cases of radiat-
rectly connected and articulated to the sternum
ing radicular pain or even muscle paresis depending on the
spinal cord segment affected. • False ribs (Costal spuriae, ribs VIII–XII), they are not directly
connected with the sternum
• Free ribs (Costae fluctuantes, ribs XI and XII, variably also the
Xth rib), they end free between the pectoral muscles
The VIIIth and IXth ribs, as well as the Xth rib, are involved in the
3.3.4 Thorax development of the rib arch (Arcus costae) in approximately one
third of the cases. In doing so, the cartilaginous parts accumulate
Bony thorax and joints from below on the next higher rib.
The chest (Cavea thoracis, thorax, › Fig. 3.69) is formed from:
• 12 thoracic vertebrae (Vertebrae thoracicae I–XII) Basic structure of the ribs
• 12 pairs of ribs (Costae I–XII) The bony part of the rib (Os costae) is articulated in contact with
• Breastbone (Sternum) the vertebrae and continues forward as cartilage (Cartilago costa-
The rib pairs I–X are connected via the rib cartilage and the lis). On the Os costae, a distinction is made between (› Fig. 3.71):
rib-sternal joints with the sternum. Dorsally the ribs articulate with • Rib head (Caput costae): articulates with the thoracic vertebral
the thoracic spine via rib-vertebral joints. In each case 2 ribs bor- bodies
der an intercostal space (Spatium intercostale) with intercostal • Rib neck (Collum costae): connects to the rib head
muscles and vascular, lymphatic and nervous systems. The 10th • Rib tubercle (Tuberculum costae): articulates with the Proc.
and 11th ICS are already part of the abdominal wall. The chest en- transversus of the vertebral body

132
 3.3 Spine, spinal cord and thorax

Apertura thoracis superior

Incisura clavicularis Manubrium sterni

Angulus sterni

Incisura jugularis
Corpus sterni Sternum

Cartilago costalis
Proc. xiphoideus

Arcus costalis Corpus vertebrae

(Vertebra cervicalis VII)

Costa I [prima]
Manubrium sterni

Corpus sterni

Cartilago costalis
a Apertura thoracis inferior

Vertebra cervicalis VII

[prominens], Proc. spinosus
Vertebra thoracica I,
Proc. spinosus

Tuberculum costae

Angulus costae Arcus costalis

Corpus vertebrae
(Vertebra lumbalis I)
Proc. transversus
Costa XI

Costa XII
Articulatio
costotransversaria b

Costa XII
Vertebra lumbalis I,
c Proc. spinosus

Fig. 3.69 Bony thorax. a Ventral view. b Right lateral view [L266]. c Dorsal view.

• Rib angle (Angulus costae): connects with the Tuberculum costae Individual differences
• Rib body (Corpus costae): continues to the front into the rib The IIIrd–Xth ribs are the typical ribs. The Ist, IInd, XIth and XIIth
cartilage ribs deviate from the typical rib structure (› Fig. 3.70, › Fig. 3.71).
From the IVth rib, the cartilaginous portions of the ribs become • Costae III–X: they have the typical rib form with wedge-shaped
longer, form an arch and pull cranially ascending in the direction Caput costae, which each bear 2 joint facets (Facies articulares
of the sternum. The bony parts, particularly the rib body, display 3 capitis costae). The Tuberculum costae has a joint surface (Fa-
different curvatures: cies articularis tuberculi costae). The intercostal vessels and
• Surface curvature: outer surface is bent downwards and to the nerves (V., A. and N. intercostalis) are positioned on the Sulcus
outside costae. The Corpus costae exhibits a cavity for contact with the
• Edge curvature: the rib head is higher compared to the ventral rib cartilage at the ventral end.
rib ends by 2 vertebrae • Costa I: is flattened, shorter, wider and more strongly bent than
• Rib torsion: the ribs are twisted around their longitudinal axis the rest of the ribs. The Sulcus arteriae subclaviae and the Sul-
All curvatures are strongly formed particularly in the upper ribs cus venae subclaviae (for the vessels of the same name) run
(exception Ist rib) and thus regionally different. This has an impact along the surface. In addition, the attachment zones for the Mm.
on the respiratory mechanics (see below). scaleni anterioris (Tuberculum musculi scaleni anterioris) and
medius can be recognised. Their head only has one joint facet

133
3 Torso

• Two-headed ribs: two ribs are partially fused.

XII • Fork ribs: the rib forks in the front portion into 2 ends.
Costae • Rib notching: asures are extensions of the intercostal arter-
fluctuantes ies, which run in the Sulcus costae, in the case of aortic
XI
coarctation and the resulting pressure on the bone are re-
ferred to as rib erosion. The vessels then usually run in an
extremely tortuous shape.
X • Lumbar ribs (approx. 7–8 % of the population): these are
Costae spuriae additional ribs that are similar to the XIth and XIIth ribs and
begin at the Ist or IInd lumbar vertebral body. They can have
a topographic relationship to the kidneys and cause pain
here.
IX

Rib-vertebral joints
VIII Caput and Tuberculum costae articulate with the thoracic verte-
brae in the Articulationes costovertebrales (true joints). In doing
so, the rib head articulates in the Articulationes capitis costae; the
rib tubercles in the Articulationes costotransversariae:
VII • Articulatio capitis costae: The Ist, XIth and XIIth ribs articulate
with the corresponding thoracic vertebral bodies via an articular
facet. The IInd–Xth ribs articulate in contrast with the higher, as
VI well as the corresponding thoracic vertebral body (› Fig. 3.72).
The resulting 2 joints are separated by a ligament (Lig. capitis
costae intraarticulare, › Fig. 3.72b), which runs from the in-
Costae verae V tervertebral disc to the centre of the rib head. The joint capsule is
reinforced by the circular Lig. capitis costae radiatum.
• Articulatio costotransversaria: The rib tubercles of the Ist–Xth
IV ribs articulate with the Procc. transversi of the corresponding
vertebra (› Fig. 3.72, › Fig. 3.73). The joint capsules are rein-
III forced by strong ligaments. Dorsally, the Lig. costotransversari-
um laterale connects the Proc. transversus and Angulus costae
II
and ventrally the Lig. costotransversarium is stretched between
Proc. transversus and Collum or Caput costae(› Fig. 3.73). The
I
Lig. costotransversarium superius from the rib neck reaches
the Proc. transversus of the next highest vertebra and suspends
Costa prima the ribs (› Fig. 3.73).

Sternum
Fig. 3.70 Bony part of the ribs I–XII left side, superior view. [L266]
The breastbone (Sternum) in adults, is a composite flat bone con-
sisting of 3 pieces (› Fig. 3.74). It consists of:
and it is more strongly curved (surface curvature). Edge curva- • Handle (Manubrium sterni): articulates with the Claviculae
ture and rib torsion are missing. and the Ist and IInd pair of ribs and has a cranial indentation
• Costa II: the Sulcus costae is only indicated. There is also a Tu- (Incisura jugularis).
berositas musculi serrati anterioris for the origin of the M. ser- • Body of the sternum (Corpus sterni): articulates with the rib
ratus anterior. The IInd ribs have 2 joint facets like the IIIrd–Xth pairs II–VII.
ribs. • Xiphoid process (Proc. xiphoideus): can be created with carti-
• Costae XI and XII: they do not have a Tuberculum costae and lage or bone.
no Sulcus costae. They do not have contact with the costal arch; The 3 bones are interconnected via synchondroses. The Manubrium
their front end is pointed. They have only one joint surface on is slightly tilted in the sagittal plane against the Corpus in a cranio­
their head. dorsal direction and forming the Angulus sterni (LUDOVICI). In
more than 30% of cases, a gap filled with synovial fluid occurs be-
tween the Manubrium and Corpus sterni. In this case, one speaks of
Clinical remarks a Symphysis manubriosternalis. The cartilage adhesion between
Ribs anomalies often occur in the population (approximately Corpus sterni and Proc. xiphoideus consists of fibrous cartilage
6%): (Symphysis xiphosternalis). With increasing age (from the 40th
• Cervical ribs (approx. 1 % of the population): the rib system year of life ) the 3 sections fuse mostly by bone with each other.
at the VIIth cervical vertebra is enlarged. The additional ribs The sternum articulates with the collar bones (Articulationes ster-
can be unilateral or bilateral but only the Proc. transversus
noclaviculares) and the rib pairs and I–VII (Articulationes ster-
can also be enlarged in isolation. If the additional ribs are in
contact with the sternum (either via connective tissue or even nocostales, see below).
bones), the lower roots of the brachial plexus can be com-
pressed, which leads to sensory disorders and motor deficits
in the innervation area of the spinal nerves C8 and T1.

134
 3.3 Spine, spinal cord and thorax

Sulcus arteriae Sulcus venae subclaviae

Caput costae subclaviae
Tuberculum musculi
scaleni anterioris
Collum costae

Corpus costae
Collum costae,
Crista colli costae Tuberculum
costae

II
Angulus costae

Tuberositas musculi
serrati anterioris
Caput costae

Collum costae

Facies articularis
tuberculi costae
Corpus costae
Tuberculum costae
Angulus costae III

Facies articularis Crista capitis costae

capitis costae
Crista colli costae Collum costae

Facies articularis
tuberculi costae Tuberculum costae

Sulcus costae

VIII Fig. 3.71 Ribs, Costae; Ist–IIIrd

ribs (cranial view) and VIIIth rib
(caudal view).

Foramen intervertebrale Proc. articularis superior

Fovea costalis superior

Proc. transversus
Facies interverte-
Fovea costalis bralis (cover plate)
proc. transversi Fovea costalis superior
Articulatio
Capsula articularis
Tuberculum costae capitis
costae
Articulatio capitis costae
Articulatio
costotrans- Tuberculum costae
versaria
Discus Nucleus
intervertebralis pulposus Discus
inter-
Collum costae Anulus vertebralis
fibrosus
Collum costae Fovea costalis inferior Caput costae
Sulcus costae Articulatio capitis costae Lig. capitis
Lig. capitis
costae
Facies articularis Caput costae costae radiatum
intraarticulare
inferior
Fovea costalis inferior
a b

Fig. 3.72 Costovertebral joints (Articulationes costovertebrales). a Costovertebral joints at the height of the VIIth and VIIIth thoracic vertebrae;
right lateral view. b Rib head joint (Articulatio capitis costae), right lateral view. [L266]

135
3 Torso

Lig. longitudinale anterius Nucleus pulposus

Discus intervertebralis
Anulus fibrosus

Lig. capitis costae radiatum

Lig. longitudinale posterius

Articulatio capitis costae Facies articularis superior

Lig. costotransversarium Lig. costotransversarium

superius (teilweise reseziert)

Articulatio costotransversaria

Foramen
vertebrale Lig. flavum Fig. 3.73 Ligaments of the cos-
Lig. costotrans-
versarium laterale Lig. supraspinale Lig. interspinale tovertebral joints (Articulatio-
nes costovertebrales).

Incisura jugularis
Incisura clavicularis
Incisura clavicularis

Manubrium sterni Incisura costalis I

Manubrium sterni
Incisura costalis I

Angulus sterni*
Incisura costalis II Symphysis Incisura costalis II
[Synchondrosis]
manubriosternalis

Incisura costalis III

Incisura costalis III
Corpus sterni
Corpus sterni

Incisura costalis IV Incisura costalis IV

Incisura costalis V Incisura costalis V

Incisura costalis VI Incisura costalis VI

Incisura costalis VII Incisura costalis VII
Symphysis xiphosternalis

Proc. xiphoideus Proc. xiphoideus

a b

Fig. 3.74 Sternum. a Ventral view. b Lateral view from the left side. * LUDOVICI

Clinical remarks sterni. Due to the incongruity of the articular surface, the joint has
a fibre cartilaginous Discus articularis, which divides the joint into
For the assessment of bone marrow cells (bone marrow smear)
two chambers (dithalamic joint). The shape of the joint enables
the bone is punctured, typically at the iliac crest. A sternal
puncture is also possible; however, it is only very rarely car- multiaxial movements and extremely different stresses in various
ried out today. For this purpose, one uses a strong biopsy nee- joint positions, which are of importance for the shoulder girdle
dle with Arretier plate and punctures under local anaesthesia (› Chapter 4.3). The joint capsule is strengthened by:
in the median line of the Corpus sterni between the attach- • Lig. sternoclaviculare anterius
ments of the IInd and IIIrd ribs. Punctures should not be made • Lig. sternoclaviculare posterius
in the vicinity of the costosternal connections (occurrence of • Lig. interclaviculare
the synchondroses), and the lower two thirds of the Corpus
• Lig. costoclaviculare
sterni (there can be a Fissura sterni congenita caused by the
paired bone system of the sternum) are also obsolete, be- The joint is also discussed in the context of the upper extremities
cause the puncture needle could easily enter the heart or the (› Chap. 4.3.2).
lungs (pleura).
Rib-sternal joints
The Ist rib and often also the VIth and VIIth ribs are connected to
the sternum with their cartilaginous component as synchondroses
Sternoclavicular joint (Articulationes costochondrales). In rare cases true joints (diar-
Sternoclavicular joint (Articulatio sternoclavicularis) is a func- throses, sternocostal joints) can occur, such as between the IInd
tional ball and socket joint with three degrees of freedom. The Fa- and Vth ribs (› Fig. 3.75). Each of the Incisura costalis sterni ar-
cies articularis sternalis articulates with the Incisura clavicularis ticulates with the ventral end of the rib cartilage.

136
 3.3 Spine, spinal cord and thorax

Incisura clavicularis Incisura jugularis

Costa I [prima]
Angulus sterni Synchondrosis
manubriosternalis

Cartilago Articulatio
costalis sternocostalis
(synovial joint
with two
chambers)

Movement of the
sternum from
top front

Elevation
of the
lateral
rib
shaft

Proc. xiphoideus Movement

Synchondrosis Articulationes costocostales of a bucket handle
xiphosternalis (joints between the
rib cartilage)

Fig. 3.75 Articulationes sternocostales. Ventral view. [L266]

Fig. 3.76 Movement of the thoracic wall. [L126]

The 2nd sternocostal joint regularly has a Lig. sternocostale in-
traarticulare. The joint capsules of the rib-sternum joints are rein- lationes costovertebrales (Articulationes capitis costae radiatae
forced by the Ligg. sternocostalia radiata. At the front the liga- and Articulationes costotransversariae form a functional unit) and
ments connect to the Membrana sterni externa and at the back to the Articulationes sternocostales. They therefore serve the respi-
the Membrana sterni interna. The ligaments radiate caudally as ratory mechanisms. In the context of breathing, the thoracic skele-
Ligg. costoxiphoidea to the xiphoid process. The cartilage connec- ton (› Fig. 3.76):
tions on the rib arch are referred to as Articulationes interchon- • moves the sternum to the upper front. The movement comes
drales. Joint clefts can sometimes occur here. about when the front end of the ribs are lower than the rear. In
In the course of life the rib cartilage ossifies fully up to old age. this process, the angle between Manubrium and Corpus sterni
slightly flattens. The movement changes the extent of the thorax
NOTE in an anteroposterior direction.
In the case of a cardiac arrest a cardiac massage is performed as a • elevates the lateral rib shafts (lifting for inspiration, lowering for
life-saving measure. In this case, there are often rib fractures in the expiration). This results in changes in the lateral and anteropos-
ossified rib cartilage even when correctly executed. These are nor- terior directions. The ribs move laterally like a bucket handle.
mal and do not pose further far-reaching risks for the patient. Car- The middle portions of the rib shafts are even lower than the
diac massage should therefore be continued even after one or
more rib fractures.
ends of the two ribs at different heights.
The elastic rib cartilages are also significantly involved in the posi-
tional changes of the ribs. With the ossification of the rib cartilage
Thorax mechanisms in old age, thoracic mobility is restricted and the respiratory width
A key feature of the bony and cartilaginous chest wall are move- decreases.
ments that serve to alter the chest volume, and to enable transport The muscles responsible for the movements of the thorax are dis-
of air in and out of the lungs. The central elements are the Articu- cussed in › Chap. 3.1.2.

137
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4 Upper extremity
Volker Spindler, Jens Waschke

4.1 Overview . . . . . . . . . . . . . . . . . 141 4.6 Nerves of the

upper extremity . . . . . . . . . . . 174
4.2 Development of upper 4.6.1 Sensory innervation . . . . . . . . 174
and lower extremities . . . . . . 142
4.6.2 Structure of the
4.2.1 Course . . . . . . . . . . . . . . . . . . . 142 Plexus brachialis . . . . . . . . . . . 175
4.2.2 Bones . . . . . . . . . . . . . . . . . . . . 143 4.6.3 N. axillaris . . . . . . . . . . . . . . . . 178
4.2.3 Muscular system . . . . . . . . . . 143 4.6.4 N. radialis . . . . . . . . . . . . . . . . 178
4.2.4 Nerves . . . . . . . . . . . . . . . . . . . 145 4.6.5 N. musculocutaneus . . . . . . . . 180
4.2.5 Blood vessels . . . . . . . . . . . . . 145 4.6.6 N. medianus . . . . . . . . . . . . . . 181
4.3 Shoulder girdle . . . . . . . . . . . . 145 4.6.7 N. ulnaris . . . . . . . . . . . . . . . . . 183
4.3.1 Bones of the shoulder girdle . 145 4.6.8 N. cutanei brachii
and antebrachii medialis . . . . 184
4.3.2 Joints and ligament connections
of the ­shoulder girdle . . . . . . . 146 4.7 Arteries of the
4.3.3 Shoulder girdle mechanics . . 147 upper extremity . . . . . . . . . . . 184
4.3.4 Shoulder girdle muscles . . . . 148 4.7.1 A. subclavia . . . . . . . . . . . . . . . 185
4.7.2 A. axillaris . . . . . . . . . . . . . . . . 186
4.4 Upper arm . . . . . . . . . . . . . . . . 150
4.7.3 A. brachialis . . . . . . . . . . . . . . 187
4.4.1 Humerus . . . . . . . . . . . . . . . . . 150
4.7.4 A. radialis . . . . . . . . . . . . . . . . 188
4.4.2 Shoulder joint . . . . . . . . . . . . . 150
4.7.5 A. ulnaris . . . . . . . . . . . . . . . . . 189
4.4.3 Shoulder joint mechanics . . . 151
4.4.4 Shoulder muscles . . . . . . . . . . 152 4.8 Veins of the upper extremity . 190
4.8.1 Superficial veins . . . . . . . . . . . 190
4.5 Forearm and hand . . . . . . . . . 155
4.8.2 Deep veins . . . . . . . . . . . . . . . . 191
4.5.1 Bones of the forearm . . . . . . . 156
4.5.2 Elbow joint . . . . . . . . . . . . . . . 156 4.9 Lymphatic vessels
4.5.3 Joint connections between of the upper extremity . . . . . . 191
the forearm bones . . . . . . . . . 157 4.9.1 Epifascial and subfascial
4.5.4 Elbow joint and distal lymph vessels . . . . . . . . . . . . . 191
radioulnar joint ­mechanics . . 157 4.9.2 Lymph nodes of the axilla . . . 191
4.5.5 Muscles . . . . . . . . . . . . . . . . . . 157
4.10 Topographically important
4.5.6 Structure and bones aspects of the arm . . . . . . . . . 192
of the hand . . . . . . . . . . . . . . . 159
4.10.1 Trigonum clavipectorale . . . . 192
4.5.7 Joints of the hand . . . . . . . . . . 160
4.10.2 Axillary cavity . . . . . . . . . . . . . 192
4.5.8 Hand-joint mechanics . . . . . . 163
4.10.3 Axillary spaces
4.5.9 Muscles of the forearm and triceps groove . . . . . . . . . 193
and hand . . . . . . . . . . . . . . . . . 164
4.10.4 Elbow . . . . . . . . . . . . . . . . . . . . 193
4.5.10 Auxiliary structures of the muscu-
lature in the area of the hand 169 4.10.5 Carpal tunnel
and GUYON’s canal . . . . . . . . 194
 CLINICAL CASE

Humeral shaft fracture

Case study Diagnostics
A 33-year-old man is brought into hospital in an ambulance. Whilst A computer tomography (CT) of the whole body, as conducted
cycling he was clipped by an overtaking lorry and fell onto his right routinely in the trauma room, shows a comminuted fracture of the
arm and upper body. As a matter of routine, the patient is sent into right humerus in the area of the shaft. Otherwise, no other fractures
the trauma room of A & E and examined in detail after the A & E or organ damage are noticeable.
doctor has removed the vacuum splint.

Diagnosis
Findings
Comminuted fracture of the right humeral shaft with damage to the
The patient is conscious and fully orientated. He has severe pain, N. radialis.
especially in the right upper arm. Heart rate (90/min), respiratory rate
(30/min) and blood pressure (140/100 mm Hg) are all slightly
increased. The A & E doctor reports an approximately 6 × 8 cm sized Treatment
wound on the right upper arm with visible bone fragments in the
wound bed. Due to the possibility of an operation, the attached Due to the complex fracture with an obvious nerve lesion, an
compresses are initially not removed. During manual examination of operation is indicated. After exposing the fracture area, the N.
the remaining bony skeleton no abnormal mobility or grinding noises radialis is examined. A few small splinters of bone which have
(crepitations) are triggered. Neurological examination shows a limply penetrated into the nerve are removed. Also, a larger bone fragment
drooping right hand that the patient can raise only minimally against that was compressing the nerve is repositioned. The fracture is
gravity. In addition, there is a noticeable numbness on the radial side extensively repositioned and stabilised with a plate whilst preserving
of right forearm and back of the hand, especially between thumb and the N. radialis.
forefinger. The blood flow of the right hand is not restricted. Apart
from multiple grazing and bruising on the face, the right upper body
and both hands, the rest of the physical examination yields nothing Further developments
remarkable.
On the day after the procedure physiotherapy is started. Full mobility
of the shoulder and elbow is achieved again after a few weeks;
however, it is many more weeks before the patient can extend his
wrist again and no further sensory disorders are detectable.

You were present during your practical year while the patient was in the emergency department.
Everything went quite quickly and on leaving, the senior consultant gives you 2 bullet
points to think about…

Rep safe and unsafe fracture signs

Safe fracture signs: bone rub (Crepitatio), open fracture
(visible bone fragments), abnormal mobility, axle deformity of
the bone
Unsafe fracture signs: pain, swelling, haematoma, Increased
warmth, movement restrictions

Rep peripheral paralysis

(traumat.) nerve paralysis → those muscles supplied by the nerve
are no longer innervated → function failure
Wrist drop: paralysis of radial nerve: back of the hand can no
longer be raised → falls down = drop hand
 4.1 Overview

4.1 Overview tised locally. Knowledge of the blood vessels is particularly relevant

in the case of circulation disorders and thromboses (internal medi-
Dissection of the extremities necessitates much time and effort in cine, vascular surgery) and lymph vessels with their individual
the dissection process until in particular the complicated areas, lymph node stations for tumour diagnosis in various fields, such as
such as the axilla (Fossa axillaris) and the hand with their entire dermatology and gynaecology (breast cancer with the possibility of
vascular, lymphatic and nervous systems, are laid bare. As always metastases in axillary lymph nodes).
during preparation, the individual structures can only be presented Through its distinctive movement possibilities, the upper extremi-
carefully and completely with good theoretical knowledge. ty of a person is adapted to its functions as a gripping organ and an
In a clinical setting the anatomy of the passive (bone, joints with important instrument of interaction with the environment. It is di-
ligaments) and active (muscles) musculoskeletal system of the vided into the shoulder girdle (Cingulum pectorale) and the arm as
limbs are of great significance for the specialties of orthopaedics, a free-swinging part. The arm is divided into upper arm (Brachi-
emergency surgery and radiology, since injuries and degenerative um), forearm (Antebrachium) and hand (Manus) (› Fig. 4.1). The
changes to arms and legs are frequent. In addition, peripheral neu- longitudinal axis of the upper arm and forearm bones laterally
roanatomy (branches of the spinal nerves) is particularly important form the arm exterior angle of 170°. The rotational axis of the up-
for diagnostics in neurology and general medicine. Since in neu- per arm in the shoulder joint corresponds to the line connecting
rology, e.g. in the case of spastic tonus escalation, individual mus- the humeral head and elbow joint. It is extended as a diagonal axis
cles are also increasingly being treated by injection of botulinum of the forearm from the proximal to the distal joint between the
toxin, the exact topography of individual muscles has also become forearm (radioulnar joints). Turning/rotational movement (prona-
increasingly relevant in addition to their function. Also, in anaes- tion/supination) of the forearm takes place around this axis.
thesia, targeted nerve plexuses and individual nerves are anaesthe-

Rotational axis of the upper arm

Clavicula
Cingulum
pectorale
Scapula Articulatio
acromioclavicularis
Articulatio humeri

Shaft axle
of the humerus
Brachium
Humerus

170˚ Articulatio
humeroradialis
Cubitus Articulatio
humeroulnaris Articulatio cubiti
Articulatio
Pars libera radioulnaris
membri proximalis
superioris Radius

Ante- Shaft axis of the

brachium Ulna forearm bones

Diagonal axis
of the forearm
Articulatio radioulnaris distalis

Articulatio radiocarpalis
Carpus, Ossa carpi
Articulatio mediocarpalis
Metacarpus,
Ossa metacarpi Articulationes
carpometacarpales
Articulationes
Manus metacarpophalangeae
Digiti manus, Articulationes interphalangeae
Ossa digitorum manus proximales

Articulationes interphalangeae Fig. 4.1 Skeleton of the upper

manus distales extremity, Membrum superius,
right. Ventral view.

141
4 Upper extremity

4.2 Development of upper and lower extremities 4.2.1 Course

The limbs develop in the 4th week. A fin-like arm bud forms on the
Skills 26th–27th day and therefore 2 days earlier than the leg bud. The
After working through this chapter, you should be able to: extremity systems at this point in time consist of a core of connec-
• describe the main features of limb development with the tive tissue (mesenchymal), which is derived from the mesodermal
most important developmental periods somatopleura, and of an encasing surface ectoderm which later
• explain from which embryonic germinal layer the different forms the epidermal layer of the skin (› Fig. 4.2).
tissues arise
The extremity buds can be distinguished in different sections into a
• know the clinically relevant variations and deformations.
division of arm and leg systems in the 5th–6th week. From the 6th
week the finger rays separate from each other through pro-

Fin-like
arm bud

Hand plate has formed

5th week
32nd day

Groove between
the finger radiations

Finger radiation appears

in the hand plate
5th week
35th day Finger radiation

Fingers are
short and connected
by webs

6th week
44th day

Fingers and toes

7th week are long and separated
48th day from each other

Knee
8th week rotates craniolaterally
56th day
Feet have plantar flexion
are adducted and supinated

Fig. 4.2 Embryonic limb development (5th–8th week). [E581]

142
 4.2 Development of upper and lower extremities

grammed cell death (apoptosis) in the interlying tissue. By the end Clinical remarks
of the 8th week the fingers and toes are completely separated.
Bone age
In the 8th week there is a rotation of the extremities systems
(› Fig. 4.2): the arm system revolves 90°, so that the elbow is From the progression of the ossification (bone age), future
growth and adult height can be predicted in children by x-ray
aligned caudally. The flexor muscles then lie ventrally and the ex-
examinations. In x-ray examinations of children, it must be
tensor muscles dorsally. The leg system also rotates by almost 90° noted that the bones consist partly of individual bone cores,
but in the opposite direction, so that the knee points in a craniolat- which are not yet osseously connected to each other. They are
eral direction. This means that with the leg the extensor muscles of therefore not bone fractures.
the upper and lower leg lie ventrally, but the flexor muscles lie dor-
sally. Furthermore, in the 8th week the foot is initially plantarflect- Deformities
Congenital club-foot is the most common extremity deformity
ed, adducted and supinated. By the 11th week, however, this foot
(1 : 1000 births). This condition means the foot is fixed in
position is normally reversed. plantar flexion and supination. Therefore, it is assumed that
this deformity is caused by the lack of reversion from a foot
position that is physiological between the 8th and 11th week.
4.2.2 Bones Also congenital hip dysplasia/hip dislocation is common
(1 : 1000 births) and occurs 5 × more frequently in girls than in
The mesenchyme of the arm bud is consolidated and forms a carti- boys. Due to the incomplete formation of femoral head and/or
acetabulum as the joint socket, the joint luxates and when un-
laginous skeleton as the precursors of later bones in the 4th–6th
treated leads to walking disorders and severe arthritis.
week on the arm and in the 6th–8th week on the leg (› Fig. 4.3). Fingers or toes can be surplus (polydactyly) or grow together
This process advances from proximal to distal. In this cartilaginous (syndactyly). Hands and feet can also be divided, if the finger
skeleton bone cores form from the 7th week which initiate ossifica- rays do not form properly (split hand and split foot). In the
tion and thus the conversion of the cartilaginous skeleton into worst cases, parts of the limbs can be missing (meromelia) or
bone tissue (chondral ossification). Ossification progresses ac- the entire limb is not created (amelia). This may happen if in
cording to a specific pattern: the early phases of limb development between the 26th and
36th day harmful environmental factors (teratogens) interfere.
• By the 12th week bone cores can be found in all bones of the up-
This was recognised in the years 1957–1962 when these de-
per extremity apart from the wrist (› Fig. 4.4a). The bone cores formities often occurred when pregnant women had taken tha-
of the wrist first emerge postnatally between the 1st and 8th year lidomide as a sleeping pill and to reduce morning sickness.
of age. An exception is the Clavicula, which is the first bone (7th
week) to form, emerges without a cartilaginous skeleton and thus
directly from the mesenchyme (desmal ossification).
• In the lower extremity ossification develops a little later (› Fig.
4.4b). In the thigh and leg bones the first bone cores emerge 4.2.3 Muscular system
roughly in the 8th embryonic week, but they only first emerge in
the toes between the 9th week and the 9th month. The tarsal The muscle cells of the limbs differentiate into the limb buds
bones (1st–4th year of life) and the pelvic girdle (partly up to the (› Fig. 4.5a and b). The ectoderm at the distal edge of the limb
20th year of life) ossify postnatally. buds (ectodermal marginal ridge) forms growth factors, which at-
The epiphyseal plates join between the 14th and 25th years and in tract precursors of muscle cells from the somites of the mesoderm
most bones up to the 21st year of life. The growth length of the ex- into the torso region. By the 6th week the precursor cells in the limb
tremities is thereby terminated. systems form the ventral and dorsal muscle masses, from which
Joints (diarthroses) between the individual bones are present from the flexor and extensor muscles later develop. Since the limb mus-
the start of the foetal period (from the 9th week). cles develop out of precursor cells from the ventral (hypaxial) mus-
cle system of somites, the muscles of the limbs are all later inner-
vated by the anterior branches of the spinal nerves. The motor
nerve fibres grow in the 5th week into the limb systems. The mus-
cle fibres for the arms then develop from the muscle systems of
segments C5–T1, which form the anterior branches of the spinal

Ossa
carpi
Mesenchymale
structure of the Humerus
forearm bones
Ectoderm
Radius
a Ectodermal ridge b c Ulna

Scapula Loose mesenchyme

Carpus
Phalanges
Dense mesenchyme
Fig. 4.3 Development of carti-
Humerus Cartilage laginous primary stages of the
Radius Ectoderm arm skeleton. a 28th day,
Ulna b 44th day, c 48th day and
d Metacarpalia d 56th day of development.
[E581]

143
4 Upper extremity

7th EW
18th–19th LY 13th–15th LY
1st LY
15th–18th LY 3rd–4th EM
18th–20th LY
15th–16th LY 13th–15th LY
10th–12th LY 4th–5th EM
18th–21st LY 13th–15th LY 7th–8th LY
2nd–5th LM 18th LY 5th–8th LM
6th–7th EM
2nd–3rd LY 18th–19th LY 3rd–5th LY
16th–18th LY
5th LY 17th–20th LY
8th EW
20th–25th LY 13th–15th LY
10th–13.th LY
2nd–4th 15th–18th LY 4th–6th LY
LY 19th–20th LY
7th–8th EW 16th–20th LY

EW = embryonic week
EM = embryonic month 8th EW
LM = month of life
LY = year of life

13th–16th LY 5th LY
16th–24th LY
8th–13th LY 12th LY
8th–12th LY 3rd–4th LY
1st LY 9th EM
13th–17.th LY
5th–7th LY
10th EM
14th–18th LY
10th–12th LY 5th–6th LY 17th–18th LY
17th–19th LY
12th–14th LY
7th EW

7th EW 8th EW

7th–8th EW

20th–24.th LY
21st–25th LY 7th–8.th LY
1st–2nd LY 6th LM 17th–18th LY
5th–7th LY
10th–12th LY 17th–18th LY
2nd–4th LY 2nd–4th LY
9th EW
9th EW
2nd–3rd LY

1st–3rd LY
9th EW 9th EW 3rd–4th LY
2nd–3rd LY
3rd–4th LY 15th–21st LY
11th–12th EW
2nd–3rd LY 1st–2nd LY
7th–8th EW 5th EM
3rd–5th LY
a b 8th EM
9th EW Fig. 4.4 Ossification of the
skeleton, location of the ossifi-
Os scaphoideum 3rd–6th LM Os pisiforme 8th–12th LY Talus 7th EM Os cuneiforme mediale 2nd–3rd LY cation centres and chronologi-
Os lunatum 3rd–6th LY Os triquetrum 1st–4th LY Calcaneus 5th–6th EM Os cuneiforme intermedium 3rd–4th LY cal sequence of ossification
Os trapezium 3rd–8th LY Os hamatum 2nd–5th LM Os naviculare 4th LY Os cuneiforme laterale 12th LM
Os trapezoideum 3rd–7th LY Os capitatum 2nd–4th LM Os cuboideum 10th EM centre development. a Upper
extremity. b Lower extremity.

Pharyngeal arch Structures of the

muscles eye muscles
Eye Former position of the Occipital dermomyotomes
muscles occipital somites and myotomes
Section plane
of b C1
C2 Cervical dermomyotomes
Cervical dermo- C3
C4 and myotomes
Leg muscles myotome C5
C6
C7
Arm muscles C8

Somites of the Eye T1

T2
T3
tail bud Ventrolateral T4

Lumbar trunk musculature T5

T6
T7
a dermomyotome T8
T9 Thoracic
T11
myotomes
Epaxial L1
T12
L2
trunk musculature L5 L4 L3

Regressing caudal Lumbar dermomyotomes

Hypaxial
Rr. dorsales et c myotomes and myotomes
trunk musculature
ventrales of the
spinal nerves Extensors of the arms

Flexors of the arms

Intercostal muscles
b Heart

Fig. 4.5 Development of the musculature in the 6th week. a, c Schematic diagram. b Cross-section. [E347-09]

144
 4.3 Shoulder girdle

Preaxial margin Ventroaxial of cases), which can remain if the distal portion of the A. bra-
C3 limit chialis is not replaced by a more deeply coursing segment.
C4
C5 C3
C4
C3 This superficial A. brachialis then courses subcutaneously
C6 C5 C4 C5
C7 C7
C6
C7 C6
T1 T2
through the elbow and in the case of accidental puncture
C8 C8 T1
T1
T2 during blood collection or administration of medication can
a
T2
b c Ventral side lead to spurting bleeding or incorrect arterial injection. There-
Postaxial margin fore, before puncture there should always be a manual palpa-
Ventroaxial
tion to test whether the respective vessel in the elbow still ac-
L4 L4 boundary S4
L2
L2
tually has a pulse and can thus be seen as an artery.
L3 L4 L3 L3
L5 S1 S3
L4 L5 S2
L5 S1 S2 S3 L2
S1 L5
S2
S3
d e f Dorsal side

Fig. 4.6 Development of dermatomes. a–c Upper extremity. [E581] 4.3 Shoulder girdle
d–f Lower extremity. Arrangement of the dermatomes at the begin-
ning (a and d) and end of the 5th week (b and e) as well as in adults
(c and f). The ventroaxial boundary marks the area in which there is Skills
hardly any overlapping of the innervation areas. [E581]
After working through this chapter, you should be able to:
• explain on a skeleton the bony structures of the shoulder
nerves of the Plexus brachialis from their spinal cord segments girdle and its joints together with the range of movement
(› Fig. 4.5c). The muscle precursor cells for the legs originate • explain the course of the ligaments of the shoulder girdle as
well as all muscles with origin, attachment and function,
from segments L2–S3, the motoneurons of which are correspond-
and show these on a skeleton or specimen.
ingly merged in the Plexus lumbosacralis.

4.2.4 Nerves
4.3.1 Bones of the shoulder girdle
The sensory nerve fibres grow out along the motor fibres and ini-
tially reach segmentally arranged skin areas (› Fig. 4.6a and b). The bones of the shoulder girdle are:
Due to the growing out of the limbs, the arrangement of the cuta- • Clavicle (Clavicula)
neous areas, which are innervated by a spinal cord segment also • Shoulder blade (Scapula)
changes. (dermatomes = radicular fields). In contrast to the torso,
where dermatomes are arranged in a belt shape, dermatomes in the Clavicula
limbs initially proceed almost longitudinally and later during de- The Clavicula joins the sternum with the shoulder blade and is well
velopment in an increasingly oblique direction (› Fig. 4.6). Arms palpable nearly horizontally. It has a thickened medial end, Ex-
and legs exhibit a ventroaxial border in which the individual senso- tremitas sternalis, and a flattened lateral end, Extremitas acromi-
ry innervated areas hardly overlap. alis, › Fig. 4.7). Because of 2 bends the Clavicula is curved and
slightly S-shaped, so that ventrally the lateral half is concave and
the medial half is convex. Dorsally located underneath at the lateral
4.2.5 Blood vessels bend is the Tuberculum conoideum as a small apophysis. From
here, the Linea trapezoidea extends laterally. Both parts of the Lig.
The blood vessels of the limb systems originate from the dorsal in- coracoclaviculare are fastened to these structures. Also on the un-
tersegmental arteries (› section 6.1.3). Firstly, an axial artery derside of the lateral third is a depression, the Sulcus musculi sub-
forms in the median plane, from which later on branches grow out clavii, in which the M. subclavius lies against the bone. The Clavic-
at the distal end. In the arm the axial artery forms the A. brachia- ula originates predominantly by membrane ossification and in the
lis, but remains on the forearm behind the growth of the limb sys- 7th week is the first osseous skeletal element of an embryo.
tem and later forms the A. interossea communis with its branches.
The A. mediana, emerges distally from the axial artery, which,
however, is only temporarily formed and later becomes reduced to
Clinical remarks
the A. comitans nervi mediani. Then the A. ulnaris and A. radialis Because of the exposed position of the Clavicula and its
form as the main vessels of the forearm and maintain connection S-shape that e. g. cannot withstand axial loads arising from
to the digital arteries. falls onto an outstretched arm, fractures are frequent. In a typ-
The axial artery in the leg is called the A. ischiadica because it ac- ical fracture in the middle third of the Clavicula the lateral part
is dragged downwards by the weight of the arm, but the medi-
companies the N. ischiadicus. It regresses at the thigh and is later re-
al part, on the other hand, is dragged upwards by the pull of
placed by the newly growing A. femoralis. Emerging from it in the the M. sternocleidomastoideus.
lower leg are the A. tibialis anterior and the A. tibialis posterior.

Clinical remarks Shoulder blade (Scapula)

Remnants of the axial arteries can remain as variants. The A. The Scapula is a triangular, mostly flat bone with an anferior sur-
mediana can, e.g. as a variant as a strong vessel on the fore- face facing the thorax (Facies costalis) and a posterior surface (Fa-
arm still be connected to the palmar arches. What can be par- cies posterior) (› Fig. 4.8a). Corresponding to the triangle shape,
ticularly relevant is a superficial A. brachialis (present in 8% a distinction is made between 3 sides (Margo lateralis, medialis
and superior) and 3 angles (Anguli lateralis, inferior and superior).

145
4 Upper extremity

Facies Extremitas Medial clavicular joint

articularis acromialis Corpus Extremitas
claviculae sternalis The Articulatio sternoclavicularis is the only truly articulated con-
acromialis
nection between the upper extremity and the torso (› Fig. 4.9).
The joint surfaces of the Extremitas sternalis of the Clavicula and
the Incisura clavicularis of the Manubrium sterni are both slightly
Impressio ligamenti
saddle-shaped but functionally they are ball joints. A Discus ar-
Linea costoclavicularis ticularis divides the joint almost completely. Because of the very
trapezoidea Sulcus musculi strong ligaments, luxation of the joint is extremely rare.
subclavii
Tuberculum Facies articularis The following ligaments secure the medial clavicular joint:
conoideum sternalis • Ligg. sternoclavicularia anterius and posterius on the front
and back of the joint
Fig. 4.7 Clavicle, Clavicula, right. Caudal view.
• Lig. interclaviculare, which connect both clavicles with each
other along the top of the breastbone
A short neck piece, the Collum scapulae, forms an appendage • Lig. costoclaviculare, which stretches from the cartilage of the
which protrudes in the lateral angle, into which the Cavitas gle- first rib to the medial end of the Clavicula.
noidalis is sunken. It forms the joint socket for the head of the hu- Also, the M. subclavius, which stretches from the first rib to the
merus. There are 2 small elevations on its upper and lower edges, Clavicula, supports the fixation of the Clavicula to the thorax and
the Tubercula supraglenoidale and infraglenoidale as the origins thus acts as an active ligament.
for the Caput longum of the M. biceps brachii and the M. triceps
brachii, respectively (› Fig. 4.8). At the Margo superior of the Lateral clavicular joint
Scapula the coracoid process (Proc. coracoideus) bends forwards. The lateral clavicular joint (Articulatio acromioclavicularis) is a
Medial to the Proc. coracoideus, the superior border is indented by plane joint and connects the lateral end of the Clavicula with the ac-
the Incisura scapulae, which is bridged by a ligament (Lig. trans- romion of the Scapula (› Fig. 4.10). It is stabilised by 3 ligaments:
versum scapulae superius). Spine of the Scapula (Spina scapulae) • Lig. acromioclaviculare, which constitutes a reinforcement of
is elevated from the Facies posterior and articulates with the Clavic- the joint capsule
ula with its end section, the acromion. From the base of the Spina • Lig. trapezoideum from the Linea trapezoidea of the Clavicula
scapulae there is a ligament connection (Lig. transversum scapulae to the Proc. coracoideus
inferius) to the neck of the shoulder blade. • Lig. conoideum from the Tuberculum conoideum of the Clavic-
On the Scapula there are 3 recesses: ula to the Proc. coracoideus.
• Fossa subscapularis, Ventral; origin of the M. subscapularis
• Fossa supraspinata, dorsal to and above the Spina scapulae; ori-
gin of the M. supraspinatus Clavicula Discus articularis
• Fossa infraspinata, dorsal below the Spina scapulae; origin of Lig. interclavi-
culare
the M. infraspinatus

Capsula Lig. costo-

4.3.2 Joints and ligament connections of the articularis claviculare
s­ houlder girdle Cartilago
costalis I Lig. sternoclavi-
Manubrium culare anterius
A distinction is made between 2 joints on the shoulder girdle: sterni
• Medial clavicular joint (Articulatio sternoclavicularis)
• Lateral clavicular joint (Articulatio acromioclavicularis)

Fig. 4.9 Medial clavicular joint, Articulatio sternoclavicularis,

Ventral view.

Margo superior Incisura scapulae Acromion Tuberculum

supraglenoidale
Angulus superior Proc. coracoideus

Fossa Proc. cora-

supraspinata Acromion coideus

Spina Angulus acromii Cavitas

scapulae glenoidalis
Cavitas glenoidalis Tuberculum
infraglenoidale
Margo Angulus lateralis Facies
medialis posterior
Collum scapulae Facies costalis
Margo lateralis Margo lateralis
Fossa
a infraspinata b
Fig. 4.8 Shoulder blade,
Angulus inferior Scapula, right. a Dorsal view.
b Lateral view.

146
 4.3 Shoulder girdle

Articulatio acromioclavicularis,
Lig. acromioclaviculare
Acromion

Lig. coracoacromiale Lig. coracoclaviculare,

Lig. trapezoideum
M. supraspinatus, Tendo
Bursa synovialis
Proc. coracoideus Lig. coracoclaviculare,
Lig. coracohumerale Lig. conoideum
Lig. transversum scapulae
Tuberculum
superius
majus
M. subscapularis, Incisura scapulae
Tendo Bursa subtendinea musculi
subscapularis
Capsula articularis,
M. biceps brachii,
Ligg. glenohumeralia:
Caput longum
– (superius)
– (medium)
– (inferius)

(Recessus
axillaris)

Fig. 4.10 Lateral clavicular

joint, right. Ventral view.

The Ligg. trapezoideum (lateral) and conoideum (medial) are merged • TOSSY II: additional partial rupture of the Lig. coracoclavicu-
into the Ligg. trapezoideum (lateral) and conoideum (medial). lare (2 ligaments affected)
Three other ligament connections have no direct relation to the • TOSSY III: complete tear of the Lig. acromioclaviculare and
clavicular joints: the Lig. coracoclaviculare (all 3 ligaments torn)
Especially in the case of TOSSY III the lateral end of the Clavic-
• The Lig. coracoacromiale connects the Proc. coracoideus and ula is higher than the Acromion. The clear step formation can
Acromion and together with them forms the so-called roof of be pushed back into the normal position (‘piano key phenom-
the shoulder. enon’, › Fig. 4.11).
• The Lig. transversum scapulae superius bridges the Incisura Clinically, a classification by ROCKWOOD based on that by
scapulae. TOSSY is now primarily used, as this is more suitable for
• The Lig. transversum scapulae inferius is only inconsistently whether an operation is indicated.
formed and is located directly below the lateral end of the Spina
scapulae.

Clinical remarks 4.3.3 Shoulder girdle mechanics

In contrast to injuries to the medial clavicular joint, trauma to The Clavicula can be dislocated in the sternoclavicular joint
the Articulatio acromioclavicularis (clinical: dropped shoul- around the sagittal and longitudinal axes (› Fig. 4.12, › Ta-
der) is common. Typically they arise through a fall onto the ble 4.1). Thereby the Clavicula moves in the form of a cone with the
shoulder with an outstretched arm, often through sports acci- tip in the sternoclavicular joint and the base in the acromioclavicu-
dents. A distinction is made according to TOSSY, between 3
lar joint (‘circles of the shoulder’). In addition, due to the relatively
levels of severity:
• TOSSY I: strain or partial rupture of the Lig. acromioclavicu- weakly developed saddle form of the articular surfaces of the ster-
lare (1 ligament affected) noclavicular joint, light rotational movements of the Clavicula

Lig. acromioclaviculare

M. trapezius

Lig. conoideum
Lig. coracoclaviculare
Lig. trapezoideum
Fig. 4.11 Piano key phenome-
non in the case of avulsion of
the Lig. acromioclaviculare and
Lig. coracoclaviculare.

147
4 Upper extremity

Table 4.1 Range of movement in the shoulder girdle. 40°

Movement Range of movement

Elevation/depression 40°–0°–10°
0°
Protraction/retraction 25°–0°–25°

10°

around its longitudinal axis are possible. Functionally, the clavicu-

lar joints act together as ball joints. a
During movements in the clavicular joints the Scapula is by neces-
sity always moved as well. In the process it slides extensively with
25°
its anterior side on the thorax. In addition, the Scapula also rotates
around a sagittal axis. Thus, the Angulus inferior can be rotated ap-
proximately 30° medially and approximately 60° laterally. This ro- 0°
tation capability is essential for abduction of the arm in the shoul-
der joint beyond 90°, which is designated as elevation. b 25°

NOTE Fig. 4.12 Range of movement in the shoulder girdle. a Elevation/

The Scapula can be moved extensively against the torso: depression. b Protraction/retraction.
• Shifting movements to ventral (e.g. enclosing the contralateral
upper arm with the hand) and to dorsal (e.g. tying an apron) The dorsal muscles of this group (› Fig. 4.14, › Table 4.3) are
• Shift movement to cranial (e.g. shrugging the shoulders) and to
• M. trapezius
caudal
• Rotation around a sagittal axis (e.g. in arm elevation)
• M. levator scapulae
• M. rhomboideus major
• M. rhomboideus minor
The dorsal group lies superficially on the back; however, the mus-
4.3.4 Shoulder girdle muscles cles did not develop in the area of the torso, but in the arm system.
They are also not innervated by the Rr. posteriores of the spinal
Shoulder girdle muscles are designated according to their function nerves, like true back muscles are. Therefore, these muscles are also
as muscles, which have their origin at the torso skeleton and skull referred to as migrated (secondary) back muscles.
and their attachment to the Scapula or Clavicula (› Fig. 4.13, The Clavicula and Scapula are moved by the shoulder girdle mus-
› Fig. 4.14). Accordingly, they move only these two bones. A spe- cles as a unit against the abdominal wall. Functionally 4 muscle
cial situation here is the ability to deploy some of these muscles as slings are differentiated, which mediate the shift and rotational
auxiliary respiratory muscles for respiratory support. In the case movements of the Scapula on the thoracic wall (› Fig. 4.15).
of a fixed shoulder girdle (e.g. propping up on a handrail) they in- • longitudinal sling: M. levator scapulae and Pars ascendens of
duce elevation of the rib cage and inspiration. the M. trapezius
The ventral muscles of the shoulder girdle (› Fig. 4.13, ­ • transverse sling: Pars transversa of the trapezius, Pars superior
› Table 4.2) include: and pars divergens of the M. serratus anterior
• M. serratus anterior • upper oblique sling: Pars descendens of the M. trapezius,
• M. pectoralis minor M. pectoralis minor
• M. subclavius • inferior oblique sling: Mm. rhomboidei and Pars convergens of
The ventral group originates on the anterior side of the thoracic the M. serratus anterior
cage of the ribs.

M. subclavius

M. pectoralis
minor
M. serratus
anterior

Fig. 4.13 Ventral shoulder

g
­ irdle muscles. a M. serratus
a b
anterior. b M. pectoralis minor
and M. subclavius.

148
 4.3 Shoulder girdle

M. trapezius,
Pars descendens

M. trapezius, M. levator
Pars transversa M. rhomboideus scapulae
minor

M. rhomboideus
major

M. trapezius,
Pars ascendens

Fig. 4.14 Dorsal shoulder girdle

a muscles. a M. trapezius.
b M. levator scapulae and Mm.
rhomboidei.

The 2 muscles of a sling act as antagonists and thus move the Scap- in a wing shape (Scapula alata). This is particularly visible
ula in opposing directions. If both muscles of a sling contract the when propped up by a wall or in bed. Failure of the M. sub-
Scapula is pressed onto the thorax. Here the transverse sling is the clavius and M. pectoralis minor are functionally insignificant.
most important. During rotation of the Scapula in a lateral direc-
tion (movement of the Cavitas glenoidalis cranially) the M. serra-
tus anterior and the Partes descendens and ascendens of the M. tra-
pezius work together. Clinical remarks
In the event of failure of the M. trapezius and also the Mm.
Clinical remarks rhomboidei the medial border of the Scapula is elevated and
in the case of a lesion of the M. levator scapulae the shoulder
In the event of failure of the M. serratus anterior patients are is slightly lowered. Since during elevation the M. trapezius is
particularly impaired, as arm elevation is not possible. It is also involved in rotation of the Scapula, this is restricted and
also noticeable that the medial border of the Scapula projects the Cavitas glenoidalis is directed downwards.

Table 4.2 Ventral shoulder girdle muscles.

Innervation Origin Attachment Function

M. pectoralis minor
Nn. pectorales medialis and (II) III–V ribs near the bone Tip of the Proc. coracoideus Shoulder girdle: lower
lateralis cartilage margin Thorax: raises the upper ribs (inspiration: auxiliary breathing muscle)
M. subclavius
N. subclavius Cartilage bone margin of I rib Lateral third of the Clavicula Shoulder girdle: stabilises the sternoclavicular joint, protects Vasa sub-
clavia; the fascia of the M. subclavius is firmly fused with the adventitia of
the V. subclavia and thereby holds it open.
M. serratus anterior
N. thoracicus longus I–IX rib Medial on the Scapula Shoulder girdle: pulls the Scapula ventro-laterally, together with the
• Pars superior: Angulus Mm. rhomboidei presses the Scapula onto the thorax
superior • Pars superior: lifts the Scapula
• Pars divergens: Margo • Pars divergens: lowers the Scapula
medialis • Pars convergens: lowers the Scapula and turns its lower angle outwards
• Pars convergens: Angulus for elevation of the arm above the horizontal plane together with the M.
inferior trapezius
Thorax: raises the ribs (inspiration) whilst the Scapula is fixed

149
4 Upper extremity

Table 4.3 Dorsal shoulder girdle muscles.

Innervation Origin Attachment Function

M. trapezius
N. accessorius [XI] and branches of • At the Os occipitale between the • Pars descendens: acromial third • Pars descendens: prevents lowering of the shoulder
the Plexus cervicalis Linea nuchalis suprema and of the Clavicula girdle and the arm (e.g. when carrying suitcases), lifts
­Linea nuchalis superior • Pars transversa: Acromion the Scapula and turns its lower angle outwardly for
• Procc. spinosi of the cervical and • Pars ascendens: Spina scapulae elevation of the arm, with fixed shoulders rotates the
thoracic vertebrae head to the contralateral side, stretches the cervical
spine in bilateral innervation
• Pars transversa: pulls the Scapula downwards
• Pars ascendens: lowers the Scapula and turns it
downwards
M. levator scapulae
Dorsal scapular nerve, (direct Tubercula posteriora of the Procc. Angulus superior of the Scapula Shoulder girdle: lifts the Scapula
branches of the Plexus cervicalis) transversi of I–IV cervical vertebrae
M. rhomboideus minor and major
N. dorsalis scapulae Proc. spinosus of the VI. and VII. Margo medialis of the cranial Pulls the Scapula medially and cranially, together with
cervical vertebrae (minor) and the (minor) and caudal (major) Scapu- the M. serratus anterior fixes the Scapula to the torso
4 upper thoracic vertebrae (major) la of the Spina scapulae

4.4.1 Humerus
M. trapezius, M. levator scapulae
Pars descendens At the proximal end of the humerus (Humerus) a distinction is
M. trapezius, made between an anatomical and a clinical neck section: the Col-
Pars transversa lum anatomicum separates the Caput humeri from the laterally
M. pectoralis minor located Tuberculum majus and the ventrally directed Tuberculum
minus (› Fig. 4.16a). Both tubercles are separated by the Sulcus
M. serratus anterior,
Pars divergens et intertubercularis and taper out distally as the Crista tuberculi ma-
Mm. rhomboidei
Pars superior joris and minoris. At the Collum chirurgicum distal to the two tu-
bercula, fractures of the humerus are common.
The Tuberositas deltoidea for the attachment of the M. deltoideus
M. trapezius, is located on the shaft (Corpus humeri) . The Sulcus nervi radialis
Pars ascendens serves the N. radialis on the posterior side as a guiding furrow
(› Fig. 4.16b) in which it can be damaged in the case of humeral
shaft fractures .
M. serratus anterior,
The distal end of the humerus, is formed by the Condylus humeri
Pars convergens (› Fig. 4.16c). This carries both joint plates of the elbow joint, the
Trochlea humeri medial/ulnar and the Capitulum humeri lateral/
radial. Above the two joint plates are 2 indentations that come into
contact with the two forearm bones during flexion. The Fossa coro-
noidea for the corresponding extension of the Ulna is medial and
Longitudinal loop Upper angular loop
the Fossa radialis is lateral. Dorsally the Fossa olecrani impedes ex-
tending movement through contact with the olecranon of the Ulna.
Transverse loop Inferior angular loop Proximal to the Condylus the Epicondyli medialis and lateralis are
elevated as apophyses, which taper out upwards on both sides as
Fig. 4.15 Muscle slings for moving the Scapula. the Cristae supraepicondylares medialis and lateralis. On the dorsal
side of the Epicondylus medialis is the Sulcus nervi ulnaris (› Fig.
4.16b), in which the N. ulnaris is palpably located under the skin. If
4.4 Upper arm it is compressed against the bone here, painful paraesthesia ensues
(‘funny bone’).
Skills
After working through this chapter, you should be able to: 4.4.2 Shoulder joint
• explain the bony structures of the humerus as well as the
development and range of movement of the shoulder joint In the shoulder joint (Articulatio humeri) the almost spherical
• demonstrate the ligaments of the shoulder joint and explain humeral head articulates with the Cavitas glenoidalis of the Scapu-
their significance for the mobility of the shoulder joint
la. The surface of the Cavitas glenoidalis is, however, much smaller
• know all shoulder muscles with origin, attachment and func-
tion and show them on a specimen than that of the humeral head. A loose connective tissue joint lip
• demonstrate the interplay of shoulder girdle and shoulder (Labrum glenoidale) therefore enlarges the joint plate. The shoul-
joint for the mobility of the upper extremity der joint is the ball joint with the largest range of movement in the
human body.

150
 4.4 Upper arm

Sulcus inter- Caput humeri Collum

tubercularis anatomicum
Collum anatomicum
Tuberculum
majus Tuberculum minus Tuberculum
majus
Collum Collum
chirurgicum chirurgicum

Crista tuber- Crista tuberculi minoris

culi majoris

Corpus humeri
Tuberositas
deltoidea Sulcus nervi
radialis

Facies
Margo medialis posterior
Margo lateralis
Fossa radialis
Crista supraepicon-
dylaris lateralis Fossa coronoidea
Crista supraepicon- Fossa
Epicondylus
dylaris medialis olecrani
lateralis
Epicondylus
Capitulum humeri
medialis
Trochlea humeri Sulcus nervi Trochlea
Condylus humeri
a humeri b
ulnaris Fig. 4.16 Humerus, right.
a Ventral view. b Dorsal view.

The wide joint capsule originates at the Labrum glenoidale and ex- • M. teres minor (dorsal below)
tends to the Collum anatomicum of the humerus. When the arm • M. subscapularis (ventral)
hangs down, it has a reserve fold caudally (‘Recessus axillaris’, As a special feature the original tendon of the Caput longum of the
› Fig. 4.10). The following ligaments reinforce the joint capsule M. biceps brachii runs through the joint cavity and attaches to the
(› Fig. 4.10, › Fig. 4.17): humerus in the Sulcus intertubercularis (› Fig. 4.10).
• Lig. coracohumerale (cranially) from the base of the Proc. cora- Cranially, the shoulder joint is delineated by the ‘shoulder roof ’.
coideus to the joint capsule This is formed by the Acromion and Proc. coracoideus of the Scap-
• Ligg. glenohumeralia superius, medius and inferius (ventrally), ula, which are connected by the Lig. coracoacromiale. Below the
from the Collum scapulae to the joint capsule shoulder roof there are larger bursae:
In addition, the end tendons of the 4 muscles of the rotator cuff radi- • The Bursa subacromialis on the attachment tendon of the M.
ate into the joint capsule and reinforce and tense them (› Fig. 4.17): supraspinatus (› Fig. 4.17) connects mostly laterally with the
• M. supraspinatus (cranial) Bursa subdeltoidea. The two bursae are also referred to as ‘sub-
• M. infraspinatus (dorsal above) acromial accessory joints’, as they ensure low friction gliding of
the head of the humerus under the shoulder roof.
M. supraspinatus
• The Bursa subcoracoidea under the Proc. coracoideus often
Bursa sub- connects with the Bursa subtendinea musculi subscapularis
acromialis under the tendon attachment of the M. subscapularis and com-
Lig. coraco- municates with the joint cavity.
Acromion acromiale
Proc. cora-
coideus Clinical remarks
M. supraspi- The wide joint capsule can become ‘sticky’ during longer im-
Lig. coraco-
natus, Tendo
humerale
mobilisation of the shoulder joint, especially in the area of
the so-called Recessus axillaris. Therefore, in the case of oper-
M. infraspinatus,
Tendo
M. subscapularis, ations in the area of the shoulder joint attempts should be
Tendo
made to facilitate movement of the shoulder joint as early as
M. teres minor
M. biceps brachii, possible.
Caput longum, Tendo

M. subscapularis

4.4.3 Shoulder joint mechanics

The shoulder joint is the joint with the largest range of movement
of the human body. It is a ball joint with mobility potential around
Fig. 4.17 Shoulder joint, right. Lateral view. 3 axes:

151
4 Upper extremity

• Anteversion and retroversion around a transverse axis: movement Abduction beyond 90° is designated as elevation. This movement
of the arm to the front or back can only be carried out in combination with a rotation of the Scap-
• Abduction and adduction around a sagittal axis: movement of the ula, as the shoulder roof impedes further abduction in the shoulder
arm towards and away from the torso joint; however, rotational movements of the Scapula begin long be-
• External rotation and internal rotation around an axis along the fore reaching the maximum abduction in the shoulder joint of 90°.
humeral shaft: rotation of the arm outwards or inwards.
The large range of movement in the shoulder joint is due to the fact
that the stability of the joint is accomplished less by bone inhibition
Clinical remarks
and ligament guidance, but mainly by muscles. In addition, during Due to weak ligament protection and bone guidance luxations
shoulder movement the shoulder girdle is usually also moved. This of the shoulder joint are very common. The most common lux-
noticeably increases the range of movement of the upper extremity ation is ventral and caudal under the Proc. coracoideus (Luxa-
compared to movements in the shoulder joint alone (› Table 4.4, tio subcoracoidea). A patient with such a first luxation usually
› Fig. 4.18). suffers from severe pain. The shoulder curvature is reduced
and the affected arm appears longer in a lateral comparison
(› Fig. 4.19). For repositioning, the ARLT method is often
used (› Fig. 4.19). In this case the patient sits down and
Elevation 180° 170° Flexion places the arm over the back of a padded chair that serves as
an abutment. With a bent elbow joint, the doctor pulls along
the axis of the humerus until the head of the humerus ‘jumps’
back into the plate under light internal rotation.

90° 90°

40° 4.4.4 Shoulder muscles

Abduction Adduction 40°
Extension Shoulder muscles refer to the muscles that move the shoulder joint
0° 0°
a b and have an attachment in the upper arm. The muscles are divided
according to their location into 3 groups:
0°
• Ventral group:
Medial rotation Lateral rotation
– M. pectoralis major
– M. coracobrachialis
60° • Lateral group:
70° – M. deltoideus
– M. supraspinatus
• Dorsal group:
100° 90°
c
– M. infraspinatus
– M. teres minor
Fig. 4.18 Range of movement in the shoulder joint involving the – M. teres major
shoulder girdle (thick line) as well as in the shoulder joint alone (thin – M. subscapularis
line). – M. latissimus dorsi

Table 4.4 Range of movement in the shoulder joint with and without Ventral group
the involvement of the shoulder girdle. The large, fan-shaped M. pectoralis major (› Fig. 4.20, › Ta-
Movement Shoulder joint Shoulder joint and ble 4.5) is located very superficially and is thus responsible for the
shoulder girdle expression of the chest wall relief. Its fibres cross each other lateral-
ly, so that those of the Pars clavicularis join distally to the Crista
Abduction/adduction 90° – 0° – 40° 180° – 0° – 40°
tuberculi majoris of the Humerus, which, in contrast, proximally
Anteversion/retroversion 90° – 0° – 40° 170° – 0° – 40° forms the Pars sternoclavicularis and thereby the anterior axillary
External rotation/internal rotation 60° – 0° – 70° 90° – 0° – 100° fold. In an elevation movement the muscle fibres disentangle. The

Fig. 4.19 Luxation of the shoul-

der joint. a Reduction of the
shoulder bulge to the right in
Luxatio subacromialis. b Reposi-
a b tioning manoeuvre following the
method of arlt.

152
 4.4 Upper arm

Table 4.5 Ventral shoulder muscles.

Innervation Origin Attachment Function

M. pectoralis major
Nn. pectorales medialis • Pars clavicularis: sternal half of the Crista tuberculi majoris of the Shoulder joint: adduction (most important muscle),
and lateralis ­Clavicula humerus internal rotation, anteversion (most important muscle),
• Pars sternocostalis: Manubrium und retroversion from anteversion position
­Corpus sterni, cartilage of the II–VII ribs Thorax: with fixed shoulder girdle lifts the sternum and
• Pars abdominalis: anterior lamina of the ribs (inspiration: auxiliary breathing muscles)
rectus sheath
M. coracobrachialis
› See Chap. 4.5.5

M. pectoralis major is the most important muscle for adduction duct in a neutral position because at this juncture they are located
and anteversion. In the case of propped up arms, it is an important below the sagittal axis of the shoulder joint. In the case of greater
auxiliary respiratory muscle. abduction (> 60°) of the arm, however, they end up above this axis
The M. coracobrachialis performs the same functions as the M. and therefore support the Pars acromialis in further abduction.
pectoralis major. Corresponding to its location and innervation, This means that the supraspinatus also functions synergistically
however, it is usually numbered amongst the upper arm muscles (› Fig. 4.21b, › Table 4.6) and its attachment tendon is separat­ed
(› Chap. 4.5.5). From the group of upper arm muscles the M. bi- by the Bursa subdeltoidea of the M. deltoideus. It is most import-
ceps brachii and the M. triceps brachii also impact (only the Ca- ant at the start of an abduction movement (‘ignition function’ of
put longum) on the shoulder joint. Corresponding to their lever the M. supraspinatus).
arms, however, they are only minimally involved in the corre-
sponding joint excursions but together with the M. deltoideus and
the M. coracobrachialis they primarily assist the stabilisation of the
Clinical remarks
humeral head in the socket. In the event of failure of the M. deltoideus the arm can practi-
cally no longer be abducted because the M. supraspinatus is
too weak to hold the arm. In the case of a longer lasting le-
Clinical remarks
In the case of failure of the M. pectoralis major anteversion
and adduction are severely impaired; therefore, the arms can-
not be crossed in front of the body! The anterior axillary fold
can wear away through atrophy of the muscle.
M. deltoideus,
Pars clavicularis

M. deltoideus, M. deltoideus,
Lateral group Pars spinalis Pars acromialis
The M. deltoideus is a massive, complexly built muscle in the form
of a triangle standing on its apex (› Fig. 4.21a, › Table 4.6). In this
way it gives the shoulder its contour. It can be involved in all move-
ments depending on the position of the shoulder joint. With its
Pars acromialis it is the most important muscle for abduction. The a
Pars clavicularis is situated in front of the transverse and rotational
axes, thus this part can be anteverted and rotated inwards. For the
Pars spinalis the reverse is true; it is located dorsally of the two axes
and thus causes retroversion and external rotation. Both parts ad-

M. pectoralis major,
Pars clavicularis
M. supraspinatus
M. pectoralis major,
Pars sternocostalis

M. pectoralis major,
Pars abdominalis

Fig. 4.20 Ventral shoulder muscles – M. pectoralis major, right. Fig. 4.21 Lateral shoulder muscles. a M. deltoideus, lateral view.
Ventral view. b M. supraspinatus, dorsal view.

153
4 Upper extremity

sion, atrophy of the shoulder is visible. Also in the case of a › Table 4.7). The muscle is important for retroversion from an
M. supraspinatus lesion abduction is limited as the ‘ignition anteversion position (thrust movement). Here, it acts synergistical-
function’ is missing. ly with the M. pectoralis major, which is why both muscles are very
The attachment tendon of the M. supraspinatus runs below well-defined in swimmers or high bar gymnasts. Since the M. latis-
the shoulder roof in the ‘subacromial space’. Due to the local
simus dorsi lies over the rib cage, it can support exhalation as an
spatial restriction the tendon is, e g. in the case of chronic in-
flammation of the bursa, very vulnerable and ruptures (supra- auxiliary expiration respiratory muscle, e. g. during coughing.
spinatus or shoulder impingement syndrome) commonly en- The M. teres major (› Fig. 4.22a, › Table 4.7) supports the M.
sue. latissimus dorsi in movement against resistance.

Clinical remarks
Dorsal group In the event of failure of the M. infraspinatus the external ro-
The M. infraspinatus is the most important lateral rotator in the tation is severely affected. If, however, the M. subscapularis is
shoulder joint, and is supported in this by the M. teres minor not innervated, the internal rotation is considerably limited,
(› Fig. 4.22a, › Table 4.7). Both muscles originate from the Scap- so that the arms cannot be brought behind the back. Despite
its size failure of the M. latissimus dorsi is in contrast func-
ula and run dorsally to the Humerus to the Tuberculum majus. The
tionally relatively insignificant. In the examination, however, it
most important medial rotator is the M. subscapularis (› Fig. becomes obvious that the arms cannot be crossed behind the
4.22b, › Table 4.7), which is the only muscle to originate from the back (‘apron grip’) and the rear axillary fold is smoothed out.
ventral side of the Scapula. It stretches ventrally from the Humerus This muscle can be well utilized for reconstruction of the fe-
to the Tuberculum minus. male breast, e.g. after resection for breast cancer. For this pur-
The largest muscle of the human body with respect to surface area pose, a part of the muscle in the area of origin is detached and
is the M. latissimus dorsi, which covers the posterior side of the moved ventrally. Failure of the Mm. teres major and minor is
functionally insignificant.
trunk in the lower thoracic and lumbar regions and in forming the
rear posterior axillary fold stretches to the humerus (› Fig. 4.22c,

Table 4.6 Lateral shoulder muscles.

Innervation Origin Attachment Function

M. deltoideus
N. axillaris • Pars clavicularis: acromial third of the Tuberositas deltoidea Shoulder joint: abduction (most important muscle)
­Clavicula • Pars clavicularis: adduction (from approx. 60° increas-
• Pars acromialis: Acromion ingly abduction), medial rotation, anteversion
• Pars spinalis: Spina scapulae • Pars acromialis: abduction up to the horizontal plane
• Pars spinalis: adduction (from approx. 60° onwards
increasingly abduction), lateral rotation, retroversion
M. supraspinatus
N. suprascapularis Fossa supraspinata, Upper facet of the Tuberculum Shoulder joint: abduction up to the horizontal plane, low
Fascia supraspinata majus, joint capsule lateral rotation; strengthening of the joint capsule (rotator
cuff)

Table 4.7 Dorsal shoulder muscles.

Innervation Origin Attachment Function

M. infraspinatus
N. suprascapularis Fossa infraspinata, Fascia infraspinata Middle facet of the Tuberculum Shoulder joint: lateral rotation (most important muscle);
majus, joint capsule strengthening of the joint capsule (rotator cuff)
M. teres minor
N. axillaris Middle third of the Margo lateralis Lower facet of the Tuberculum Shoulder joint: external rotation, adduction; strengthen-
majus, joint capsule ing of the joint capsule (rotator cuff)
M. teres major
N. thoracodorsalis Angulus inferior Crista tuberculi minoris Shoulder joint: medial rotation, adduction, retroversion
M. subscapularis
Nn. subscapulares Fossa subscapularis Tuberculum minus, joint capsule Shoulder joint: medial rotation (most important muscle);
strengthening of the joint capsule (rotator cuff)
M. latissimus dorsi
N. thoracodorsalis • Procc. spinosi of the 6 lower thoracic verte- Crista tuberculi minoris Shoulder joint: adduction, medial rotation, retroversion
brae and of the lumbar vertebrae (most important muscle)
• Fascia thoracolumbalis
• Facies dorsalis of the Os sacrum
• Labium externum of the Crista iliaca
• IX–XII ribs
• Frequently Angulus inferior of the Scapula

154
 4.5 Forearm and hand

In addition, the upper arm muscles M. biceps brachii, the M.

coracobrachialis and the M. triceps brachii also participate in
movements in the shoulder joint.
The following muscles are involved in the respective movements
(most important muscle in bold type):
Abduction:
• M. deltoideus
• M. supraspinatus
• M. infraspinatus (cranial part)
M. infraspinatus • M. biceps brachii (Caput longum)
Adduction:
• M. pectoralis major
• Mm. teres major and minor
M. teres minor • M. latissimus dorsi
M. teres major • M. deltoideus (Pars spinalis and Pars clavicularis)
• M. triceps brachii (Caput longum)
• M. biceps brachii (Caput breve)
• M. coracobrachialis
a • M. infraspinatus (caudal part)
Anteversion:
• M. pectoralis major
• M. deltoideus (Pars clavicularis)
• M. biceps brachii
M. subscapularis • M. coracobrachialis
Retroversion:
• M. latissimus dorsi
• M. deltoideus (Pars spinalis)
• M. teres major
b • M. triceps brachii (Caput longum)
Lateral rotation:
• M. infraspinatus
• M. teres minor
• M. deltoideus (Pars spinalis)
Medial rotation:
• M. subscapularis
• M. pectoralis major
• M. latissimus dorsi
• M. teres major
• M. deltoideus (Pars clavicularis)
• M. coracobrachialis

4.5 Forearm and hand

Skills
After working through this chapter, you should be able to:
• explain the bony structures of the forearm and hand, as well
M. latissimus dorsi as the structure and function of all joints on a specimen
• know the course of the ligaments of the elbow joint and the
basics of the ligaments of the hand joints
• know the origin, attachment, function and innervation of all
muscles and to show this on a specimen
• explain the functions of the M. biceps brachii depending on
the position of the elbow joint as well as explain its interac-
tion with the M. brachialis
• know the importance of tendon sheaths and retinacula for
the function of muscles and to explain the functional rela-
tionship between the short finger muscles and the dorsal
aponeurosis
c

Fig. 4.22 Dorsal shoulder muscles. a M. infraspinatus, M. teres major

and M. teres minor, dorsal view. b M. subscapularis, ventral view.
c M. latissimus dorsi, dorsal view.

155
4 Upper extremity

4.5.1 Bones of the forearm The diaphysis of the radius is connected with the Caput radii via
the radial neck (Collum radii) and is triangular in cross-section,
The forearm is formed by two bones: so that 3 borders arise (Margines anterior, interosseus and poste-
• Radius rior). Ventral is the Tuberositas radii, which serves as an attach-
• Ulna ment for the M. biceps brachii.
The radius and ulna are articulated by 2 joints (the Articulatio ra- The distal radial epiphysis carries the stylus process (Proc. styloi-
dioulnaris proximalis and Articulatio radioulnaris distalis) as well deus radii) and an articular surface for the distal radioulnar joint,
as by a rigid syndesmosis, the Membrana interossea antebrachii the Incisura ulnaris.
(› Fig. 4.23). Proximally on the dorsal side, the ulna has a prominent apophysis,
The Caput radii is located proximally and has 2 joint plates, the the olecranon (elbow). Ventral to the apophysis is the Proc. coro-
Fovea articularis (cranial) and the Circumferentia articularis (lat- noideus, where there are also two joint surfaces, the Incisura
eral) that are involved in the structure of the elbow joint. trochlearis and the Incisura radialis.
As for the radius, for the diaphysis a differentiation is made be-
tween 3 borders (Margines anterior, interosseus and posterior).
Ventral is the Tuberositas ulnae for the attachment of the M. bra-
Lig. anulare radii
chialis.
Incisura
trochlearis The Caput ulnae is located distally and with the Circumferentia
articularis supports the ulnar part of the joint surface for the distal
Circumferentia
articularis radioulnar joint as well as the Proc. styloideus ulnae.
Articulatio radioulnaris
M. biceps brachii, proximalis
Tendo NOTE
Chorda obliqua The radius and ulna each have a slim head and a thickened end. In
the case of the radius the head is located proximally (at the elbow
joint), whereas it is distal in the case of the ulna (in the direction of
the wrist).
Radius

4.5.2 Elbow joint
Membrana interossea
antebrachii The elbow joint (Articulatio cubiti) is a composite joint, which is
formed by the humerus, radius and ulna (› Fig. 4.24). It is further
divided into 3 joints:
• Articulatio humeroulnaris
• Articulatio humeroradialis
• Articulatio radioulnaris proximalis
Ulna All 3 parts of the joint are surrounded by a common joint capsule.
In their entirety, the partial joints act as a hinge-pivot joint.
The Articulatio humeroulnaris is a pure hinge joint, in which the
Articulatio radioulnaris
trochlea of the humerus articulates with the Incisura trochlearis of
distalis, Capsula articularis the ulna. Here the bone guidance is very well-defined by the troch-
Facies articularis carpalis
lea, which is shaped like a horizontal hourglass.
In the Articulatio humeroradialis the Capitulum humeri and the
Fig. 4.23 Bone and bone connections of the forearm, right. Ventral Fovea articularis of the Caput radiale move against each other.
view. From the shape of the articular surfaces this joint is a ball joint;

Humerus

Epicondylus Epicondylus
lateralis medialis

Capitulum Trochlea Capsula articularis,

humeri humeri Membrana fibrosa

Incisura trochlearis
Circumferentia Proc. coronoideus Lig. collaterale Lig. collaterale
articularis radiale ulnare
Incisura Lig. anulare radii
radialis
Collum radii Collum radii
Tuberositas
Tuberositas ulnae M. biceps brachii, Tendo Ulna
radii Fig. 4.24 Elbow joint (Articula-
Radius Chorda obliqua
tio cubiti), right. Ventral view.
a Joint surfaces of the elbow
a b joint. b Ligaments of the elbow
joint.

156
 4.5 Forearm and hand

however, coupling of the radius to the ulna by an annular ligament 90°

(Lig. anulare radii) and to the Membrana interossea antebrachii
prevents abduction and adduction movements.
The Articulatio radioulnaris proximalis is a pivot joint. The joint 150°
head is formed by the hoop-shaped Circumferentia articularis
which encompasses the Caput radii. This moves against the Incisu-
ra radialis ulnae and the Lig. anulare radii. The annular ligament is
fixed to the front edge of the Incisura radialis ulnae and winds 0°
around the Circumferentia articularis in order to reinsert at the 10°
posterior edge of the Incisura radialis.
The joint capsule encloses all 3 joint surfaces and extends from the a
humerus somewhat distally of the Epicondyli to about 1 cm distal
of the Lig. anulare radii. The elbow joint is further stabilised by 2
strong ligaments that reinforce the joint capsule laterally and medi-
ally (› Fig. 4.24b): 0°
• Lig. collaterale ulnare: runs from the Epicondylus medialis of
the humerus and extends in a triangular shape ventrally to the
Proc. coroideus and dorsally to the olecranon
• Lig. collaterale radiale: runs from the Epicondylus lateralis of the
humerus with 2 parts into the Lig. anulare radii and thus inserts at b 90° 90°
the anterior and posterior edges of the Incisura radialis ulnae
Fig. 4.25 Range of movement of the elbow joint. a Lateral view.
b Ventral view.
4.5.3 Joint connections between the forearm bones
Table 4.8 Range of movement of the elbow joint:
Turning/rotational movements of the forearm (pronation and supi-
Movement Range of movement
nation) are carried out in both joints together. The axis is thus the
diagonal axis of the forearm, which connects the two radioulnar Extension/flexion 10°–0°–150°
joints to each other: Supination/pronation 90°–0°–90°
• Articulatio radioulnaris proximalis (part of the elbow joint,
› Chap. 4.5.2)
• Articulatio radioulnaris distalis (thumbs to lateral, the palm pointing upwards) the radius and ulna
The distal radioulnar joint is formed by the Incisura ulnaris radii are parallel (› Fig. 4.39b). In pronation (thumb pointing medial-
and the Circumferentia articularis ulnae. This is a pivot joint with a ly, the palm pointing downwards), both bones cross each oth-
movement axis. er(› Fig. 4.39a). Thus, in rotational movements the radius circles
The Membrana interossea antebrachii spans between the two Mar- around the ulna, guided in the process by the Lig. anulare radiai
gines interosseae of the radius and ulna and forms a syndesmosis and the Membrana interossea.
(› Fig. 4.23). It is important for stabilising rotational movements of
the forearm. It also serves as a muscle origin and in the process sep-
arates the flexor muscles of the forearm from the extensor muscles. 4.5.5 Muscles
Proximally the Membrana interossea antebrachii has an entry point
for the A./V. interossea posterior and a hollow to create space for the The most important muscles for movement in the elbow joint are
Tuberositas radii in pronation and supination movements. Located located on the upper arm. Besides flexion and extension, they are
there with the Chorda obliqua is a ligament tension directed against also significantly involved in supination movements. A distinction
the fibre course of the Membrana interossea. is made between 3 ventral and 2 dorsal muscles (› Fig. 4.26b,
› Table 4.9):
Ventral group:
4.5.4 Elbow joint and distal radioulnar joint • M. biceps brachii
m
­ echanics • M. brachialis
• M. coracobrachialis
In the elbow joint flexion and extension movements are carried Dorsal group:
out around the transverse axis. In addition, in conjunction with the • M. triceps brachii
distal radioulnar joint rotational movements occur around an • M. anconeus
axis, which runs diagonally through the forearm from the radial to
the ulnar head, and is referred to as pronation and supination Ventral group
(› Fig. 4.25, › Table 4.8; also › Fig. 4.39). The M. biceps brachii is superficial and thus determines the relief
A clear extension is not possible because it is prevented by the bone of the ventral upper arm (› Fig. 4.26). The original tendon of the
constraint of the olecranon in the Fossa olecrani of the humerus Caput longum originates at the Tuberculum supraglenoidale of
prevents. The flexion, however, is not limited by bony structures, the Scapula within the joint capsule of the shoulder joint. It runs
but by the soft tissue constraint of the upper arm muscles. Rota- through the joint cavity and leaves the capsule space in the Sulcus
tional movements of the forearm can be carried out in isolation intertubercularis. In this way, the tendon is involved in stabilisation
only when the elbow is flexed and the upper arm is laid flat, other- of the shoulder joint. The Caput breve originates at the Proc. cora-
wise movements in the shoulder joint also occur. In supination coideus. In addition to its attachment to the Tuberositas radii, the

157
4 Upper extremity

M. coraco-
brachialis
M. triceps brachii,
Caput laterale
M. triceps brachii,
Caput longum
M. biceps brachii, M. biceps brachii, M. triceps brachii,
Caput longum Caput breve Caput mediale
M. brachialis

M. anconeus

Aponeurosis musculi
bicipitis brachii

a b c

Fig. 4.26 Upper arm muscles, right. a M. brachialis and M. coracobrachialis, ventral view. b M. biceps brachii, ventral view. c M. triceps brachii
and M. anconeus, dorsal view.

Table 4.9 Ventral upper arm muscles.

Innervation Origin Attachment Function

1
M. biceps brachii
N. musculocutaneus • Caput longum: Tuberculum supraglenoi- Tuberositas radii, Shoulder joint: anteversion, medial rotation, abduction
dale Fascia antebrachii (Caput longum), adduction (Caput breve) elbow joint: flex-
• Caput breve: tip of the Proc. coracoideus ion (most important muscle), supination (most important
muscle of the flexed elbow)
M. brachialis
N. musculocutaneus Facies anterior of the humerus (lower half) Tuberositas ulnae Elbow joint: flexion, tenses joint capsule
2
M. coracobrachialis
N. musculocutaneus Proc. coracoideus Medial to the middle of the Shoulder joint: medial rotation, adduction, anteversion
Humerus
1
The tendon of the Caput longum runs freely through the shoulder joint.
2
The muscle is normally penetrated by the N. musculocutaneus.

M. biceps brachii runs into the Aponeurosis musculi bicipitis bra-

chii, which is integrated into the superficial muscle fascia of the
forearm, the Fascia antebrachii. The M. biceps brachii is the stron-
gest flexor in the elbow joint and is also involved in movements of
the shoulder joint. It is also the most important supinator of the
flexed elbow joint. The muscle is particularly effective from the pro-
M. biceps brachii, Tendo
nation position since its tendon winds around the radius, bolstered
by the Bursa bicipitoradialis. In contraction, the tendon curls up
similarly to a yo-yo (› Fig. 4.27). In the case of an extended arm,
however, the tension axis of the M. biceps brachii runs parallel to Bursa bicipitoradialis Radius

the pronation/supination axis so that it can exert no force.

The M. brachialis is located under the M. biceps brachii (› Fig.
4.26a). It is a classical example of a flexor muscle because with its
short lever it can carry out a large flexion movement with little
contraction. In this way, it brings the M. biceps brachii into a more
favourable position, so that it can aid flexion better. Thus, both Tuberositas
radii
muscles act synergistically (› Fig. 4.28).
Due to its position and innervation the M. coracobrachialis is also
counted among the upper arm muscles (› Fig. 4.26a); however, it
Pronation Supination
does not move the elbow joint, but only the shoulder joint. Because
its muscle belly is normally (in approx. 90% of cases) penetrated by Fig. 4.27 Course of the attachment tendon of M. biceps brachii in
the N. musculocutaneous, it is an important orientation mark for relation to the radius during pronation (left) and supination (right).
the Plexus brachialis. [L126]

158
 4.5 Forearm and hand

One-armed
lever
Humerus
Scapula
M. biceps Caput longum
brachii Caput breve

Two-armed
lever
Caput laterale
M. triceps
Caput longum
brachii
Caput mediale

M. brachialis

Radius Ulna Fig. 4.28 Synergism of upper

arm flexors.

Clinical remarks der joint and separates the lateral and medial shoulder gaps from
each other.
In the event of a failure of the M. biceps brachii and the
M. brachialis, mostly caused by a lesion of the N. musculocu- The M. anconeus is functionally insignificant and is to be seen rath-
taneus, flexion of the elbow is significantly impaired. Minimal er as a distal separation of the M. triceps brachii (› Fig. 4.26c).
bending, however, is still possible since the impaired flexors
of the forearm (innervation by N. medianus) and also the radi-
al muscle group of the forearm (innervation by N. radialis) can 4.5.6 Structure and bones of the hand
bend. If the M. biceps brachii is affected, supination of the
flexed elbow is restricted and the biceps tendon reflex (trig-
The hand (Manus) is divided into three sections (› Fig. 4.29):
gered by a blow to the attachment tendon above the Tuberosi-
tas radiii) is eliminated. A failure of the M. coracobrachialis, • Wrist (Carpus)
on the other hand, is relatively insignificant. • Middle hand (Metacarpus)
In the case of lesions of the M. triceps brachii, extending the • Fingers (Digiti manus)
elbow is impossible and the triceps tendon reflex (triggered by The digits and the bones of the metacarpus are numbered I–V
a blow to the attachment tendon above the olecranon) cannot from radial to ulnar. The first digit is the thumb (Pollex); the sec-
be triggered. ond digit is the index finger (Index); the third digit the middle fin-
The M. biceps brachii is the marker muscle for spinal cord seg-
ger (Digitus medius); the fourth digit the ring finger (Digitus anu-
ment C6, and the M. triceps brachii for segment C7, because
both muscles are predominantly supplied by the respective
laris); and the fifth digit the little finger (Digitus minimus).
segments. This plays an important role in in the diagnosis of The 8 carpal bones are arranged in 2 rows of 4 bones each (› Fig.
herniated discs in the area of the cervical spine since in these 4.29).
cases, only one of the two muscles fails and not the remaining Proximal row (from radial to ulnar):
muscles supplied by the same nerve. • Scaphoid bone (Os scaphoideum)
• Semilunar bone (Os lunatum)
• Triquetral bone (Os triquetrum)
• Pisiform bone (Os pisiforme)
Dorsal group Distal row (from radial to ulnar):
The M. triceps brachii is the most important extensor in the elbow • Greater multangular bone (Os trapezium)
region (› Fig. 4.26c, › Table 4.10). The Caput mediale and Caput • Lesser multangular bone (Os trapezoideum)
laterale only have an effect on the elbow joint; the Caput longum is • Capitate bone (Os capitatum)
additionally involved in retroversion and adduction in the shoul- • Hamate bone Os hamatum)

Table 4.10 Dorsal muscles of upper arm.

Innervation Origin Attachment Function

M. triceps brachii
N. radialis • Caput longum: Tuberculum infraglenoidale Olecranon Shoulder joint: adduction, retroversion (Caput longum)
• Caput mediale: Facies posterior to the medial Elbow joint: extension (most important muscle)
humerus and distal to the Sulcus nervi radialis
• Caput laterale: Facies posterior of the lateral
humerus proximal to the Sulcus nervi radialis
M. anconeus1
N. radialis Epicondylus lateralis humeri Facies posterior of the ulna, Olecranon Elbow joint: extension
1
The muscle lies on the lateral part of the Caput mediale of the M. triceps brachii.

159
4 Upper extremity

Radius Ulna

Os lunatum

Os scaphoideum

Os capitatum Os triquetrum
Os pisiforme Ossa carpi
Os trapezium Os hamatum, Hamulus ossis hamati
Os trapezoideum

Ossa metacarpi I–V

Phalanx proximalis

Phalanx distalis Ossa digitorum

Corpus phalangis

Caput phalangis
Basis phalangis

Tuberositas phalangis
distalis Fig. 4.29 Hand skeleton, right.
Palmar view.

NOTE
Surprisingly, the relatively senseless mneumonic ‘Some Lovers Try
4.5.7 Joints of the hand
Positions That They Can't Handle’ can, nevertheless, be quite help-
ful in learning the sequence of the individual carpal bones and is A differentiation is made between the following joints or joint
therefore well known to any medical student. groups on the hand:
• Proximal wrist joint (Articulatio radiocarpalis) between the
The carpal bones form the base of the carpal tunnel (Canalis car- radius and proximal row of carpal bones
pi). On both the Os scaphoideum and the Os trapezium a palmar • Distal wrist joint (Articulatio mediocarpalis) between the
tubercle is formed (Tubercula ossis scaphoidei and trapezii). These proximal and distal rows of carpal bones
form the radial wall of the carpal tunnel ‘Eminentia carpi radialis’. • Articulationes intercarpales between individual carpal bones
The ulnar wall is formed by the Os pisiforme together with a prom- • Articulationes carpometacarpales between the distal row of
inence of the hamate bone (Hamulus ossis hamati) ‘Eminentia carpal bones and the Ossa metacarpi
carpi ulnaris’. In this way a groove is formed, referred to as the • Articulationes intermetacarpales between the Ossa metacarpi
­Sulcus carpi. As a roof, the Retinaculum musculorum flexorum • Metacarpophalangeal joints (Articulationes metacarpopha-
closes the groove to the carpal tunnel, through which the tendons langeae) between the Ossa metacarpi and Phalanges proximales
of the long finger flexors and also the N. medianus pass. The pisiform • Articulationes interphalangeae manus between the bones of
bone is also embedded in the tendon of the M. flexor carpi ulnaris the digits
and is thus functionally a sesamoid bone. Accordingly, the ligaments of the joints of the hand are divided
The 5 metacarpals form the bones of the middle hand. In each into different groups:
case, a distinction is made between basis, corpus and caput. As an • Ligaments between forearm and wrist
anomaly the Os metacarpal III has a Proc. styloideus. • Ligaments between the carpal bones
Even in the fingers there are differences. Whereas the thumb con- • Ligaments between carpal bones and metacarpus
sists of 2 bones (Phalanges proximalis and distalis), in the other 4 • Ligaments between the metacarpal bones
digits there are three bones (Phalanges proximalis, media and dis- • Ligaments between metacarpal bones and proximal phalanges of
talis). Just like on the metacarpal bones, here there is also a differ- the digits
entiation between basis, corpus and caput. • Ligaments between the phalanges

NOTE NOTE
All bones of the metacarpus and of the digits are divided into ba- Wrist joints in the proper sense of the word refer to the Articulatio
sis, corpus and caput. The thumb skeleton consists only of 2 radiocarpalis and the Articulatio mediocarpalis, because they en-
bones. sure the movement of the hand opposite the forearm.
Clinically, abbreviations for the finger joints are often used:
MCP = metacarpophalangeal joint (finger basis joint)
PIP = proximal interphalangeal joint (finger middle joint)
DIP = distal interphalangeal joint (finger end joint)

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 4.5 Forearm and hand

Proximal and distal wrist joints Other joints of the wrist and middle hand
The proximal wrist (Articulatio radiocarpalis) is a condyloid joint The Articulationes intercarpales in each row are functionally am-
(› Fig. 4.30). The proximal articular surface is formed by the Fa- phiarthroses because they are tautly tightened by ligaments on the
cies articularis carpalis of the radius as well as by a Discus articu- palmar and dorsal side as well as by interosseous ligaments. In the
laris distal of the Caput ulnae. The distal articular surface is created same way, the Articulationes carpometacarpales II–IV as well as
by 3 of the 4 bones of the proximal row of carpal bones. In this way Articulationes intermetacarpales II–V are clamped to amphiar-
the Os scaphoideum and Os lunatum articulate directly with the throses. The Articulatio carpometacarpalis pollicis (Carpometacar-
radius; in contrast, the Os triquetrum articulates with the Discus pal thumb joint) occupies a special place with its good mobility.
articularis. As ligaments between the carpal bones (› Fig. 4.31) the liga-
These 3 bones in turn form the proximal articular surfaces of the ment complexes can be divided into 3 levels (Ligg. intercarpalia
distal wrist joint (Articulatio mediocarpalis) and articulate here dorsalia, palmaria and interossea). In principle, the ligaments are
with all 4 bones of the distal row of carpal bones. Due to the trans- named according to the bone that they are connected to. Here only
verse intersection of wave-shaped articular surfaces, the distal 3 major ligament structures are highlighted:
wrist joint is an interlocking hinge joint; however, functionally it • The Lig. carpi radiatum radiates on the palmar side in a star
works together with the proximal wrist joint in the sense of a con- shape from the Os capitatum in all directions.
dyloid joint. The Os pisiform is not involved in the formation of • The so-called Lig. carpi arcuatum on the dorsal side connects
the wrist and, therefore, is actually not even a carpal bone. the Os scaphoideum in an arch-like form over the Os lunatum
with the Os triquetrum.
NOTE • The Lig. pisohamatum constitutes the continuation of the at-
In the case of a palmar flexed hand, 2 grooves of skin on the inter- tachment tendon of the M. flexor carpi ulnaris to the hamate
section from forearm to hand are usually noticeable. The proximal bone, into which the Os pisiform is incorporated.
flexor groove (‘Restricta’) projects approximately onto the proximal
wrist joint, the distal flexor groove (‘Rascetta’) roughly onto the Carpometacarpal joint of thumb (Articulatio carpometacarpa-
­distal wrist joint.
lis pollicis)
As the German name suggests (Daumensattelgelenk), this joint is a
Ligaments between forearm and carpal bones (› Fig. 4.31): classic example of a saddle joint. It articulates the concave articular
The following 2 ligaments inhibit ulnar abduction of the hand: surfaces of the Os trapezium and the Basis Ossis metacarpi I.
• Lig. collaterale carpi radiale: strong ligament between Proc. The wide joint capsule is reinforced by palmar and dorsal ligaments
styloideus radii and Os scaphoideum. (Ligg. carpometacarpalia palmaria and dorsalia). Serving as the
• Ligg. radiocarpale palmare: on palmar side runs diagonally most important ligament for stabilising the joint, are fibrous con-
from the radius to the centrally located carpal bones located nections that are referred to as the ‘Lig. trapeziometacarpale pal-
near the ulna. The distal contractions inhibit ulnar abduction mare’, which define abduction of the thumb from palmar outwards
and the proximal parts inhibit adial abduction. (radial abduction).
The following 3 ligaments inhibit radial abduction of the hand:
• Lig. collaterale ulnare: from the Proc. styloideus ulnae to the
Os triquetrum
Clinical remarks
• Lig. radiocarpale dorsale: runs diagonally from the dorsal side Due to the loose ligament fastening of the carpometacarpal
of the radius to the carpal bones located near the ulna, especially thumb joint luxations are very common (classical ‘ski pole
to the Os triquetrum ­injury’ by getting caught in a ski pole strap).
• Lig. ulnocarpale palmare: runs flatly from the Proc. styloideus
ulnae to Os lunatum and Os triquetrum
Particularly palmar, but also dorsally the radial and ulnar ligament
tensors together form the so-called V-ligaments in that they con-
verge on the wrist joint.

Radius Articulatio radioulnaris distalis

Os lunatum
Ulna
Articulatio radiocarpalis
Discus articularis
Os capitatum
Os triquetrum
Os scaphoideum
Lig. collaterale
carpi ulnare
Lig. collaterale carpi radiale

Os trapezoideum Articulatio
mediocarpalis
Os trapezium Os hamatum

Articulatio carpometa- Lig. intercarpale

carpalis pollicis interosseum
Articulationes
Os metacarpi I carpometacarpales

Ligg. metacarpalia interossea Fig. 4.30 Joints of the wrist and

middle hand, right.

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4 Upper extremity

Radius Ulna

Proc. styloideus radii Articulatio radioulnaris distalis

Proc. styloideus ulnae
Os lunatum
Lig. ulnocarpale palmare
Lig. radiocarpale palmare
Os pisiforme
Lig. carpi radiatum Lig. pisohamatum
Articulatio carpometa- Lig. pisometacarpale
carpalis pollicis
Lig. carpometacarpale
Os capitatum palmare
Hamulus ossis hamati

Ligg. metacarpalia
palmaria

Ossa
sesamoidea Ligg. palmaria
Ligg. metacarpalia
a transversa profunda

Ulna
Radius
Proc. styloideus
ulnae
Lig. radiocarpale dorsale
Lig. collaterale
carpi ulnare
Proc. styloideus radii
Os triquetrum
Lig. collaterale carpi radiale

Ligg. intercarpalia Os scaphoideum

dorsalia
Ligg. intercarpalia dorsalia
Os hamatum
Os capitatum Os trapezoideum

Ligg. carpometacarpalia
dorsalia
Ligg. metacarpalia
dorsalia

b
Ligg. collateralia
Articulationes
Fig. 4.31 Ligament systems of
metacarpophalangeae the hand, right. a Palmar view.
b Dorsal view.

Carpometacarpal joints (Articulationes carpometacarpales) Finger joints (articulationes metacarpophalangeae and

II–V and intermetacarpal joints (Articulationes intermetacar- ­articulationes interphalangeae manus)
pales) The metacarpophalangeal joints (Articulationes metacarpopha-
In these joints the distal row of the carpal bones articulates with langeae) II–V are ball joints (› Fig. 4.32). Here they articulate the
the Ossa metacarpi and the bases of the metacarpal bones articu- convex articular surfaces of the heads of the metacarpal bones with
late amongst themselves. The tight ligaments allow Articulationes the articular surfaces of the base of the proximal finger bones that
carpometacarpales II–IV and articulationes intermetacarpales to form the joint socket. As an anomaly, the metacarpophalangeal
become amphiarthroses. Only the carpometacarpal joint of the joint of the thumb forms a hinge joint, whereby only movements
small finger is slightly more flexible, which can be seen by the fact around one axis are possible.
that the ball of the small finger on the intersection to the small fin- Proximal and distal interphalangeal joints of the fingers (Articu-
ger can be deflected in a palmar direction roughly from the level of lationes interphalangeae manus) are hinge joints between the pha-
the palm. This reinforces the concavity of the palm, which is im- langes and accordingly have restricted flexion and extension move-
portant for gripping a spherical object, e.g. a handball. ment capability.
The carpometacarpal joints are stabilised by the Ligg. carpometa- The wide joint capsules of all finger joints are each stabilised by 2
carpalia palmaria and dorsalia (› Fig. 4.31). The Lig. pisometa- ligament systems (› Fig. 4.33):
carpale is the continuation of the M. flexor carpi ulnaris tendon to • Ligg. collateralia (both ulnar and radial)
the Ossa metacarpi IV and V. The Ligg. metacarpalia palmaria, • Ligg. palmaria (ventral)
interossea and dorsalia clamp the metacarpal bones to each other.

162
 4.5 Forearm and hand

0° Passive
Os metacarpi
60° 100°
Articulatio
metacarpophalangea
Dorsal
Phalanx proximalis 30° 30° extension
Active

Phalanx distalis
Articulatio 0°
Articulatio
interphalangea Phalanx interphalangea
manus proximalis media manus distalis

Fig. 4.32 Finger joints (Articulationes digiti), right. Lateral view. Active
Palmar
a b flexion
Os metacarpi
60° 80°
Passive
Lig. collaterale Articulatio
metacarpophalangea
Fig. 4.34 Range of movement of the hand joints.

Ligg. palmaria
Phalanx proximalis greater involvement of this joint in palmar flexion. It is the reverse
in dorsiflexion. Here, the distal row of carpal bones rotates to a
Lig. collaterale greater extent against the proximal row, so that the midcarpal joint
carries out the greater part of dorsal extension.
Articulationes
interphalangeae Phalanx media Radial and ulnar abduction however, occurs around one axis,
manus Lig. collaterale which runs from dorsal to palmar through the Os capitatum. In the
neutral position the Os lunatum is in contact with both the radius
Phalanx distalis
and the Discus articularis. In ulnar abduction the proximal carpal
bones slide radially, so that the Os lunatum is still only abutting the
Fig. 4.33 Ligaments of the finger joints, right. Lateral view. radius. Radial abduction, on the other hand, takes place mainly in
the distal wrist joint; the Os lunatum remains in the proximal wrist
The Ligg. collateralia run diagonally from proximal/dorsal to dis- largely in the central position. Due to the movement of the distal
tal/palmar. The Lig. palmare forms the base of the tendon sheaths row of carpal bones against the proximal, the Os trapezium and the
of the long finger flexors. Os trapezoideum are moved onto the Os scaphoideum. In order to
The joint capsules of the metacarpal joints are also connected to make room for the movement, the scaphoid bone tilts ventrally. In
each other by a diagonally running ligament, the Lig. metacarpale radial abduction from palmar outwards, this tilting is palpable be-
transversum profundum (› Fig. 4.31a). ginning at the ball of the thumb; here one can feel the movement of
the Os scaphoideum.

4.5.8 Hand-joint mechanics NOTE

Palmar flexion as well as radial and ulnar abduction: mainly in the
Proximal and distal wrist joints proximal wrist joint.
Proximal and distal wrist joints do not move in isolation from each Dorsal extension: mainly in the distal wrist joint.
other, but functionally form a single unit. The range of movement
is given in › Fig. 4.34and in › Table 4.11.
In general ulnar and radial abduction as well as the greater part Carpometacarpal thumb joint
of palmar flexion occur in the proximal wrist joint, whilst the In the carpometacarpal thumb joint the following movements
greater part of dorsal extension is carried out in the distal wrist around 2 axes occur:
joint. The movement of the individual carpal bones is, however, • Abduction (abduction of the thumb) and adduction (applica-
more complex. In the case of palmar flexion the proximal row of tion of the thumb to the ring finger) around a slightly slanted
carpal bones rotates against the articular surface of the radius and dorsopalmar axis.
the Discus articularis just like the distal row against the proximal • Flexion (tilting thumb to palmar) and extension (thumb to dor-
one. Due to the stronger rotation in the proximal joint there is sal) around one axis, which runs from the carpometacarpal
thumb joint approximately to the top of the small finger.
Table 4.11 Range of movement from the proximal and distal carpal A special feature in this joint is opposition movement, during
joint. which the tip of the thumb is drawn near to finger tips of the other
fingers. In this case adduction and flexion movements are carried
Movement Range of movement out in combination. In addition, there is a slight rotation around
Dorsal extension/palmar flexion 60°–0°–60° the longitudinal axis of the Os metacarpale I. In the process, the
Ulnar abduction/radial abduction 30°–0°–30°
contact of the articular surfaces of the carpometacarpal thumb
joint is partly neutralised.

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4 Upper extremity

Clinical remarks 4.5.9 Muscles of the forearm and hand

The carpometacarpal thumb joint is designed by the form of
A topographical distinction is made between forearm muscles and
its joint surfaces for movements around 2 axes. In an opposi-
tion movement, however, rotation also ensues, which increas- hand muscles. The forearm muscles are located with their muscle
es stress to the articular surfaces. This non-physiological bellies on the forearm; however, many of them insert in the area of
stress is seen as a reason why arthrosis (rhizarthrosis) often the carpus or the finger bones. Therefore, there are muscles that
occurs in this joint. also move the fingers in addition to acting on the wrist joints. Since
the superficial muscles originate from the Humerus, they are also
involved in flexion of the elbow.
The displacement of the bellies of some stronger muscles for finger
Finger joints movement onto the forearm enables the delicate shape of the hand,
In the metacarpophalangeal joints both flexion/extension move- thus creating the prerequisite for fine motor movements.
ments as well as abduction (abduction of the fingers) and adduc- The hand muscles, on the other hand, have their origin at the hand
tion (adduction of fingers II, IV and V to the middle finger) are bones and thus have no effect on movement of the hand compared
possible due to their spherical shape (› Fig. 4.35, › Table 4.12). to the forearm. Therefore, they only move the fingers.
The Lig. metacarpale transversum profundum limits larger abduc-
tion movements. With a stretched finger even a slight rotation is Forearm muscles
passively feasible at most. The collateral ligaments prevent a larger On the forearm there are 19 muscles in total, making finely tuned
abduction of the fingers in a flexed position of the base joint. movements of the hand and the individual fingers possible. These
In the carpometacarpal thumb joint only marginal abduction or are divided into three groups:
adduction as well as rotation is possible. Here movement is limited • Ventral group
to flexion and extension. • Lateral (radial) group
In the interphalangeal joints once again only flexion and exten- • Dorsal group
sion are possible. Extension is inhibited by the Ligg. palmaria and The ventral and dorsal groups are each divided into a superficial
the Ligg. collateria are also involved. and a deep layer. Due to its innervation the radial muscle group is
often merged with the dorsal group on the forearm to the extensors
Table 4.12 Range of movement in the finger joints. of the wrist.
Ventral superficial group (sequence from radial to ulnar):
Movement Base joints Proximal joints Distal joints
• M. pronator teres (proximal)
Dorsal extension/ 30°–0°–90° 0°–0°–100° 0°–0°–90 • M. flexor carpi radialis
palmar flexion • M. palmaris longus
Ulnar abduction/ (20–40)°–0°–(20–40)° – – • M. flexor digitorum superficialis
radial abduction • M. flexor carpi ulnaris
Ventral deep group (from radial to ulnar):
• M. flexor pollicis longus
NOTE • M. flexor digitorum profundus
In each of the finger joints flexion to around 90° is possible. Signif- • M. pronator quadratus (distal)
icant extension, however, is only possible in the metacarpophalan- Lateral (radial) group (from proximal to distal):
geal joints. Hereby, extension movements in all base joints, espe-
cially those passively involved, vary very differently in their individ-
• M. brachioradialis
ual extents. • M. extensor carpi radialis longus
• M. extensor carpi radialis brevis
Dorsal superficial group (from radial to ulnar):
• M. extensor digitorum
0° • M. extensor digiti minimi
• M. extensor carpi ulnaris
Dorsal deep group (from radial to ulnar):
• M. supinator (proximal)
a • M. abductor pollicis longus
90° • M. extensor pollicis brevis
30° • M. extensor pollicis longus
• M. extensor indicis
In the case of the flexor muscles the division into superficial and
0° deep muscles represents a simplification that occurs due to their
common origins and their innervation. Here, the M. flexor digito-
b rum superficialis lies under the remaining superficial muscles and
forms a middle layer, whilst the M. pronator quadratus is located
0° under the attachment tendons of the remaining deep flexors. Thus,
there are a 4 layers in total.
90°

Superficial flexors
c 100° All superficial flexors have at least one of their origins at the Epi-
condylus medialis humeri and lie ventral of the transverse axis of
Fig. 4.35 Range of movement of the finger joints, right.

164
 4.5 Forearm and hand

M. pronator M. flexor
teres carpi ulnaris
M. palmaris M. flexor
M. flexor carpi
longus digitorum
radialis M. flexor digitorum profundus
superficialis M. pronator
M. flexor quadratus
pollicis longus

a b c d
Fig. 4.36 Ventral muscles of the
forearm, right. Ventral view.

Table 4.13 Ventral superficial muscles of the forearm.

Innervation Origin Attachment Function

M. pronator teres
N. medianus Caput humerale: Epicondylus medialis of the Lateral in the middle of the radi- Elbow joint: pronation (most important muscle), flexion
humerus us
Caput ulnare: Proc. coronoideus
M. flexor carpi radialis
N. medianus Epicondylus medialis of the humerus, Fascia Palmar on Os metacarpi II Elbow joint: flexion, pronation
antebrachii Wrist: palmar flexion, abduction radial
M. palmaris longus (inconstant muscle)
N. medianus Epicondylus medialis of the humerus Aponeurosis palmaris Elbow joint: flexion
Wrist: palmar flexion, tension of palmar aponeurosis
M. flexor digitorum superficialis1
N. medianus • Caput humeroulnare: Epicondylus medialis With 4 long tendons at the mid- Elbow joint: flexion
of the humerus, Proc. coronoideus dle phalanx of the 2nd –5th fin- Wrist: palmar flexion
• Caput radiale: Facies anterior of the radius gers Finger joints (II–V): flexion (most important flexor of the
middle joints)
M. flexor carpi ulnaris
N. ulnaris Caput humerale: Epicondylus medialis of the Via the Os pisiforme and the Ligg. Elbow joint: flexion
humerus pisometacarpale and pisohama- Wrist: palmar flexion, abduction to ulnar
Caput ulnare: olecranon, proximal on the tum at the Basis of Os metacarpi
Margo posterior of the Ulna V and of the Os hamatum
1
The tendons of these muscles are penetrated by the tendons of the M. flexor digitorum profundus shortly before their base.

the elbow joint (› Fig. 4.36, › Table 4.13). Their main function is lies of the middle and the ring finger cover the bellies of the index
movement of the hand and fingers, but they also flex the elbow and the little finger.
joint. All muscles apart from the M. flexor carpi ulnaris are inner- The M. palmaris longus is inconsistent and in about 20% of the
vated by the N. medianus. cases it is missing on one side (visible in a flexed hand position
The M. flexor carpi ulnaris serves as a guide for the N. ulnaris and is when only the tendon of the M. flexor carpi radialis protrudes at
also innervated by it. Its end tendon does not run through the carpal the distal forearm instead of 2 tendons). Apart from the M. flexor
tunnel, but on its ulnar side to the Os pisiform. There it continues carpi ulnaris, the M. palmaris longus is the only one of the long
into the Lig. pisohamatum to the Hamulus ossis hamati and into the flexors whose end tendon does not run through the carpal tunnel.
Lig. pisometarcapale to the Basis ossis metacarpi V.
The M. pronator teres is the most important pronator (› Fig. Deep flexors
4.36). Its two heads are penetrated by the N. medianus, making it The deep flexors originate at the radius, ulna and Membrana inter-
rare that initiation of this nerve occur. ossea antebrachii (› Fig. 4.36, › Table 4.14). Therefore, they have
The M. flexor digitorum superficialis runs to fingers II–V and is no flexion function in the elbow joint. Like the superficial muscles,
the most important flexor in the proximal interphalangeal joints. they are innervated by the N. medianus (albeit by its deep R. inter-
Its 4 end tendons each split into a radial and an ulnar string, each osseus antebrachii anterior). An exception is the M. flexor digito-
of which attaches laterally to the base of the Phalanx media of fin- rum profundus, which receives a double innervation whereby its 2
gers II–V. Between each string there remains a gap, which is pene- radial bellies (for index finger and middle finger) are innervated by
trated by an end tendon of the M. flexor digitorum profundus. The the N. medianus, but the 2 ulnar bellies (for ring and small finger)
4 muscle bellies are not on the same plane, but the two middle bel- by the N. ulnaris. The M. flexor digitorum profundus is similar to

165
4 Upper extremity

Table 4.14 Ventral deep forearm muscles.

Innervation Origin Attachment Function

M. flexor digitorum profundus
N. ulnaris for the ulnar Facies anterior of the Ulna, Distal phalanx of the 2nd–5th Wrist: palmar flexion
part, N. medianus for Membrana interossea fingers Finger joints (II–V): flexion (most important flexor of the
the radial part distal finger joints)
M. flexor pollicis longus
N. medianus Facies anterior of the radius Distal phalanx of the thumb Wrist: palmar flexion
Carpometacarpal thumb joint: flexion, opposition
Thumb joints: flexion
M. pronator quadratus
N. medianus Distal to the Facies anterior of the ulna Facies anterior of the radius Radioulnar joints: pronation

the M. flexor digitorum superficialis with 4 end tendons to fingers Lateral/radial groups
II–V; however, after it has traversed the forked end tendons of the The muscles of the lateral or radial group originate in the area of
M. flexor digitorum superficialis, it inserts to the base of the distal the Epicondylus lateralis and evolutionarily belong to the extensors
phalanges. It is the most important flexor in the distal interphalan- (› Fig. 4.37, › Table 4.15). Like all other extensors of the upper
geal joints (since it is the only one). extremities, they are also innervated by the N. radialis. The term
As the only one of the ventral forearm muscles, the M. flexor polli- ‘extensor’ refers here again to their effect on the wrist joints; how-
cis longus runs to the thumb and with its attachment to the distal ever, in the elbow joint all 3 muscles act as flexors.
phalanx of the thumb, it is also the only flexor in the carpometa- The M. brachioradialis is the muscle which originates furthest to
carpal thumb joint. The M. pronator quadratus lies under all other proximal and is the only one to lie against the Proc. styloideus radii
muscles of the forearm. It is the only one to have an almost trans- thus having no effect on the wrist joints. Therefore, its main func-
verse fibre course and it supports the M. pronator teres during pro- tion is flexion in the elbow joint, where it is the most effective out
nation. of a middle flexed position. It is also involved in both supination

Clinical remarks
In the case of failure or tendon rupture of the M. flexor digito-
rum superficialis flexion in the finger joints is restricted, but
due to the M. flexor digitorum profundus still possible. If this M. brachioradialis
is also affected, e.g. because of a deep laceration, then flex- M. extensor carpi
ion in the proximal and also distal interphalangeal joints is radialis longus
impossible. If the cause is a proximal (!) lesion of the N. medi- M. extensor carpi
anus then, due to the double innervation of the M. flexor digi- radialis brevis
torum profundus, it results in the image of an ape hand.
With the M. flexor digitorum superficialis there is sometimes
also a permanent contraction (dystonia), which often affects
just a single finger (‘writer's cramp’). In these cases, the af-
fected muscle belly must be treated by targeted injection of
botulinum toxin, which inhibits synaptic transmission at the
muscular end sheet.
In the case of lesions of the M. pronator teres pronation of the
forearm is severely affected.
In case of failure of the M. flexor pollicis longus flexion in the
distal interphalangeal joint of the thumb is no longer possible.
Fig. 4.37 Lateral (radial) forearm muscles, right. Dorsal view.

Table 4.15 Lateral (radial) forearm muscles.

Innervation Origin Attachment Function

M. brachioradialis
N. radialis Margo lateralis of the humerus Proximal of the Proc. styloideus Elbow joint: flexion, pronation or supination (out from the
of the radius opposite end positions)
M. extensor carpi radialis longus
N. radialis Crista supraepicondylaris lateralis to Epicon- Dorsal at Os metacarpi II Elbow joint: flexion, slight pronation (out from the oppo-
dylus lateralis site end positions)
Wrist: dorsal extension, abduction to radial
M. extensor carpi radialis brevis
N. radialis Epicondylus lateralis of the humerus Dorsal at Os metacarpi III Elbow joint: flexion, slight pronation (out from the oppo-
site end positions)
Wrist: dorsal extension, abduction to radial

166
 4.5 Forearm and hand

by overlap the muscles of the radial group in the distal third of the
forearm.
The same applies for the M. extensor pollicis longus as for the M.
M. supinator flexor pollicis longus. It is the only muscle that is located at the dis-
M. extensor tal phalanx of the thumb and therefore is the only extensor in the
digitorum
distal interphalangeal thumb joint.
M. extensor M. extensor
pollicis longus
The M. supinator runs from dorsal coming laterally around the
digiti minimi
­radius and inserting at its ventral side (› Fig. 4.38c and › Fig.
M. extensor M. abductor
carpi ulnaris pollicis longus 4.39). It is the most important supinator in an extended elbow joint
M. extensor
(in flexion: M. biceps brachii). The muscle is penetrated by the R.
M. extensor pollicis brevis profundus of the N. radialis (supinator canal), which switches to
indicis the dorsal side of the forearm after coming out of the elbow. The
intersection point through the muscle is covered by a sickle-like
reinforcement of muscle fascia (FROHSE’s arcade) , at which the R.
profundus can be damaged.

a b c Clinical remarks
Fig. 4.38 Dorsal forearm muscles, right. Dorsal view. In the case of failure of the Mm. extensor carpi radialis longus
and brevis a clinical image of drop wrist ensues, as both mus-
(from a pronation position) and pronation (from a supination po- cles serve especially to stabilise the wrist joints. If, however,
sition). the superficial and deep extensors of fingers and thumb fail,
extension of the finger joints is severely impaired, but is still
The Mm. extensor carpi radialis longus and brevis run parallel,
possible due to the effect of the Mm. lumbricales and Mm. in-
share the 2nd tendon compartment with their end tendons and in- terosseis at the proximal and distal interphalangeal joints of
sert side-by-side on the dorsal side of the Os metacarpale II and the fingers; however, at the thumb extension is no longer pos-
III. Since the M. extensor carpi radialis brevis, with its attachment sible and abduction is also decreased. Since extension of the
to the Os metacarpale III, runs very closely to the abduction axis of wrist joints is also necessary for prestretching of the finger
the wrist joints, it has minimal involvement in radial abduction. flexors to counteract their active insufficiency, fist closure is
also weakened when finger extensors fail. In the event of fail-
ure of the M. supinator, supination of the extended arm is no
Superficial extensors
longer possible, but that of the flexed elbow is still possible
The largest superficial extensor, the M. extensor digitorum, inserts because here the M. biceps brachii is the most important mus-
at the dorsal aponeuroses of fingers II–V and is supported in its ex- cle.
tension effect at the little finger by the attached end tendon of the
M. extensor digiti minimi (› Fig. 4.38a, › Table 4.16). The M.
extensor carpi ulnaris, with its attachment at the Os metacarpale
V has no effect on the finger joints, but only serves ulnar abduction Pronators and supinators of the forearm
and extension of the wrist joints. The turning/rotational movement of the forearm is of great signifi-
cance for the functioning of the upper extremity because it increas-
Deep extensors es the range of movement (in conjunction with shoulder joint and
All deep extensors are innervated by the R. profundus of the N. ra- movements of the shoulder girdle) so far that the palm can be ro-
dialis. The M. abductor pollicis longus and the M. extensor polli- tated by 360° in total. In this respect, in the two radioulnar joints
cis brevis (› Fig. 4.38b, › Table 4.17) are very easy to recognise pronation (thumb to medial) and supination (thumb to lateral) of
due to their course. They stretch diagonally from radial and there- 90° from each respective normal position are possible.

Table 4.16 Superficial dorsal forearm muscles.

Innervation Origin Attachment Function

M. extensor digitorum
N. radialis Epicondylus lateralis of the humerus, Fascia Dorsal aponeuroses of the Elbow joint: extension
(R. profundus) antebrachii 2nd–5th fingers Wrist: dorsal extension
Finger joints (II–V): extension (most important extensor of
the base and proximal joints)
M. extensor digiti minimi
N. radialis Lateral epicondyle of the humerus, antebra- Dorsal aponeurosis of the 5th Elbow joint: extension
(R. profundus) chial fascia finger Wrist: dorsal extension
Finger joints (V): extension (most important extensor of
the base and proximal joints)
M. extensor carpi ulnaris
N. radialis • Caput humerale: Epicondylus lateralis of Dorsal at Os metacarpi V Elbow joint: extension
(R. profundus) the humerus Wrist: dorsal extension, abduction to ulnar
• Caput ulnare: Olecranon, Facies posterior
of the ulna, Fascia antebrachii

167
4 Upper extremity

Table 4.17 Dorsal deep forearm muscles.

Innervation Origin Attachment Function

M. supinator
N. radialis Epicondylus lateralis humeri, Crista musculi Facies anterior of the radius Radioulnar joint: supination (most important muscle of
(R. profundus) supinatoris of the ulna, Ligg. collaterale radi- (proximal third) the flexed elbow)
ale and anulare radii
M. abductor pollicis longus
N. radialis Facies posterior of Ulna and radius, Os metacarpi I Wrist: dorsal extension
(R. profundus) Membrana interossea Carpometacarpal thumb joint: abduction
M. extensor pollicis brevis
N. radialis Facies posterior of ulna and radius, Base phalanx of the thumb Wrist: dorsal extension
(R. profundus) Membrana interossea Carpometacarpal thumb joint: abduction, reposition
Metacarpophalangeal thumb joint: extension
M. extensor pollicis longus
N. radialis Distal half of the Facies posterior of the ulna, Endphalanx distalis of the thumb Wrist: dorsal extension
(R. profundus) Membrana interossea Carpometacarpal thumb joint: extension, reposition
Thumb joint: extension
M. extensor indicis
N. radialis Distal quarter of the Facies posterior of the Dorsal aponeurosis of the index Wrist: dorsal extension
(R. profundus) ulna, Membrana interossea finger Finger joints (II): extension, adduction

Humerus
Humerus

M. brachio- M. brachioradialis
radialis

N. medianus
M. biceps brachii
M. biceps
brachii N. medianus

N. radialis, N. radialis,
R. profundus R. profundus

M. pronator teres, M. biceps brachii,

M. supinator Caput ulnare Tendo
M. pronator teres, M. supinator
Caput humerale
M. pronator
M. palmaris teres
longus M. palmaris
M. flexor M. flexor longus
carpi radialis carpi radialis

Radius Radius Ulna

Ulna

M. pronator
quadratus M. pronator
quadratus

Fig. 4.39 Position of the fore-

arm bones and involved mus-
a b cles, right, ventral views. a Pro-
nation position. b Supination
position.

The most important pronators are(› Fig. 4.39a): Although slightly weaker than the M. brachioradialis, the other
• M. pronator teres (strongest pronator!) two muscles of the radial group (Mm. extensor carpi radialis lon-
• M. pronator quadratus gus and brevis) can also act as pronators and supinators, if the fore-
• M. brachioradialis (only from supination position) arm is in the respective opposite position and the muscles are thus
The most important supinators are (› Fig. 4.39b) brought into a position in which they intersect the diagonal axis of
• M. biceps brachii (for flexed elbow) the forearm. In a similar way, the M. flexor carpi radialis and the
• M. supinator (for extended elbow) M. palmaris longus support pronation (› Fig. 4.39a).
• M. brachioradialis (only from pronation position)

168
 4.5 Forearm and hand

NOTE At the ball of the thumb the M. abductor pollicis brevis, the M. flex-
The muscles that are necessary for turning movements have 2 fea-
tures in common:
or pollicis brevis and the M. adductor pollicis are ordered from radi-
• All muscles intersect the diagonal axis of the forearm (› Chap. al to ulnar (› Fig. 4.41, › Table 4.18). The M. opponens pollicis lies
4.1, overview) beneath the M. abductor pollicis brevis. The muscles are mostly in-
• All important pronators and supinators have their attachment at nervated by the N. medianus. Exceptions are the M. adductor polli-
the radius cis, as well as the Caput profundum of the M. flexor pollicis brevis,
which are supplied by the R. profundus of the N. ulnaris.
At the hypothenar eminence the M. abductor digiti minimi, the
Hand muscles M. flexor digiti minimi brevis and the M. opponens digiti minimi
Depending on their localisation the 11 hand muscles are divided can be found in the order from radial to ulnar (› Table 4.19). All
into 3 groups: muscles of the hypothenar eminence are innervated by the N. ul-
• Muscles of the thenar eminence (Thenar) naris (R. profundus). The M. palmaris brevis, on the other hand, is
• Muscles of the middle hand a cutaneous muscle, which has no function for the joints of the lit-
• Muscles of the little finger eminence (Hypothenar) tle finger and is the only muscle to be innervated by the R. superfi-
All hand muscles (apart from the Mm. lumbricales) originate at the cialis of the N. ulnaris.
carpal or metacarpal bones. Innervation is either via the N. ulnaris or The muscles of the middle hand (› Table 4.20) are mainly sup-
the N. medianus; the N. radialis does not supply any hand muscles. plied by the N. ulnaris (exception: Mm. lumbricales I and II – N.
The muscles of the metacarpus are mainly located in the depth of medianus). The Mm. interossei palmares and dorsales together are
the palm or between the finger rays (› Fig. 4.41and › Fig. 4.42), the most important flexors in metacarpophalangeal joints II–V
whilst the thenar and hypothenar muscles mostly run to palmar of (› Fig. 4.42a, b). Due to their course on the sides facing the middle
the hand skeleton (› Fig. 4.40and › Fig. 4.41). They therefore finger, the Mm. interossei palmares adduct fingers II, IV and V in
raise the thenar and hypothenar eminences. the metacarpophalangeal joints › Fig. 4.42c). In contrast, the in-
Thenar muscles: terossei abduct in these joints.
• M. abductor pollicis brevis The Mm. lumbricales similarly flex in the metacarpophalangeal
• M. flexor pollicis brevis joints (› Fig. 4.42d). Due to their distal radiation into the dorsal
• M. opponens pollicis aponeurosis they are, however, the most effective extensors in the
• M. adductor pollicis distal interphalangeal joints.
Lumbrical muscles:
• Mm. lumbricales I–IV
• Mm. interossei palmares I–III 4.5.10 Auxiliary structures of the musculature in
• Mm. interossei dorsales I–IV the area of the hand
Hypothenar muscles:
• M. abductor digiti minimi In the area of the hand, because of the large strain and of the long
• M. flexor digiti minimi brevis course of the tendons, special auxiliary structures (tendon
• M. opponens digiti minimi sheaths) are necessary. Likewise, there are supporting structures
• M. palmaris brevis that prevent tendons shifting against or egressing out of the level of
the palmar or dorsal side of the hand. The Retinaculum musculo-

M. palmaris longus, Tendo

Retinaculum musculorum
flexorum
M. palmaris brevis
Aponeurosis palmaris
M. abductor pollicis brevis
Hypothenar
Thenar

M. flexor M. abductor digiti minimi

pollicis brevis
Lig. metacarpale
transversum superficiale

Mm. lumbricales

Fig. 4.40 Palmar muscles,

Palma manus, right. Palmar
view.

169
4 Upper extremity

Radius

Ulna

M. flexor digitorum
profundus, Tendines

M. abductor digiti minimi

M. abductor
pollicis brevis M. flexor digiti minimi
M. flexor pollicis brevis, M. opponens digiti minimi
Caput superficiale
Mm. lumbricales
M. opponens pollicis

M. flexor pollicis brevis,

Caput profundum
Mm. interossei dorsales
M. adductor pollicis,
Caput transversum

Mm. inter-
ossei
dorsales

Mm. interossei
palmares
Fig. 4.41 Middle layer of the
M. flexor digitorum
hand muscles, right. Palmar
superficialis, Tendines
view.

Table 4.18 Muscles of the ball of the thumb (Thenar muscles).

Innervation Origin Attachment Function

M. abductor pollicis brevis
N. medianus Retinaculum musculorum flexorum, Radial sesamoid bone of the Carpometacarpal thumb joint: abduction, opposition
Eminentia carpi radialis thumb base joint, proximal Thumb base joint: flexion
­phalanx of the thumb
M. flexor pollicis brevis
• Caput superficiale: N. • Caput superficiale: Retinaculum musculo- Radial sesamoid bone of the Carpometacarpal thumb joint: opposition, adduction
medianus rum flexorum thumb base joint, proximal Thumb base joint: flexion
• Caput profundum: N. • Caput profundum: Ossa capitatum and ­phalanx of the thumb
ulnaris (R. profundus) trapezium
M. opponens pollicis
N. medianus Retinaculum musculorum flexorum, Eminen- Os metacarpi I Carpometacarpal thumb joint: opposition
tia carpi radialis
M. adductor pollicis
N. ulnaris (R. profundus) • Caput obliquum: Os hamatum, Ossa meta- Ulnar sesamoid bone of the Carpometacarpal thumb joint: adduction, opposition
carpi II–IV thumb base joint, proximal Thumb base joint: flexion
• Caput transversum: Os metacarpi III ­phalanx of the thumb

Table 4.19 Muscles of the ball of the small finger (Hypothenar muscles).

Innervation Origin Attachment Function

M. palmaris brevis
N. ulnaris Aponeurosis palmaris Skin of the hypothenar eminence Tenses the skin in the area of the hypothenar eminence
(R. superficialis)
M. abductor digiti minimi
N. ulnaris (R. profundus) Os pisiforme, Retinaculum musculorum Proximal phalanx Carpometacarpal joint (V): opposition
flexorum Carpometacarpal joint (V): abduction
M. flexor digiti minimi brevis
N. ulnaris (R. profundus) Retinaculum musculorum flexorum Proximal phalanx of the 5th Carpometacarpal joint (V): opposition
Hamulus ossi hamati ­finger Carpometacarpal joint (V): flexion
M. opponens digiti minimi
N. ulnaris (R. profundus) Retinaculum musculorum flexorum Os metacarpi V Carpometacarpal joint (V): opposition
Hamulus ossi hamati

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 4.5 Forearm and hand

Table 4.20 Muscles of the middle hand.

Innervation Origin Attachment Function

Mm. lumbricales I–IV
N. medianus (I, II); Tendons II–IV of the M. flexor digitorum pro- Projecting radially into the dorsal Metacarpophalangeal joints (II–V): flexion
N. ulnaris fundus (I + II from radial side; III + IV sides aponeurosis (lateral tract) of fin- Finger joints (II–V): extension (most important extensor of
(R. profundus) facing each other, two-headed) gers II–V the metacarpophalangeal joints)
(III, IV)
Mm. interossei palmares I–III
N. ulnaris Ulnar side of the Os metacarpi II, radial side Proximal phalanx and dorsal apo- Metacarpophalangeal joints (II, IV, V): flexion (most
(R. profundus) of the Ossa metacarpi IV and V neurosis (lateral tract) of fingers important flexor!), adduction (to the middle finger)
II, IV and V Finger joints (II, IV, V): extension
Mm. interossei dorsales I–IV (two-headed)
N. ulnaris Sides facing each other of Ossa metacarpi Proximal phalanx and dorsal apo- Metacarpophalangeal joints (II–IV): flexion (most import-
(R. profundus) I–V neurosis of fingers II–IV ant flexor!), abduction (to the middle finger)
Finger joints (II–IV): extension

M. interosseus
M. interosseus dorsalis II
dorsalis III
M. interosseus
M. interosseus palmaris III dorsalis I
M. interosseus
M. interosseus palmaris II dorsalis IV

M. interosseus palmaris I
M. extensor
Mm. interossei digitorum,
palmares tendines

Dorsal aponeuroses:
middle tract
Mm. lumbricales,
a b
tendines

Mm. interossei dorsales Mm. interossei palmares

Dorsal aponeuroses:
lateral tract

M. flexor digitorum
profundus, tendines

M. lumbricalis II M. lumbricalis IV
c Abduction Adduction
M. lumbricalis III
M. lumbricalis I

M. flexor digitorum
superficialis, tendines

M. flexor digitorum
d superficialis, tendines

M. flexor digitorum
profundus, tendines

Fig. 4.42 Muscles of the metacarpus. a Mm. interossei palmares, right. Palmar view. b Mm. interossei dorsales, right, dorsal view. c Mm. inter-
ossei, diagram of their course and function. d Mm. lumbricales, right, palmar view.

171
4 Upper extremity

rum extensorum on the dorsal side is once again divided into in- ger up until their attachment (ulnar tendinous sheath). At the level
dividual chambers, which are called tendon compartments. The of phalanges II–IV there are several tendon sheaths that only com-
Retinaculum musculorum flexorum forms the roof of the carpal municate with the ulnar tendinous sheath in exceptional circum-
tunnel (see also › Chap. 4.10.5). stances.

Tendon sheaths and ligamentous structures of the long flex-

ors
Clinical remarks
The tendon of the M. palmaris longus is located at the palmar apo- Within the tendon sheaths bacterial infections can spread
neurosis. This connective tissue sheet lies superficially directly un- freely. Thus radiating from the little finger outwards all flexor
der the cutaneous integument of the metacarpus, is fastened proxi- tendons may be affected and, due to the geographical proxim-
mally to the Retinaculum musculorum flexorum, and tapers out ity between the ulnar and the radial tendon sheaths in the
area of the wrist, inflammation can spread up to the distal in-
into individual finger rays, which are fixed to the Lig. metacarpale
terphalangeal joint of the thumb. This prospect of the V-phleg-
transversum profundum (› Fig. 4.40). Diagonally running fibres mon can lead to stiffening of the whole hand if treatment is
proximal to the metacarpophalangeal joints are referred to as the insufficient.
Lig. metacarpale transversum superficiale.

The fibrous outer layer (Vagina fibrosa) of the tendon sheaths with
Clinical remarks ring and cross-shaped fibres (Pars anularis and Pars cruciformis),
Benign hardenings and node formations within the palmar which are referred to clinically as the annular and cruciate liga-
aponeurosis can cause movement restrictions and flexion ments, are fixed to the phalanges and joint capsules of the finger
contractions of the finger joints, especially of the little and joints. This ensures the coupling of the end tendons onto the finger
ring fingers. Largely unclear is the cause of DUPUYTREN’s con- bone and avoids detachment during flexion.
traction.

In order to reduce friction, the tendons of the

Clinical remarks
• Mm. flexor digitorum superficial and profundus, Ruptures of the annular and cruciate ligaments of the tendon
• M. flexor pollicis longus and sheaths are especially common in climbing sports because
• M. flexor carpi radialis these structures are put under tremendous pressure.
run in tendon sheaths (Vaginae tendinum) through the carpal
tunnel (› Fig. 4.43). The tendon sheath of the M. flexor pollicis
longus proceeds until the attachment point (radial tendinous Tendon sheaths and ligament structures of the extensors
sheath). The joint tendon sheath of M. flexor digitorum superficial- The Retinaculum musculorum extensorum secures the course of
is and profundus ends roughly at the level of the bases of the meta- the extensor muscles of the hand. For this purpose, it is divided
carpal bones and usually envelops just the tendons to the small fin- into 6 compartments that are numbered from radial from 1 to 6

Vagina tendinis musculi Vagina communis tendinum

flexoris pollicis longi musculorum flexorum

Vagina tendinum musculorum

abductoris longi et extensoris
pollicis brevis
M. flexor carpi ulnaris, Tendo
Vagina tendinis musculi
flexoris carpi radialis
Retinaculum musculorum
flexorum

Vagina tendinis musculi

flexoris pollicis longi

Vagina communis tendinum

musculorum flexorum

Vaginae synoviales
digitorum manus

Fig. 4.43 Tendon sheaths of the

palmar side of the hand, right.
Palmar view.

172
 4.5 Forearm and hand

Vagina tendinum musculorum

Vagina tendinis musculi extensorum carpi radialium
extensoris pollicis longi Retinaculum musculorum
extensorum
Vagina tendinis musculi
extensoris carpi ulnaris Vagina tendinum musculorum
abductoris pollicis longi et
Vagina tendinum musculorum extensoris pollicis brevis
extensoris digitorum et
extensoris indicis

Vagina tendinis musculi

extensoris digiti minimi

Connexus
intertendinei

M. extensor digitorum, Tendines Fig. 4.44 Dorsal tendon

sheaths of the hand, right.

(› Fig. 4.44). (Tip: Dissection of the tendon compartments is use- bres of the Mm. interossei radiate into the lateral tract, but they
ful because it makes it much easier to map the individual muscles!) mainly stretch to the middle tract. Due to the diagonal fibre course
The tendons of the following muscles pass through: of the Mm. interossei and Mm. lumbricales (from palmar of the
rotational axis of the proximal joint to dorsal of the rotational axis
1. Tendon compartment: M. abductor pollicis longus, M. extensor of middle and distal joints) the muscles act as flexors on the proxi-
pollicis brevis mal joints, but as extensors in the middle and end joints.
2. Tendon compartment: Mm. extensores carpi radialis longus
and brevis NOTE
3. Tendon compartment: M. extensor pollicis longus The most important muscles for flexion and extension of the finger
4. Tendon compartment: M. extensor digitorum, M. extensor in- and thumb joints
dicis • Flexion of the finger joints:
5. Tendon compartment: M. extensor digiti minimi – Base joints: Mm. interossei palmares and dorsales
6. Tendon compartment: M. extensor carpi ulnaris – Middle joints: M. flexor digitorum superficialis
Similarly to the flexor muscles, the extensors run in short tendon – End joints: M. flexor digitorum profundus
sheaths through the compartments of the retinaculum. • Extension of the finger joints:

The dorsal aponeurosis is a loose connective tissue ligament struc- – Base and middle joints: M. extensor digitorum, M. extensor in-
dicis
ture that runs on the dorsal side of each finger from the proximal
– End joints: Mm. lumbricales
to the distal phalanx. It is predominantly formed by the end ten- • Thumb (each with a long and a short flexor and extensor)
dons of the long finger extensors, the interossei and Mm. lumbri- – Flexion of the base joint: M. flexor pollicis brevis
cales (› Fig. 4.45) and consists of a medial and a lateral tract: – Flexion of the end joint: M. flexor pollicis longus
• The medial tract is primarily formed by the long finger exten- – Extension of the base joint: M. extensor pollicis brevis
sors and inserts at the proximal and middle phalanges. – Extension of the end joint: M. extensor pollicis longus
• The lateral tract consists primarily of the end tendons of the
Mm. lumbricales and inserts at the distal phalanx.
Because of this configuration the Mm. lumbricales are the most ef- Clinical remarks
fective extensors in the distal interphalangeal joints. Individual fi-
Injuries to the dorsal aponeurosis are common due to its ex-
posed position: In the case of a severance above the metacar-
M. interosseus
pophalangeal joint the finger can no longer be stretched effec-
dorsalis tively in the metacarpophalangeal joint; however, extension in
Lateral tract of the the proximal and distal interphalangeal joints (Mm. lumbri-
dorsal aponeurosis M. extensor cales and interossei, radiating from lateral), remains unaffect-
digitorum, Tendo ed. In a severance of the medial tract above the proximal inter-
Medial tract of the phalangeal joint the lateral tract slips to palmar and flexion in
dorsal aponeurosis the proximal interphalangeal joint and extension in the distal
interphalangeal joint occur (‘boutonniere deformity’). In a
­severance of the lateral tract in the area of the distal interpha-
langeal joint, the distal phalanx falls into a flexed position
(because the Mm. lumbricales become ineffective). The other
M. flexor digitorum joints remain unaffected (‘mallet finger’).
superficialis, Tendo
M. flexor digitorum
profundus, Tendo M. interosseus M. lum-
Rotational axis of the joint palmaris bricalis

Fig. 4.45 Dorsal aponeurosis of the fingers and effect of finger flex-
ors and extensors. [L126]

173
4 Upper extremity

4.6 Nerves of the upper extremity Spinal nerves C4–T3 are involved in sensory innervation of shoul-
der and arm. The Rr. anteriores of spinal nerves C5–T1 merge into
the brachialis plexus (Plexus brachialis), out of which the actual
Skills nerves of the arm and shoulder region finally emerge.
After working through this chapter you should be able to:
• explain the structure of the Plexus brachialis, show its struc-
tures on a specimen, and explain the symptoms associated 4.6.1 Sensory innervation
with plexus lesions
• know the functions and failures of the shoulder nerves
The following nerves ensure sensory innervation of the skin of the
• know the course, function and exact symptoms associated
with failure of major nerves of the arm and show these on a arm (› Fig. 4.46a, b):
specimen. • N. axillaris
• N. radialis

N. radialis, N. cutaneus N. axillaris, N. cutaneus

brachii lateralis inferior brachii lateralis superior

R. palmaris N. musculocutaneus,
N. cutaneus antebrachii lateralis
Nn. digitales pal-
N. medianus mares communes N. radialis,
R. superficialis Nn. supraclaviculares
Nn. digitales pal-
mares proprii Rr. cutanei anteriores
pectorales
Nn. intercostales
Rr. cutanei laterales
Nn. digitales pectorales
palmares proprii
N. ulnaris Nn. digitales pal- N. intercostobrachialis
N. cutaneus R. anterior
mares communes antebrachii N. cutaneus brachii medialis
R. palmaris medialis R. posterior
a

N. cutaneus
brachii posterior
N. axillaris,
N. cutaneus brachii N. cutaneus brachii
N. radialis
lateralis superior lateralis inferior
N. cutaneus ante- R. superficialis
Nn. supraclaviculares
brachii posterior
R. communicans
ulnaris N. radialis
N. cutaneus ante-
brachii medialis Nn. digitales
dorsales

N. medianus, Nn. digitales

Nn. thoracici, palmares proprii
Rr. cutanei posteriores

Nn. digitales
N. radialis, N. cutaneus N. musculocutaneus, palmares proprii
brachii posterior N. cutaneus antebrachii
Nn. digitales N. ulnaris
lateralis
N. cutaneus brachii dorsales
b medialis R. dorsalis
C3

C4
C7 C5
C6

c C8
T1
T2 T3
C3

C4 C5

C6 C7 C8

T2 T1
d T3

Fig. 4.46 Cutaneous nerves and segmental innervation of the upper extremity. a Cutaneous nerves, right, ventral view. b Cutaneous nerves,
right, dorsal view. c Dermatomes, right, ventral view. d Dermatomes, right, dorsal view.

174
 4.6 Nerves of the upper extremity

• N. musculocutaneus Clinical remarks

• N. medianus
Knowledge of the dermatomes is indispensable for diagnos-
• N. ulnaris
ing radiculopathy (damage of the spinal nerve root or the cor-
• N. cutaneus brachii medialis responding spinal section). In the case of intervertebral disc
• N. cutaneus antebrachii medialis prolapses that can lead to compression of the spinal nerve
In addition, individual fibres of the truncal nerves (Nn. intercosto- root, sensory deficiencies or pain in the corresponding der-
brachiales from T2 and T3) are involved in supplying the medial matomes usually enable the affected area to be well localised.
upper arm as they are attached to the N. cutaneus brachii medialis. Dermatomes C6–8 are of particular importance for diagnosis
An important point is that an area of skin is usually supplied in an of herniated discs in the area of the cervical spine.
In addition to the mostly obvious loss of function of the sup-
overlapping fashion by several nerves. The part which is only in-
plied muscles, injuries to the peripheral nerve are recognised
nervated by a single nerve is usually rather small and is referred to by sensory deficits particularly in the autonomic areas.
as an autonomic region.
An area which is specifically supplied by the spinal nerve of a spi-
nal cord segment is called a dermatome (› Fig. 4.46c, d). Whilst
dermatomes on the torso are mostly arranged horizontally, on the
arm they run along its longitudinal axis. As the comparison of 4.6.2 Structure of the Plexus brachialis
› Fig. 4.6with › Fig. 4.43c clearly shows, the torso dermatomes
located at this point were ‘lengthened’ onto the arm during growth The Rr. anteriores of the spinal nerves of C5–T1 form the Plexus
of the extremity buds. brachialis (› Fig. 4.47). This serves as a ‘distribution station’ for
Since the spinal nerves interlace within the Plexus brachialis and the nerve supply of most parts of the arm, since in the arm spinal
are positioned together with the nerves of the arm, the der- nerves are transferred to the nerves of the arm. It can be topo-
matomes do not correspond to the supply area of a nerve. graphically subdivided into:
• Pars supraclavicularis: above the Clavicula
NOTE • Pars infraclavicularis: below the Clavicula
The location of the dermatomes on the arm can be best remem- Individual nerves of the supraclavicular part also receive nerve fi-
bered by imagining the arm abducting by 90° with the thumb di- bres from segments C3 and C4.
rected upwards (› Fig. 4.46d). Here, the dermatomes are essen-
tially arranged from cranial to caudal corresponding to the supply- Pars supraclavicularis
ing spinal nerves segments:
From cranial to caudal:
In the Pars supraclavicularis the Rr. anteriores of 5 spinal nerves
• Shoulder height above the acromion: C4 amalgamate into 3 trunci (trunci):
• Skin above the M. deltoideus: C5 • Truncus superior: receives fibres from C5 and C6
• Radial side of the arm and radial fingers (thumb!): C6 • Truncus medius: is only formed by C7
• Dorsal side of the arm and middle fingers: C7 • Truncus inferior: forms from C8 and T1
• Dorsal side of the arm and ulnar fingers (little finger!): C8 The spinal nerves run together with the A. subclavia through the
• Medial side of the arm: distal: T1, proximal: T2
‘scalene hiatus’ between the M. scalenus anterior and M. scalenus
• Caudal sections of the axillary folds: T3
medius to lateral, then unite into the trunci and enter caudally of
On the ventral side segments C7 and C8 only include the area from
around the distal forearm. the Clavicula and into the axillary cavity. Located ventral of this

C4

IV
* Nn. spinales, Rr. anteriores *
+
a Truncus superior
C5
b Truncus medius
c Truncus inferior V
°
a Fasciculus lateralis *
b Fasciculus posterior C6
c Fasciculus medialis 2 1
VI
*3
Divisiones anteriores
Pars supra- Divisiones 4 + C7
a
clavicularis posteriores 5 VII
*
3
1 N. phrenicus (Plexus cervicalis)
+
b C8
* 2 N. dorsalis scapulae
6
+
c I 3 Rr. musculares
11 * 4 N. suprascapularis
T1 5 N. subclavius
A. axillaris °
a °
b 6 N. pectoralis lateralis
Pars infra- 7 II
7 N. subscapularis
clavicularis °
c 9 10 8 N. thoracodorsalis
9 N. pectoralis medialis
N. musculocutaneus 10 N. thoracicus longus
N. cutaneus brachii medialis 11 N. intercostalis
N. medianus
N. cutaneus antebrachii medialis
N. axillaris
8
N. ulnaris Fig. 4.47 Brachial plexus,
N. radialis Plexus brachialis, right.
Ventral view.

175
4 Upper extremity

neurovascular bundle and in front of the M. scalenus anterior is pathetic nerve fibres HORNER’s syndrome can ensue (nar-
the V. subclavia. rowing of the pupil, drooping upper eyelid, sinking of the
eyeball) on the corresponding side.
Occasionally, a lesion of segment C7 is referred to as a medial
Clinical remarks plexiform lesion, which is not very useful, because the lesion
does not occur in isolation. Rather, segment C7 can be in-
Lesions of the Plexus brachialis are characterised by injury volved in an upper or lower lesion. Since the guide muscle for
(e.g. strain, bruising or tear) of one or more of the spinal nerve C7 is the M. triceps brachii, this usually fails. Depending on
roots, which leads to severe functional deficiencies (› Fig. the extent of dermatome C7, sensation on the dorsal forearm
4.48a). Cause are mostly accidents (typically motorcycle acci- and the middle fingers is affected. In the case of a complete
dents or impacts on the shoulder with hyperextension of the lesion all parts of the Plexus brachialis are affected.
nerve), birth complications or incorrect positioning on the op- Therapeutically, an attempt is made to reconnect the torn
erating table. There are two main types of plexus lesions: nerve roots with each other by suturing the fascicles of the
• Upper plexus paralysis (type ERB, affect C5/C6 for the su­ nerves to their surrounding connective tissue.
perior trunk. It causes failures in the proximal arm area A new procedure in hand surgery is distal nerve transposition,
(› Fig. 4.48b): abduction and lateral rotational weakness of where in the case of upper plexiform lesions, e.g. a fascicle
the arm, failure of flexion in the elbow joint and of supina- from the N. ulnaris is connected to the failed N. musculocuta-
tion. Thus in the medial rotational position the arm (palms neous.
to posterior) the arm hangs flaccidly. In addition, sensory In anaesthesia it is common to perform different operations
deficits, especially at the shoulder, can ensue. using local anaesthesia whereby, e.g. the 3 fascicles of the
• Lower plexus paralysis (type KLUMPKE, affects C8/T1 for the Plexus brachialis are targeted via injections with local anaes-
Truncus inferior). It causes failures in the area of the distal thetics (plexus blockade).
arm, especially of the long finger flexors and the hand mus-
cles as well as sensory deficits mainly in the area of the ulnar
area of the hand (› Fig. 4.46c). Because of the involvement From the Pars supraclavicularis of the Plexus brachialis the fol-
of C8 and T1 and due to damage to preganglionic sym- lowing 4 nerves as well as individual branches to cervical muscles
originate at the level of the trunci (› Fig. 4.49):

Atrophy of the
M. deltoideus

Medulla spinalis Arm cannot

be abducted
C5
Upper plexus lesion
C6
(ERB lesion) Elbow cannot
C7 be bent
Truncus superior
C8
Truncus medius T1 Arm is rotated
internally in the
Truncus inferior shoulder joint
Lower plexus lesion
Fasciculus (KLUMPKE lesion) b
lateralis Ganglion
cervicothoracicum

Truncus sympathicus
Fasciculus medialis
Fasciculus posterior
HORNER syndrome with:
a – ptosis
– miosis
– enophthalmus

Movement of hand and

fingers restricted

Fig. 4.48 Lesions of the Plexus brachialis. a Lesion forms, right. Front view. b Clinical remarks regarding upper plexus lesion (ERB's PALSY).
c Clinical remarks regarding lower plexus lesion (KLUMPKE's PALSY). a [L126 ]; b and c [L238]

176
 4.6 Nerves of the upper extremity

N. occipitalis minor
N. accessorius

Plexus cervicalis, N. dorsalis scapulae

r. muscularis
M. scalenus anterior

M. sternocleido-
mastoideus

N. phrenicus with
accessory phrenic nerve
Nn. subscapulares N. supra-
scapularis V. subclavia
N. axillaris
A. subclavia

N. musculocutaneus M. subclavius

N. subclavius
N. radialis M. pectoralis major

N. pectoralis lateralis
M. coracobrachialis
M. pectoralis minor

N. pectoralis medialis
N. medianus
Nn. intercostales,
Rr. cutanei laterales
A. brachialis
N. thoracicus longus
A. axillaris
N. ulnaris Nn. intercostobrachiales
N. cutaneus
antebrachii medialis M. latissimus dorsi M. serratus anterior

N. cutaneus N. thoracodorsalis M. subscapularis

brachii medialis

Fig. 4.49 Plexus brachialis, right. Ventral view. [L266]

• N. dorsalis scapulae (C3–C5): it penetrates and innervates the M. vicula becomes compressed or injured due to lacerations to
scalenus medius, then runs to the lower edge of the M. levator the lateral thoracic wall, then the clinical image of Scapula
alata ensues due to the failure of the M. serratus anterior
scapulae (guide muscle!) along the Margo medialis of the scapula. (› Fig. 4.50): The scapula is shifted to medial and its medi-
It innervates the M. levator scapulae and the Mm. rhomboidei. al border is raised from the ribcage. Patients are particularly
• N. thoracicus longus (C5–C7): further caudal, the nerve pene- affected by the fact that arm elevation is no longer possible.
trates the M. scalenus medius and runs behind the Clavicula and • N. suprascapularis: a failure can occur due to compression
the Trunci to the anterior abdominal wall and runs on the M. in the Incisura scapulae or injuries in the lateral cervical re-
serratus anterior, which it innervates. gion and due to the absence of the main functions of the M.
• N. suprascapularis (C4–C6): after originating from the Truncus supraspinatus and M. infraspinatus, lead to abduction and
external rotation weaknesses.
superior, the nerve runs together with the A. suprascapularis to • An isolated lesion of the N. subclavius is very rare and has
the Incisura scapulae and under the Lig. transversum scapulae no clear clinical symptoms.
superius into the Fossa supraspinata and around the Spina scap-
ulae under the Lig. transversum scapulae inferius into the Fossa
infraspinata (› Fig. 4.72). There it innervates the M. supraspi- The Trunci of the Plexus brachialis divide after rendering the su-
natus and the M. infraspinatus. praclavicular branches into an anterior and a posterior part (Divi-
• N. subclavius (C5–C6): short branch to the M. subclavius, siones anteriores and posteriores). These then settle at the fasci-
which occasionally issues a branch to the N. phrenicus (so-called
accessory phrenicus, › Fig. 4.49).
• Muscle branches for the Mm. scaleni and the M. longus colli
(C5–C8).

Clinical remarks
Lesions of the shoulder nerves of the Pars supraclavicularis
lead to the following failures:
• N. dorsalis scapulae: in the case of functional failure of the
Mm. rhomboidei the scapula is shifted somewhat laterally
and slightly elevated from the thorax. An isolated lesion is
rare due to its protected location.
• N. thoracicus longus: if e.g. when carrying heavy loads
(backpack palsy) the N. thoracicus longus under the Cla-

Fig. 4.50 Scapula alata. [O932]

177
4 Upper extremity

cles of the Pars infraclavicularis of the Plexus brachialis (› Fig. 4.6.3 N. axillaris
4.47).
The N. axillaris (C5–C6) originates from the posterior fascicle and
Pars infraclavicularis runs together with the A. circumflexa humeri posterior through
The Pars infraclavicularis includes the fascicles from which the main the lateral axillary space (› Fig. 4.72). There it branches under
nerves of the Plexus brachialis then emerge. From the 3 fascicles the the M. deltoideus, which it supplies together with the M. teres mi-
Divisiones anteriores and posteriores of the 3 Trunci are formed: nor (› Fig. 4.51). A sensory branch, the N. cutaneus brachii later-
• Fasciculus posterior: from the Divisiones posteriores of all 3 alis superior, supplies the skin of the shoulder above the M. deltoi-
Trunci (C5–T1) deus. The skin nerve runs through the fascia at the posterior mar-
• Fasciculus lateralis: from the Divisiones anteriores of the trunci gin of the M. deltoideus.
superior and medius (C5–C7)
• Fasciculus medialis: from the Divisio anterior of the Truncus NOTE
inferior (C8–T1) Autonomic region of the N. axillaris: skin above the M. deltoideus
In their course the fascicles become attached to the A. axillaris so
that, as reflected in their names, the Fasciculus posterior lies to
posterior of the artery, the Fasciculus medialis medial and the Fas- Clinical remarks
ciculus lateralis lateral to the artery.
A lesion of the N. axillaris, e.g. due to shoulder luxation or
The fascicles have the following lateral branches, which each serve proximal fractures of the Humerus, is characterised by abduc-
muscular innervation of the shoulder (› Fig. 4.49): tion weakness in the shoulder joint, a sunken shoulder region
• N. pectoralis lateralis (C5–C7): originates from the lateral fasci- due to atrophy of the M. deltoideus (› Fig. 4.52) and a sensory
cle and passes through the Trigonum clavipectorale to the M. deficiency above the M. deltoideus.
pectoralis major, which it mainly supplies.
• N. pectoralis medialis (C8–T1): runs from the medial fascicle
via the M. pectoralis minor to the M. pectoralis major and sup-
plies both muscles. 4.6.4 N. radialis
• Nn. subscapulares (C5–C7): usually 2 short branches from the
posterior fascicle to the M. subscapularis, and more rarely also The N. radialis (C5–T1) continues the course of the Fasciculus pos-
to the M. teres major. terior (› Fig. 4.53). It courses ventrally of the attachment tendon
• N. thoracodorsalis (C6–C8): it runs coming out of the posterior of the M. latissimus dorsi and runs with the A. profunda brachii
fascicle, with the A. thoracodorsalis to the M. latissimus dorsi, through the triceps groove (between the Caput longum and Caput
which it innervates together with the M. teres major. laterale of the M. triceps brachii). In the radial groove it then at-
taches to the humerus and in the radial tunnel between the M. bra-
chialis and M. brachioradialis and runs laterally into the elbow. On
Clinical remarks its way at the upper arm from proximal to distal, it gives off the fol-
Lesions of the shoulder nerves of the Pars infraclavicularis lowing branches:
lead to the following failures: • N. cutaneus brachii posterior: outlet in the area of the triceps
• Nn. subscapulares: for example, with a proximal fracture of groove to supply the skin of the posterior upper arm.
the humerus, muscle function failure of the eponymous • N. cutaneus brachii lateralis inferior: outlet before attaching to
muscles causes significant weakening of medial rotation in
the humerus in the Sulcus nervi radialis.
the shoulder joint.
• N. thoracodorsalis: adduction of the retroverted arm is dis-
rupted. The arms can no longer be crossed behind the back.
The rear axillary fold is sunken. Despite the size of the M.
latissimus dorsi, the damage is minimal since it and the M.
teres major are not particularly important for movement in
the shoulder joint.
Fasciculus posterior
• Nn. pectorales: here, weakness in adduction and antever-
sion often ensues. The arms can no longer be crossed in
front of the body.
M. deltoideus
Injuries to individual nerves are relatively rare due to their pro-
tected position.
N. axillaris

The main nerves of the arm emerging distally from the fascicles are: M. teres minor

Fasciculus posterior: N. cutaneus brachii

• N. axillaris (C5–C6) lateralis superior
• N. radialis (C5–T1)
Fasciculus lateralis:
• N. musculocutaneus (C5–C7)
• N. medianus, radix lateralis (C6–C7)
Fasciculus medialis:
• N. medianus, Radix medialis (C8–T1)
• N. ulnaris (C8–T1)
• N. cutaneus brachii medialis (C8–T1)
• N. cutaneus antebrachii medialis (C8–T1) Fig. 4.51 N. axillaris, right. Dorsal view.

178
 4.6 Nerves of the upper extremity

The N. radialis enters laterally through the radial tunnel (between

the M. brachioradialis and M. brachialis) into the elbow and di-
vides into its 2 terminal branches:
• R. superficialis
• R. profundus

R. superficialis
The purely sensory branch follows the course of the N. radialis fur-
ther. Together with the A. radialis, it runs along the M. brachiora-
dialis (guide muscle!). Then it runs through the Tabatière (‘Fovea
radialis’, between the tendons of the Mm. extensor pollicis longus
and brevis) onto the dorsal side of the wrist, the radial side of which
it supplies. Here, it dispatches the R. communicans ulnaris to the
N. ulnaris. The R. superficialis divides into 5 Nn. digitales, out of
Fig. 4.52 Lesion of the N. axillaris, right. Lateral view. which 2 each provide sensory supply to the radial and ulnar dorsal
side of the thumb and of the forefinger and one supplies the radial
• Muscle branches to the M. triceps brachii: outlet before the Sul- dorsal side of the middle finger (radial 2½ fingers on the dorsal
cus nervi radialis. side); however, this supply area only covers the skin over the proxi-
• N. cutaneus antebrachii posterior: outlet in the Sulcus nervi mal and intermediate phalanges; the dorsal side of the distal pha-
radialis; runs between the attachment of the M. deltoideus and langes is innervated by the terminal branches of the N. medianus
M. triceps brachii through the fascia and supplies the extensor from ventral outwards.
side of the forearm.
• Muscle branches for the radial group of the forearm (M. bra- NOTE
chioradialis, Mm. extensores carpi radialis longus and brevis). Autonomic region of the N. radialis: skin on the dorsal side be-
tween thumb and index finger (first interdigital space).

Fasciculus posterior

N. radialis
N. cutaneus brachii posterior
Triceps slit
N. cutaneus brachii
lateralis inferior
M. triceps brachii
N. cutaneus ante-
brachii posterior
M. brachioradialis
M. extensor carpi radialis longus
M. extensor carpi radialis brevis
Radial tunnel M. brachialis
R. profundus
M. extensor digitorum R. superficialis
Supinator canal
FROHSE’s arcade
M. extensor digiti minimi
M. brachioradialis
M. supinator
M. extensor carpi radialis longus
N. interosseus posterior M. extensor carpi radialis brevis
M. abductor pollicis longus
M. extensor indicis M. extensor pollicis brevis
M. extensor pollicis longus

R. superficialis
Nn. digitales dorsales

Fig. 4.53 Course and innerva-

tion area of the N. radialis,
right. Anterior view.

179
4 Upper extremity

R. profundus
The R. profundus penetrates the M. supinator somewhat distal of
the elbow (supinator canal). At its entrance, the canal is covered
by a crescent-shaped reinforcement of muscle fascia (FROHSE’s ar-
cade). Then the R. profundus loops around the radius onto the
dorsal side of the forearm and runs between the deep and superfi-
cial layers of the extensor muscles distally. On its way it supplies all
the extensor muscles of the forearm and tapers out into the sensory
N. interosseus antebrachii posterior, which is involved in the in-
nervation of the wrist joint.
1
N. radialis
Clinical remarks
N. cutaneus brachii
The N. radialis emits branches over the entire length of the posterior
arm. In the case of injuries to the nerve, symptoms thus de- M. triceps brachii,
pend on the location of the injury (› Fig. 4.54). Caput laterale
There are 3 lesion locations, which have their own clinical
2a
characteristics:
M. triceps brachii,
• Proximal lesion (1 in › Fig. 4.54): the damage in the area of Caput longum
the axilla can be caused by crutches, upon which the weight N. cutaneus
of the body in the axillary cavity is supported. A more com- antebrachii posterior
mon cause is incorrect positioning during an operation. It M. triceps brachii, R. profundus
leads to paralysis of all of the muscles supplied by the N. Caput mediale
2b
radialis. The following movements are not or only weakly
possible:
– Extension in the elbow joint (failure of the M. triceps bra- N. interosseus
chii) antebrachii posterior
– Supination of the extended arm (failure of the M. supina-
tor and of the M. brachioradialis)
– Extension in the wrist and Base/Middle joints (failure of
all dorsal forearm muscles and of the radial group). It
causes an image of drop wrist (› Fig. 4.55): The hand
cannot be raised against gravity.
– A strong closed fist is not possible because, due to the 3
active insufficiency of the finger flexors, dorsal extension R. superficialis
in the wrist joints is necessary.
– Sensory deficiencies are also possible on the back of the
upper arm and forearm, in the first interdigital space and
at the dorsal 2½ fingers.
• Medial lesion (2a and 2b in › Fig. 4.54): a cause of damage
between axilla and forearm can be a pressure sore due to
lying on one's side (‘park bench palsy’), but also fractures of
the upper arm or a compression while passing through the
supinator.
– If the nerve in the Sulcus nervi radialis is damaged (most Fig. 4.54 Lesions of the radial, right. Dorsal view.
commonly, 2a in › Fig. 4.54), there is no loss of exten-
sion in the elbow joint or sensory deficits on the dorsal
Autonomic region of the Nervus radialis
side of the upper arm because the corresponding branch-
es lead off beforehand. The rest of the clinical image cor-
responds to that of a proximal lesion.
– In the case of damage in the area of FROHSE’s arcade (2b
in › Fig. 4.54) only the R. profundus is affected. Sensory
loss of the hand does not appear (R. superficialis intact,
the supply of the wrist joint through the R. profundus is of
little relevance), and drop hand is also not detectable be-
cause the branches to the Mm. extensor carpi radialis
muscles lead off before the M. supinator and these mus-
cles suffice to prevent a drop of the hand against gravity.
A loss of extension in the fingers is noticeably present;
however, the strength in fist closure is also lessened. Fig. 4.55 Clinical aspects of proximal lesion of the N. radialis (‘wrist
• Distal lesion (3 in › Fig. 4.54): with a lesion of the forearm drop’).
or wrist, e.g. due to a laceration or a distal radial fracture,
only the R. superficialis is affected. There are no motor defi-
cits and, therefore, no drop hand. The sensory deficit ex-
tends to the skin in the first interdigital space and over the 4.6.5 N. musculocutaneus
dorsal 2½ fingers.
The N. musculocutaneus (C5–C7) branches off from the lateral fas-
cicle. It usually penetrates the M. coracobrachialis and runs distally
between the M. brachialis and the M. biceps brachii (› Fig. 4.56).

180
 4.6 Nerves of the upper extremity

Fasciculus lateralis

N. musculocutaneus

M. coracobrachialis

M. biceps brachii

M. brachialis

N. cutaneus antebrachii
lateralis

Fig. 4.56 Course and innerva-

tion area of the N. musculocuta-
neous, right. Ventral view.

There it penetrates the fascia laterally somewhat above the elbow medial fascicle on the ventral side of the A. axillaris (› Fig. 4.57).
with its sensory terminal branch, the N. cutaneus antebrachii lat- This formation is referred to as the median fork. The amalgamated
eralis, and supplies the skin at the lateral forearm up to the wrist nerve branch courses distally in the Sulcus bicipitalis medialis on
joints. The N. musculocutaneus issues (in this order) motor branch- the Septum intermusculare brachii mediale and then runs medially
es to supply the M. coracobrachialis, M. biceps brachii and M. of the A. brachialis on the M. brachialis into the elbow. There it
brachialis. Therefore, it supplies all the ventral upper arm muscles. runs between the two heads of the M. pronator teres and further
between the Mm. flexores digitorum superficialis and profundus
up to the wrist joints, where it runs via the carpal tunnel (Canalis
Clinical remarks carpi, bottom: Ossa carpi, roof: Mm. flexores digitorum superficialis
The N. musculocutaneus is endangered in shoulder luxation. and profundus) and further under the palmar aponeurosis to the
As a result of the nerve injury, supination of the flexed elbow fingers (› Fig. 4.73).
and flexion in the elbow joint are extremely restricted. Weak
flexion is still possible because the superficial flexors of the
forearm (innervated by the N. medianus) and the radial mus- Clinical remarks
cle group (innervated by the N. radialis) also carry out this
function. There can be slight sensory deficit on the forearm The very common compression of the N. medianus in its
because the innervation areas of the 3 cutaneous nerves over- course through the Canalis carpi (› Fig. 4.73) is called carpal
lap here. tunnel syndrome. After failure of conventional treatment (pro-
tection, rest), treatment consists of a division of the Retinacu-
lum musculorum flexorum.

4.6.6 N. medianus NOTE

Autonomic region of the N. medianus: distal phalanges of index
The N. medianus (C6–T1) is formed by an amalgamation of the and middle fingers.
Radix lateralis of the lateral fascicle and the Radix medialis of the

181
4 Upper extremity

Fasciculus medialis

Fasciculus lateralis

N. medianus

1a

Septum intermusculare
brachii mediale

1b
M. pronator teres

M. flexor carpi radialis M. palmaris longus

M. flexor digitorum superficialis

N. interosseus
M. flexor pollicis longus antebrachii anterior

M. pronator quadratus M. flexor digitorum

profundus
N. medianus, R. palmaris
M. abductor pollicis brevis
2
M. opponens pollicis
Carpal tunnel, Retinaculum musculorum
M. flexor pollicis brevis, flexorum
Caput superficiale Nn. digitales palmares
communes

Fig. 4.57 Course and innerva-

tion areas of the N. medianus,
right. Ventral view.

The N. medianus first gives off branches at the forearm, thus it has Clinical remarks
no effect at the upper arm. These branches are:
• Rr. musculares run to nearly all ventral forearm muscles (except With the N. medianus a distinction is made clinically between
a proximal and a distal lesion:
the M. flexor carpi ulnaris and ulnar muscle bellies of the M. • Proximal lesion: damage in the area of the Sulcus bicipitalis
flexor digitorum profundus). medialis (1a in › Fig. 4.57, common in the case of lacera-
• N. interosseus antebrachii anterior: it courses with the A. in- tions) or the elbow (1b in › Fig. 4.57, in distal humeral frac-
terossea anterior on the Membrana interossea to the M. pronator tures, incorrect blood withdrawal, compression between the
quadratus. It provides motor innervation to all deep flexor mus- two heads of the M. pronator teres):
cles of the forearm (apart from the two ulnar muscle bellies of – When trying to close the fist, ape hand occurs (› Fig.
the M. flexor digitorum profundus) and from palmar it provides 4.58, failure of the M. flexor digitorum superficialis and
the radial part of the M. flexor digitorum profundus). Fin-
sensory innervation to the wrist joints. gers IV and V can still be partially flexed as the corre-
• R. palmaris: this cutaneous branch supplies the eminence of the sponding sections of the M. flexor digitorum profundus is
thumb and the radial side of the palm. innervated by the N. ulnaris.
• Nn. digitales palmares communes: they emerge after the N. – Thumb-little finger test is negative (failure of the M. op-
medianus has passed through the carpal tunnel and divide again ponens pollicis); the tip of the thumb can no longer touch
into the sensory Nn. digitales palmares proprii. In each case 2 the tip of the small finger.
of these terminal branches supply the palmar surface of the – Hypotrophy of the thenar muscles.
– Ape hand: adduction position due to preponderance of
thumb, index and middle fingers, and a 7th branch stretches to
adduction (the M. adductor pollicis is innervated by the N.
the radial side of the ring finger. These branches additionally in- ulnaris).
nervate the distal sections of the dorsal palms. Therefore, the – Bottle sign: Due to failure of the M. abductor pollicis bre-
branches of the N. medianus provide sensory innervation to the vis, the neck of a bottle can no longer be completely en-
palmar parts of the 3½ radial fingers and their end sections on closed.
the dorsal side. Its motor innervation areas are: – Sensory deficiency on the palmar side of the radial 3½
– most thenar muscles (apart from the M. adductor pollicis and fingers and especially at the distal phalanges of index and
middle fingers.
Caput profundum of the M. flexor pollicis brevis)
– the Mm. lumbricales I and II

182
 4.6 Nerves of the upper extremity

• Distal lesion: this damage in the area of the wrist joints (2 in 4.6.7 N. ulnaris
› Fig. 4.57) is usually the result of carpal tunnel syndrome,
e.g. due to swelling of the tendon sheaths when overbur- Der N. ulnaris (C8–T1) is the thickest branch of the medial fasci-
dened, rheumatic diseases or during pregnancy or due to cle. It runs in the Sulcus bicipitalis medialis to the forearm (› Fig.
lacerations (cutting the ‘arteries’). The symptoms are similar
4.59). In contrast to the N. medianus, it penetrates the Septum in-
to those of a proximal lesion; however, no ape hand occurs,
because the muscular branches for the innervation of the termusculare mediale in the middle of the upper arm and runs
long flexors exit before the carpal tunnel! dorsally onto the extensor side, where it attaches to the Epicondy-
lus medialis of the humerus in the Sulcus nervi ulnaris (cubital
tunnel). On the forearm it runs back on the flexion side in order to
then run together with the A. ulnaris along the M. flexor carpi ul-
Autonomic region
naris (guide muscle!) to the wrist joints and further through the
of the median nerve GUYON’s canal (base: Retinaculum musculorum flexorum, roof:
separation from the flexor, sometimes referred to as the ‘lig. carpi
palmare’) to the palm.

NOTE
In jolting of the elbow, the N. ulnaris can become compressed in
the Sulcus nervi ulnaris. This results in pain and pins and needles
in the sensory innervation area of the nerve (funny bone).
GUYON’s canal is bordered on both sides by parts of the Retinacu-
lum flexorum and therefore lies superficially of the carpal tunnel on
the ulnar side of the wrist (› Fig. 4.73). The GUYON’s canal is tra-
versed by the A., V. and N. ulnaris. The nerve, in particular, can be
damaged here by compression.
Fig. 4.58 Clinical remarks regarding proximal lesion of the N. medi-
anus (‘ape hand’).

Fasciculus medialis

N. ulnaris

Septum intermusculare
brachii mediale

1
Epicondylus
medialis

M. flexor carpi ulnaris

M. flexor digitorum profundus

N. ulnaris, r. dorsalis

2
M. flexor pollicis brevis, GUYON’s canal (Lig. carpi palmare)
caput profundum
R. superficialis
R. profundus

M. adductor pollicis

Mm. interossei
Fig. 4.59 Course and innerva-
tion areas of the N. ulnaris,
right. Ventral view.

183
4 Upper extremity

Like the N. medianus, the N. ulnaris does not give off any branches
on the upper arm. On the forearm 4 branches diverge:
• R. articularis cubiti: to the elbow joint.
• Rr. musculares for the M. flexor carpi ulnaris and the two ulnar Autonomic region
of the ulnar nerve
bellies of the M. flexor digitorum profundus.
• R. dorsalis: it originates half way along the forearm, runs to the
dorsal side and divides into the Nn. digitales dorsales, which
supply the back of hand from the ulnar side as well as the dorsal
side of the 2½ ulnar finger.
• R. palmaris: this small branch supplies the skin above the wrist
and the hypothenar eminence.
In GUYON's canal (› Fig. 4.73) the N. ulnaris divides into its two
terminal branches:
• R. profundus
• R. superficialis
Fig. 4.60 Clinical remarks regarding lesions of the N. ulnaris (‘claw
hand’).
R. profundus
This runs under the M. flexor digiti minimi brevis of the palmar
• Sensory deficiences on the palmar side in the 1½ fingers on
arch to the M. adductor pollicis and to the M. flexor pollicis bre- the ulnar side and especially on the distal phalanx of the
vis. On its way, it supplies the short muscles of the hand that are little finger.
not innervated by the N. medianus: In the case of proximal lesion of the N. ulnaris, as with a proxi-
• All hypothenar muscles mal lesion of the N. medianus, the N. interosseus antebrachii
• All Mm. interossei palmares and dorsales anterior can be diverted onto the respective nerve before en-
• Mm. lumbricales III and IV tering into the M. pronator quadratus in order to remedy the
• M. adductor pollicis loss of function (distal nerve transposition).
• Caput profundum of the M. flexor pollicis brevis

R. superficialis
The predominantly sensory branch (supplies only the M. palmaris 4.6.8 N. cutanei brachii and antebrachii medialis
brevis) runs over the M. flexor digiti minimi brevis distally and
branches further into 2 Nn. digitales palmares communes, which Both nerves are purely sensory and originate from the medial fas-
each divide into the Nn. digitales palmares proprii. cicle (C8–T1). They run in the Sulcus bicipitalis medialis. Fibres of
In this way the ulnar 1½ fingers are supplied from the palmar side the thoracic wall out of T2 and T3 are attached to the very thin and
as well as their distal phalanges dorsally. short N. cutaneus brachii medialis via the Nn. intercostobrachia-
les and supply the skin of the axillary cavity and the medial upper
NOTE arm. The N. cutaneus antebrachii medialis penetrates with the V.
Autonomic region of the N. ulnaris: distal phalanx of the little finger basilica into the upper arm fascia and divides into an R. anterior
and an R. posterior. It supplies the skin of the ulnar forearm up to
the wrist.
Clinical remarks
Regarding the N. ulnaris, a distinction is made between proxi-
mal and distal lesions depending on the location of the lesion, 4.7 Arteries of the upper extremity
whereby the symptoms are so clinically similar that a distinc-
tion is not useful. A proximal lesion occurs at the distal humer-
us, e.g. in fractures, or due to chronic compression in the Sul-
Skills
cus nervi ulnaris (cubital tunnel syndrome). Distal lesions are After working through this chapter, you should be able to:
usually caused by compression in the GUYON's canal (GUY- • identify all arteries of the upper extremity on a specimen
ON’s canal syndrome), e g. through hyperextension of the wrist • explain the vessel anastomoses of the shoulder and the up-
joints when typing at a computer or when (motor)cycling. Both per arm
lesion locations are characterised by the following symptoms:
• Claw hand: due to failure of the Mm. interossei and the ul-
nar Mm. lumbricales, the fingers cannot be flexed in the
base joints or extended in the end joints so that the joints The A. subclavia is the main vessel that supplies the arm (› Fig.
are brought into the respective opposite position by the 4.61). The A. axillaris continues the course of the A. subclavia from
tensing of the long flexors and extensors (› Fig. 4.60). rib I and merges at the lower edge of the M. pectoralis major into
• Atrophy of the hypothenar muscles and the Mm. interossei the artery of the upper arm, the A. brachialis. This runs within the
(sunken areas between the metacarpal bones)
• Thumb-little finger test negative (failure of the M. opponens
Sulcus bicipitalis medialis and is divided within the elbow into the
digiti minimi and the M. adductor pollicis) A. radialis and the A. ulnaris. These two arteries then run on both
• FROMENT's sign: The patient can no longer hold a sheet of the radial and the ulnar side of the ventral forearm to the hand and
paper between the adducted thumb and index finger (failure join together in the palmar hand surface via the deep and superfi-
of the M. adductor pollicis) and compensates by flexion of cial palmar arterial arch (› Fig. 4.61).
the distal phalanx of the joint.

184
 4.7 Arteries of the upper extremity

and the Dura mater and passes through the Foramen magnum
into the cranial cavity (Pars intracranialis), where, after merging
A. thoracoacromialis with the reciprocal artery to the A. basilaris, it is involved in sup-
plying the brain stem, cerebellum and posterior parts (Lobus oc-
A. subscapularis
cipitales and temporalis) of the cerebrum.
A. circumflexa A. axillaris • A. thoracica interna: it emerges caudally and runs about 1 cm
humeri posterior laterally of the edge of the sternum between the Fascia endotho-
A. brachialis
A. circumflexa racica and caudally to the ribs. At the level of the VI rib it splits
humeri anterior
into its two terminal branches (A. musculophrenica and A. epi-
A. profunda gastrica superior). Its branches are:
brachii A. collateralis – Rr. tracheales and bronchiales, Rr. thymici and Rr. mediasti-
ulnaris
A. collateralis superior nales: fine branches to the respective organs and the Mediasti-
media A. brachialis num
– A. pericardiacophrenica: runs with the N. phrenicus be-
A. collateralis tween the pericardium and Pleura mediastinalis to the dia-
radialis phragm, which it supplies along with the pericardium
A. collateralis
ulnaris inferior – Rr. sternales to the sternum
– Rr. perforantes to the chest muscles, they form the Rr. mam-
marii mediales to the chest
R. anterior – Rr. intercostales anteriores (1–6), which anastomose with
A. radialis
R. posterior the Aa. intercostales posteriores and supply ICS 1–6
A. recurrens A. recurrens
radialis ulnaris – A. musculophrenica: runs along the costal arch to the dia-
A. interossea A. ulnaris
phragm and gives off the Rr. intercostales anteriores 7–10.
recurrens – A. epigastrica superior: it continues the course, passes
A. interossea
communis through the Trigonum sternocostale of the diaphragm and
anatomises with the A. epigastrica inferior
A. interossea – Tip: take care when lifting the A. thoracica interna from the
A. interossea posterior
anterior ribs because on its way to the diaphragm it easily ruptures!
A. radialis
A. comitans • Truncus thyrocervicalis: this usually strong vessel trunk
R. carpalis palmaris nervi mediani branches off cranially, runs medially in front of the M. scalenus
R. palmaris R. carpalis dorsalis anterior and divides into 4 branches:
superficialis – A. thyroidea inferior: this is the strongest branch of the
Arcus palmaris Truncus thyrocervicalis, which runs coiled medially with the
profundus Arcus palmaris Rr. glandulares to the caudal sections of the thyroid gland. On
superficialis
its way, it gives off the Rr. pharyngeales to the Hypopharynx,
A. princeps
pollicis Aa. digitales
Rr. oesophageales to the Pars cervicalis of the Oesophagus and
palmares communes Rr. tracheales to the trachea. A stronger branch, the A. laryn-
A. radialis indicis
gea inferior, supplies the larynx from a caudal direction.
Aa. digitales – A. cervicalis ascendens: it runs as a thin vessel on the M. sca-
palmares propriae
lenus anterior cranially to supply the muscles of the neck.
Gives off the Rr. spinales to the spinal cord.
Fig. 4.61 Arteries of the arm
– A. transversa colli (A. transversa cervicis): it runs laterally
and divides into two branches:
– R. profundus: traverses the fascia of the Plexus brachialis
4.7.1 A. subclavia and becomes attached (now called the A. dorsalis scapulae)
to the Margo medialis of the scapula, where it runs caudally to
The A. subclavia originates on the right-hand side from the Trun- supply the superficial back muscles. Anastomises on the dor-
cus brachiocephalicus (1st branch of the aortic arch); on the left sal side of the scapula with the A. suprascapularis and the A.
side, it is a direct outflow (3rd branch) of the aorta (› Fig. 4.62). circumflexa scapulae.
On its way through the scalene hiatus between the Mm. scaleni an- – R. superficialis: traverses the Plexus brachialis and runs to
terior and medius it traverses the pleural cupula and then merges at the lower side of the M. trapezius.
rib I into the A. axillaris. In addition to supplying the arm, with its – A. suprascapularis: this usually rather strong vessel runs
branches the A. subclavia supplies the neck region and the organs over the Plexus brachialis and attaches to the N. suprascapu-
located there, parts of the ventral thoracic wall and parts of the laris. It runs over the Lig. transversum scapulae superius and
brain. This vessel is attached caudally in the scalene hiatus to the under the Lig. transversum scapulae into the Fossa supraspi-
Plexus brachialis, but runs dorsally of the V. subclavia. nata to supply the muscles located there (› Fig. 4.64). An R.
The A. subclavia usually has 4 branches: acromialis runs to the acromion. The A. suprascapularis usu-
• A. vertebralis: it exits medially of the M. scalenus anterior in a ally anastomoses with the A. circumflexa scapulae and often
cranial direction (Pars prevertebralis), moves into the Foramen via fine branches with the A. dorsalis scapulae (shoulder blade
transversarium of the VI cervical vertebra, usually passes anastomoses).
through the other Foramina intertransversaria upwards (Pars • Truncus costocervicalis: this short branch runs caudally and
transversaria), and then lies on the posterior arch of atlas (Pars divides behind the M. scalenus anterior into 2 terminal branch-
atlantica). It then penetrates the Membrana atlantooccipitalis es:

185
4 Upper extremity

A. basilaris
A. vertebralis,
Pars intracranialis
A. vertebralis,
Pars atlantica

A. cervicalis
ascendens A. vertebralis,
Pars transversaria
N. phrenicus
A. transversa colli,
R. superficialis
A. suprascapularis A. thyroidea inferior
A. transversa colli, R. profundus A. vertebralis,
Pars prevertebralis
A. cervicalis profunda

A. dorsalis scapulae Truncus thyrocervicalis

A. supra- Truncus costocervicalis

scapularis
A. intercostalis suprema
Incisura scapulae,
N. suprascapularis A. carotis communis

A. subclavia
Rr. perforantes

A. thoracica interna Rr. sternales

R. intercostalis anterior R. mammarius

medialis
Fig. 4.62 Branches of the A.
subclavia. [S010-2-16]

– A. intercostalis suprema: to the 1st and 2nd ICS 4.7.2 A. axillaris

– A. cervicalis profunda: runs dorsally into the depths to the
prevertebral neck muscles The A. axillaris starts at the lateral margin of the thorax at the level
– Tip: the Truncus costocervicalis can be best demonstrated in of the I rib and traverses the axillary cavity between the M. pecto-
dissection from caudal via the pleural cupola. ralis major and the end tendon of the M. latissimus dorsi (› Fig.
4.63). On the lower edge of the M. pectoralis major it merges into
NOTE the A. brachialis. The outlets of the A. axillaris supply the area of
The A. subclavia, with its outlets, in particular the Truncus thyrocer- the shoulder, its muscles and parts of the anterior abdominal wall.
vicalis is very variable. Therefore, the A. transversa cervicis can be The following 6 branches can be distinguished:
missing and instead the R. superficialis emerges directly (then • A. thoracica superior: this inconsistently thin vessel stretches to
called the A. cervicalis superficialis). The R. profundus is then, as the Mm. pectorales major and minor and also supplies them as
the A. dorsalis scapulae, also a direct branch of the Truncus or orig-
inates from the A. subclavia. The A. thyroidea inferior is also often
parts of the M. serratus anterior.
a direct branch of the A. subclavia.

R. acromialis R. clavicularis

Rr. pectorales A. thoracoacromialis

Rr. deltoideus V. subclavia

A. axillaris A. thoracica
superior
N. medianus
A. thoracica
A. circumflexa lateralis
humeri anterior
N. ulnaris, darunter
A. circumflexa N. cutaneus brachii
humeri posterior medialis
(lateral axillary foramen)
A. subscapularis

A. brachialis
N. radialis
A. circumflexa scapulae
(medial axillary foramen)
A. thoracodorsalis Fig. 4.63 Branches of the A.
axillaris. [S010-2-16]

186
 4.7 Arteries of the upper extremity

• A. thoracoacromialis: the short, strong vessel runs in a ven- the Scapula. The R. acromialis of the A. thoracoacromialis can also
tral-cranial direction and divides within the Trigonum clavipec- be involved in the formation of these bypass circulation (*** in
torale into the following branches: › Fig. 4.64).
– R. clavicularis to the Clavicula
– R. acromialis laterally to the acromion
– R. deltoideus to the M. deltoideus
Clinical remarks
– Rr. pectorales to the Mm. pectorales The shoulder blade anastomoses between the A. suprascapu-
• A. thoracica lateralis: it runs on the M. serratus anterior and laris and the A. dorsalis scapulae from the catchment area of
lateral to the M. pectoralis minor and caudally and gives off the the A. subclavia with the A. circumflexa scapulae from the A.
Rr. mammarii laterales to supply the mammary glands. axillaris constitute important collateral circulation for supply-
ing the arm, when e.g. the vessel is blocked between outflow
• A subscapularis: the short, strong vessel runs along the Margo
of the Truncus thyrocervicalis and the A. subscapularis or
lateralis of the scapula and is divided into 2 terminal branches: needs to be ligated due to vascular injury (› Fig. 4.64).
– The A. circumflexa scapulae passes through the medial axil-
lary space onto the back of the shoulder blade into the Fossa
infraspinata and anastomoses there with branches of the A.
suprascapularis and often via thin branches with the A. dorsa-
lis scapulae (› Fig. 4.64). 4.7.3 A. brachialis
– The A. thoracodorsalis continues the course of the A. sub-
scapularis, accompanies the N. thoracodorsalis and runs ante- The A. brachialis follows the course of the A. axillaris (› Fig. 4.65).
riorly on the M. serratus anterior to the M. latissimus dorsi. It runs on the inner side of the arm distally (Sulcus bicipitalis media-
Both muscles are supplied by this artery. lis) in the neurovascular pathway of the upper arm between the flex-
• A. circumflexa humeri anterior: it runs as a thin vessel for- ors and extensors. Here it is accompanied by the N. medianus and
wards around the proximal humeral shaft to the humeral head, two Vv. brachiales. The A. brachialis then rotates onto the M. brachi-
which it supplies. alis ventrally and runs radially of the N. medianus under the apo-
• A circumflexa humeri posterior: this artery is once again stron- neurosis of the M. biceps brachii into the depth of the elbow, where
ger, passes through the lateral axillary space (› Fig. 4.72) be- it branches into the A. radialis and the A. ulnaris. The A. brachialis
hind the humeral shaft and divides underneath the M. deltoide- supplies the humeral shaft and the distal epiphysis, the muscles of
us, which it also supplies. It anastomoses with the A. circumflexa the upper arm, and the elbow joint. It gives off 3 large branches:
humeri anterior. • A. profunda brachii: it usually exits a few centimetres after the
The branches of the A. axillaris are also relatively variable. The vari- A. circumflexa humeri posterior and rotates dorsally. Between
ations here generally affect the A. thoracoacromialis and the A. the lateral and the medial head of the M. triceps brachii it at-
subscapularis, from which e.g. the Aa. circumflexae humeri anteri- taches to the N. radialis and accompanies it within the Sulcus
or and posterior can branch off. nervi radialis of the humerus. Its branches are:
On the dorsal side of the scapula, 2 branches of the A. subclavia – A. collateralis media: it penetrates the M. triceps brachii and
anastomose with 1 branch of the A. axillaris (› Fig. 4.64). The divides dorsally within a vascular network on the elbow joint
A. suprascapularis (branch of Truncus thyrocervicalis) runs above (Rete articulare cubiti).
the Lig. scapulare transversum superius into the Fossa suprascapu- – A collateralis radialis: it continues the course of the A. pro-
laris and receives inflows from the A. dorsalis scapulae that runs funda brachii on the lateral side of the upper arm and partici-
along the Margo medialis of the scapula. (branch of the A. trans- pates in the Rete articulare cubiti.
versa cervicis from the Truncus thyrocervicalis; * in › Fig. 4.64). • A. collateralis ulnaris superior: this consists of one or more ar-
Both vessels then anastomose with the A. circumflexa scapulae teries along the N. ulnaris to the Rete articulare cubiti.
(branch of the A. subscapularis) (** in › Fig. 4.64), which runs • A. collateralis ulnaris inferior: it originates far distally on the
through the medial axillary space stretching onto the dorsal side of upper arm and stretches to the Rete articulare cubiti.

A. suprascapularis A. axillaris
A. subclavia
*
Rete acromiale

*** A. thoracica
R. acromialis
superior
R. deltoideus

A. circumflexa A. thoraco-
humeri posterior acromialis

**
A. circumflexa Fig. 4.64 Anastomoses
humeri anterior between A. subclavia and
A. thoracica lateralis
A. axillaris, right. Ventral view; *
anastomosis between A. supras-
A. subscapularis capularis and A. dorsalis scapu-
A. profunda brachii lae, ** further anastomosis with
the A. circumflexa scapulae,
A. brachialis A. circumflexa scapulae *** R. acromialis of the A. thora-
coacromialis.

187
4 Upper extremity

A. brachialis
N. ulnaris

A. collateralis
N. medianus ulnaris superior
A. collateralis
ulnaris inferior

M. biceps brachii,
Aponeurosis
A. recurrens
radialis A. ulnaris

A. radialis
A. brachialis N. radialis
A. profunda
N. medianus brachii

M. brachio-
A. collateralis radialis M. flexor carpi
ulnaris superior ulnaris

R. palmaris N. ulnaris
superficialis
M. biceps brachii, A. collateralis A. ulnaris
Aponeurosis ulnaris inferior A. radialis
M. brachialis
Aponeurosis palmaris
A. recurrens
radialis
M. palmaris brevis
A. ulnaris
A. radialis

Aa. digitales palmares

communes
Aa. digitales palmares
Fig. 4.65 Branches of the A. brachialis. [S010-2-16] propriae

Fig. 4.66 Branches of the A. radialis. [S010-2-16]

Clinical remarks
Due to the mostly well-defined anastomoses over the 4 collat- A. collateralis
A. brachialis
eral arteries of the upper arm with the 3 recurrent arteries from ulnaris superior
the forearm (see below) in the area of the Rete articulare cubi-
ti, the A. brachialis can be safely ligated distally of the outlet of N. medianus
A. collateralis
the A. profunda brachii, e.g. in the case of severe haemorrhag- ulnaris inferior
ing; however, the A. brachialis should never be ligated be- N. radialis A. ulnaris
tween the outflow of the A. subscapularis of the A. axillaris and
A. recurrens
the A. profunda brachii because there are no collaterals here! A. recurrens
ulnaris
This section of the artery is essential for supply of the arm. radialis
A. interossea
M. supinator
communis
A. radialis A. comitans
nervi mediani
N. radialis,
A. ulnaris
R. superficialis
4.7.4 A. radialis M. flexor
carpi ulnaris

In the elbow the A. brachialis forks into the A. ulnaris and the A. N. ulnaris

radialis (› Fig. 4.66, › Fig. 4.67, › Fig. 4.68). The A. radialis lies M. flexor digitorum
profundus
in the elbow radially to the M. pronator teres and then runs togeth-
er with the R. superficialis of the N. radialis distally along the M.
brachioradialis. The pulse of the artery can be felt at the distal end
of the radius by using the bone as a bearing. Here, the A. radialis ro- R. palmaris
tates dorsally and moves into the ‘tabatière’ on the radial side of the superficialis
carpus, to then pass through the M. interosseus dorsalis I into the R. palmaris
Retinaculum profundus
palm to form the deep palmar arch (Arcus palmaris profundus). flexorum
Arcus palmaris
superficialis
NOTE Aa. digitales palmares
The tabatière (French: snuff box, also referred to as the ‘Fovea ra­ communes
dialis’) is a depression in the area of the metacarpal bones that is
especially visible in an abducted thumb and is formed by the end
tendons of the M. extensor pollicis brevis on one side, and on the Aa. digitales
other by the M. extensor pollicis longus. The Os scaphoideum palmares propriae
forms the floor. In addition to the A. and V. radialis the R. superfi-
cialis of the N. radialis also traverse this area proximally. Fig. 4.67 A. radialis and A ulnaris with superficial palmar arch.
[S010-2-16]

188
 4.7 Arteries of the upper extremity

The A. radialis shares the blood supply of the entire forearm and 4.7.5 A. ulnaris
the hand with the A. ulnaris. It usually gives of 7 branches:
• A. recurrens radialis: it is the only branch at the proximal fore- After exiting from the A. brachialis, the A. ulnaris runs under the
arm, runs on the radial side beneath the M. brachioradialis to N. medianus and the M. pronator teres to the ulnar side of the fore-
the Rete articulare cubiti and supplies the surrounding muscles. arm (› Fig. 4.67). Here it attaches to the N. ulnaris and runs along
• R. carpalis palmaris: it runs into the carpal channel and sup- the M. flexor carpi ulnaris to the hand. There it runs between the
plies it. Os pisiforme and Hamulus ossis hamati into the GUYON's canal
• R. palmaris superficialis: together with the A. ulnaris it forms and then turns off into the palm to form the superficial palmar
the superficial palmar arterial arch under the palmar aponeuro- arch (Arcus palmaris superficialis). It has 5 branches:
sis (Arcus palmaris superficialis). • A. recurrens ulnaris: it runs proximally under the M. pronator
• R. carpalis dorsalis: this branch essentially feeds the Rete car- teres to the N. ulnaris and the Rete articulare cubiti.
pale dorsale in the area of the Retinaculum musculorum exten- • A. interossea communis: as the most powerful branch of the A.
sorum. Originating from the Rete carpale dorsale are the Aa. ulnaris, it medially runs a short section distally on the M. flexor
metacarpales dorsales, which each divide into 2 Aa. digitales digitorum profundus until it divides into the following branches:
dorsales to supply the posterior side of the fingers. – A. interossea anterior: it runs on the Membrana interossea
• A. princeps pollicis: it originates as the A. radialis passes antebrachi and penetrates far distally to discharge into the
through the M. interosseus dorsalis I and supplies the palmar Rete carpale dorsale.
surface of the thumb. – A. comitans nervi mediani: this usually thin vessel accompa-
• A. radialis indicis: it runs along the radial side of the index fin- nies the N. medianus (can also be strongly formed as an em-
ger. bryonic relic and connect to the palmar arches).
• Arcus palmaris profundus› Fig. 4.68): below the M. adductor – A. interossea posterior: it runs through a proximal gap in the
pollicis it overlies the bases of the 2nd 4th metacarpal bones and Membrana interossea antebrachii and runs on the dorsal side
connects to the R. palmaris profundus of the A. ulnaris. The Ar- of the membrane together with the R. profundus nervi radialis
cus palmaris profundus gives off 3 Aa. metacarpales palmares to the Rete carpale dorsale. Under the M. anconeus, the A. in-
to supply the Mm. interossei, which connect distally with the terossea recurrens reaches the Rete articulare cubiti.
digital arteries. • R. carpalis dorsalis: this branch runs to the dorsal side of the
wrist and discharges into the Rete carpale dorsale; however, it is
much weaker than the corresponding radial vessel.
Clinical remarks • R. palmaris profundus: it branches off in the GUYON's canal
Due to their superficial position and the many bony abut- and penetrates the hypothenar muscles to run to the Arcus pal-
ments, the distal sections of the A. radialis are very vulnera- maris profundus.
ble to injury; however, an arterial puncture here (e.g. for • Arcus palmaris superficialis: it lies under the palmar aponeuro-
blood gas analysis) is also easily possible. Due to its good ac- sis on the tendons of the long finger flexor, is fed mainly from
cessibility, the A. radialis is increasingly also the access route
the A. ulnaris and anastomoses with the R. palmaris superficialis
of choice for angiographic examination of the coronary arter-
ies (‘coronary catheter’). of the A. radialis. Originating from the superficial palmar arch
are the Aa. digitales palmares communes, which branch into 2
Aa. digitales palmares propriae along the finger edges.

A. ulnaris M. flexor carpi ulnaris

M. flexor carpi
radialis, Tendo R. carpalis dorsalis
A. radialis R. carpalis palmaris
M. abductor pollicis R. palmaris profundus
longus, Tendo
Rr. perforantes
R. carpalis palmaris
R. palmaris superficialis
Arcus palmaris
A. princeps pollicis profundus

A. radialis Aa. metacarpales

indicis palmares

Aa. digitales
palmares propriae

Aa. digitales
palmares communes
Fig. 4.68 A. ulnaris and A. radi-
alis with deep palmar arch.
[S010-2-16]

189
4 Upper extremity

Clinical remarks 4.8 Veins of the upper extremity

In a clinical examination the following pulses can be palpated
on the arm: the pulse of the A. radialis on the radial side of the Skills
wrist (ulnar of the tendon of the M. brachioradialis), the pulse
of the A. ulnaris on the ulnar side of the wrist (radial of the After working through this chapter, you should be able to:
tendon of the M. flexor carpi ulnaris). In addition, the pulse of • understand the basic principles of the venous outflow of the
the A. axillaris can be palpated in the distal axillary cavity and upper extremity
the A. brachiali can be palpated in the Sulcus bicipitalis medi- • know the large epifascial veins and show them on a specimen
alis , which, however, is less commonly used.
On the arm a system of deeply located veins, which accompany the
arteries, is differentiated from a superficial system that runs in the
NOTE subcutaneous adipose tissue. (› Fig. 4.69).
The A. ulnaris forms the Arcus palmaris superficialis, the A. radialis
forms the Arcus palmaris profundus.
4.8.1 Superficial veins

The superficial veins designated as cutaneous veins always lie over

the fascia of the upper arm and forearm, Fascia brachii and Fascia
antebrachii. A distinction is made between 2 large cutaneous vein
branches (› Fig. 4.69a):

Nodus lymphoideus
deltoidopectoralis V. subclavia
V. cephalica

V. axillaris

Nodi lymphoidei
axillares V. profunda brachii Nodi lymphoidei
axillares
V. thoracoepigastrica

(Hiatus basilicus)
V. cephalica

V. basilica Vv. brachiales

V. mediana cubiti Superficial

lymph collectors
Nodi lymphoidei
cubitales
Deep lymph
V. mediana antebrachii collectors
Vv. radiales
V. cephalica antebrachii
Vv. ulnares
V. basilica antebrachii Vv. interosseae

Arcus venosus Arcus venosus

palmaris superficialis palmaris profundus

Vv. metacarpales
palmares

Vv. digitales palmares

a b

Fig. 4.69 Veins and lymphatic pathways of the arm, right. Ventral view. a Superficial system. b Deep system.

190
 4.9 Lymphatic vessels of the upper extremity

• V. basilica: it courses proximally as a strong vessel in the Sulcus 4.9 Lymphatic vessels of the upper extremity
bicipitalis medialis, penetrates the Fascia brachii at variable
heights on the upper arm, and discharges into the Vv. brachiales.
• V. cephalica: this generally relatively thin vein runs laterally on
Skills
the upper arm proximally, traverses the upper arm fascia and After working through this chapter, you should be able to:
runs in the gap between the M. deltoideus and M. pectoralis ma- • know the principles of lymphatic drainage of the upper ex-
jor. It discharges within the Trigonum clavipectorale (Fossa in- tremity
fraclavicularis, MOHRENHEIM groove) into the V. axillaris. • explain the lymph node stations in the axillary cavity and
their clinical relevance
The superficial venous outflow of the hand is focused on the dorsal
side of the Rete venosum dorsale manus. In the palmar direction
there is usually an Arcus venosus palmaris superficialis. The V. ce-
phalica antebrachii collects blood on the radial side of the hand,
runs radially on the extension side of the forearm proximally, and 4.9.1 Epifascial and subfascial lymph vessels
carries the blood of the V. cephalica. The V. basilica antebrachii
runs on the ulnar edge of the arm and merges into the V. basilica. Similar to the veins, the lymph vessels run either epifascially or
The V. mediana cubiti connects the V. cephalica with the V. basili- subfascially (› Fig. 4.69).
ca in the elbow. In addition to the superficial vessel networks, there The superficial collectors form 3 bundles in the forearm (radial,
are often even larger vein branches (e.g. the V. mediana antebra- ulnar and medial bundle), which in the elbow predominately con-
chii in the middle of the flexion side of the forearm). The superfi- verge to the medial collector bundle of the upper arm around the
cial veins are connected via their connecting vessels (Vv. per- V. basilica. This finally discharges into the axillary lymph nodes.
forantes) to the deep veins. The dorsolateral bundle around the V. cephalica enables a second
drainage path on the upper arm, the lymph vessels of which ulti-
NOTE mately flow into the supraclavicular nodes and partially into the
The superficial veins of the arm are very variable. Therefore, e.g. axillary lymph nodes. Individual lymph nodes can be installed into
the V. cephalica or the V. mediana cubiti can be missing or addi- this bundle as an initial filter station, e.g. the Lnn. cubitales in the
tional cutaneous veins may be present. Due to the exposed loca- elbow.
tion in the subcutaneous adipose tissue, the vessels are very suit- The subfascial collectors accompany the large venous branches
able for blood collection or for intravenous administration of
drugs. For this purpose, the large calibre V. mediana cubiti in the
and also flow into the axillary lymph nodes. Here again, individual
elbow is particularly used; however, by palpation in the elbow for a regional lymph nodes, such as e g. the Lnn. brachiales can be inte-
pulse it is essential that a superficially routed A. brachialis must be grated into the deep collectors.
excluded (variation in approximately 8% of people).

4.9.2 Lymph nodes of the axilla

4.8.2 Deep veins The lymph nodes of the axilla drain almost the entire lymphatic
system of the upper extremity, as well as the upper quadrants of the
In the case of the deep veins, typically 2 veins accompany 1 artery ventral and dorsal abdominal walls. Of high clinical relevance is
(› Fig. 4.69b). These veins are often connected to each other in that fact that up to 50 lymph nodes can receive lymph from large
the form of a rope ladder via cross-bridges. Since there are only ar- parts of the mammary glands (› Fig. 4.70). The lymph nodes are
tery-accompanying veins in the deep system, they are named after divided into three levels and into different groups relative to their
the respective artery. The V. axillaris and the V. subclavia are usual- position to the M. pectoralis minor.
ly only present once on each side of the body. Both veins are locat- • Level I: lateral to the M. pectoralis minor
ed in front of their arterial counterparts. Whilst the A. subclavia – Lnn. paramammarii (at the lateral border of the mammary
passes through the scalene hiatus, the V. subclavia runs ventrally to gland)
the M. scalenus anterior. – Lnn. axillares pectorales (along the A. thoracica lateralis)
– Lnn. axillares subscapulares (around the A. subscapularis)
– Lnn. axillares laterales (lateral to the A. axillaris)
Clinical remarks • Level II: ventral and/or dorsal to the M. pectoralis minor
Since the V. subclavia is superficial and lies in front of the A. – Lnn. interpectorales (between the two Mm. pectorales)
subclavia, it is preferentially used to apply a central venous – Lnn. axillares centrales (under the M. pectoralis minor on the
catheter (CVC). As a guiding structure for the route of the A. axillaris)
puncture cannula, the lower edge of the clavicula is used. The • Level III: medial to the M. pectoralis minor
risk of incorrect puncture of the A. subclavia is very low, but
– Lnn. axillares apicales (in the area of the Trigonum clavipec-
following the puncture a breach of the rib cage must be ex-
cluded by a chest x-ray examination. torale = Fossa infraclavicularis = MOHRENHEIM groove)
The lymph initially flows mostly into the lymph nodes of levels I
and II, to then be conducted further to those of level III. After-
The deep veins of the arm are equipped with many venous valves. wards, the lymph flows into the Truncus subclavius. Thus, abnor-
These allow a blood flow directed towards the heart in any position mal cells, e.g. in tumours of the mammary gland, can be found in
of the arm. the temporal course often initially in levels I and II and only later
in level III. From level III, they enter via the subclavian trunk into
the Ductus thoracicus or directly into the left venous angle or on
the right side via the Ductus lymphaticus dexter into the right ve-
nous angle.

191
4 Upper extremity

Nodi lymphoidei
axillares apicales

Level I Level II Level III

Nodi lymphoidei axillares
centrales

Nodi lymphoidei
axillares humerales
[laterales]
Nodi lymphoidei
A. axillaris interpectorales

V. axillaris

Nodi lymphoidei axillares

subscapulares

Nodi lymphoidei
axillares pectorales
Aa.; Vv. mammariae
Aa.; Vv. mammariae
mediales
laterales
Nodi lymphoidei
paramammarii

A.; V. thoracica lateralis

Fig. 4.70 Lymph nodes of the

axilla.

Clinical remarks 4.10.1 Trigonum clavipectorale

Precise knowledge of the various lymph node stations is deci- The Trigonum clavipectorale (Fossa infraclavicularis, MOHREN-
sive, e.g. in the case of tumours of the mammary gland (breast HEIM groove) is a triangular depression of the ventral abdominal
cancer). Due to the frequency (most frequent malignant tu-
wall (› Fig. 4.71). It is bordered laterally by the M. deltoideus, me-
mour in women, every 10th woman suffers from breast cancer,
but men can also be affected) breast cancer must thus be ad- dially by the M. pectoralis major and cranially by the Clavicula.
dressed and ruled out in the case of any enlargement of the The MOHRENHEIM groove is used by various vascular, lymphat­
axillary lymph nodes. The number and location of affected ic and nervous systems as a passageway through the Fascia clavi-
lymph nodes is thereby important for tumour staging and thus pectoralis:
also determines treatment. In the past, all 3 levels, including • Nn. pectorales medialis and lateralis: to the M. pectoralis major
the pectoral muscles were resected, which was extremely dis- and M. pectoralis minor
figuring. For a long time it was standard to remove level I with
• A. thoracoacromialis: divides here into its terminal branches
the breast in order to analyse the lymph nodes. Today, treat-
ment is more sophisticated. Often treatment can preserve the • V. cephalica: enters here into the depths into the V. axillaris
breast and lymph node metastasis can be excluded by means • Lnn. axillares apicales
of scintigraphic representation of a sentinel lymph node. In
the case of complete removal of the lymph nodes (axillary
lymphadenectomy) oedema in the arm can form due to the 4.10.2 Axillary cavity
lack of removal of tissue fluid via the lymph.
The axillary cavity (Fossa axillaris) is a cavity somewhat pyramidal
in shape when the arm is hanging down loosely and filled with fat
and connective tissue. This is traversed by all vascular, lymphatic
4.10 Topographically important aspects of the and nervous systems that supply the arm (exception: V. cephalica
arm with surrounding lymphatic pathways). The skin of the axillary
cavity forms the bottom of the pyramid, the tip extends to the
shoulder joint. The anterior axillary fold is formed by the M. pecto-
Skills ralis major and the posterior axillary fold by the M. latissimus dor-
After working through this chapter, you should be able to: si.
• know the vascular, lymphatic and nervous systems that tra- Within the Fossa axillaris the 3 fascicles of the Plexus brachialis
verse the MOHRENHEIM groove run dorsally, medially and laterally to the A. axillaris. The V. axil-
• name the boundaries of the axillary spaces, and define the laris is located ventrally of this neurovascular bundle. In addition
penetrating structures and locate them on a specimen
to a large number of axillary lymph nodes, there are also the corre-
• define the course of the vascular, lymphatic and nervous
systems in the elbow sponding efferent and afferent lymphatic vessels.
• explain the composition and penetrating structures of the The vascular, lymphatic and nervous systems exit the axilla via the
carpal tunnel and GUYON's canal. axillary space dorsally.

192
 4.10 Topographically important aspects of the arm

Fasciculus lateralis Fasciculus medialis

Fasciculus A. axillaris
Rete acromiale posterior Clavicula
V. axillaris
Acromion

M. subclavius
M. deltoideus,
Pars clavicularis

Fascia clavipectoralis
V. cephalica N. pectoralis medialis

A. thoracoacromialis,
Rr. pectorales
M. pectoralis major,
Pars clavicularis

Fig. 4.71 Trigonum clavipec-

torale, right. Ventral view.

4.10.3 Axillary spaces and triceps groove Table 4.21 Delineating and permeating structures of axillary spaces
and triceps groove.
There are 2 axillary spaces (› Fig. 4.72):
• Medial axillary space (triangular) Medial axillary space Lateral axillary space Triceps groove
• Lateral axillary space (quadrangular) Delineation
Caudal of the lateral axillary space is the triceps groove, through • M. teres minor • M. teres minor • Caput longum of the
which the N. radialis runs in order to become attached to the • M. teres major • M. teres major M. triceps brachii
­humerus in the Sulcus nervi radialis (› Table 4.21). • Caput longum of the • Caput longum of the • Caput laterale of the
M. triceps brachii M. triceps brachii M. triceps brachii
• Humerus

4.10.4 Elbow Penetrating vascular, lymphatic and nervous systems

• A. circumflexa • A. circumflexa humeri • A. profunda brachii
The elbow (Fossa cubitalis) lies ventrally between the upper and scapulae posterior • N. radialis
the lower arm and is bordered on the radial side by the M. brachi- • V. circumflexa • V. circumflexa humeri
scapulae posterior
oradialis and by the M. pronator teres on the ulnar side. The base is
• N. axillaris
formed by the attachment tendons of the M. biceps brachii and the
M. brachialis.
Many vascular, lymphatic and nervous systems branch in the elbow
on their way to the forearm. Found in the depth of the elbow from
radial to ulnar are:

A.; V.; N. suprascapularis

A.; V.; N. dorsalis Lig. transversum

scapulae scapulae superius

Lig. transversum
scapulae inferius

Lateral axillary space with

N. axillaris and A.; V. circum-
flexa humeri posterior

Medial axillary space with

A.; V. circumflexa scapulae

Triceps slit with N. radialis

and A.; V. profunda brachii
M. teres minor

M. teres M. triceps brachii, Fig. 4.72 Diagram of axillary

major caput longum cavities and the triceps groove,
right. Dorsal view. [L126]

193
4 Upper extremity

• N. radialis with the A. collateralis radialis. Division into R. pro- Clinical remarks
fundus and R. superficialis
In both spaces, the nerves can be damaged, e.g. because of
• A. brachialis. Division into A. radialis and A. ulnaris. The latter
compression or lacerations (distal lesion of the N. medianus
gives off the A. interossea communis. or the N. ulnaris). Because various muscle tendons in their
• N. medianus, penetrates between the heads of the M. pronator tendon sheaths run through the carpal tunnel, carpal tunnel
teres and traverses the A. ulnaris. syndrome can also be caused by a tenosynovitis after over-
The deep compartment is terminated towards the surface anatomy load of the muscles, rheumatic diseases or oedema in preg-
by the M. bicipital aponeurosis. Running very variably over the nancy. If there is no improvement after conservative treat-
aponeurosis in its place are the V. cephalica antebrachii and the V. ment, treatment is by partitioning of the enveloping liga-
ments.
basilica antebrachii as well as the V. mediana cubiti as their con-
nection.
The base of the carpal tunnel is formed by the carpal bones. The
proximal bones (Os scaphoideum and Os trapezium) also form the
Clinical remarks radial wall of the carpal tunnel. The ulnar wall is formed by the Os
Improperly taken venous blood (puncture too deep) can injure pisiforme and a protrusion of the hamate bone (Hamulus ossis ha-
both the arterial vessels and the N. medianus (runs over the A. mati). In this way a groove is formed, referred to as the Sulcus car-
ulnaris) below the M. bicipital aponeurosis. In this case the N. pi. As a roof, the Retinaculum musculorum flexorum closes the
ulnaris is not in danger because it is protected in the Sulcus groove to the carpal tunnel, through which the tendons of the
nervi ulnaris on the dorsal side of the Epicondylus medialis.
long finger flexors and also the N. medianus pass.
The GUYON's canal is located ventrally on the ulnar side of the
wrist and is thus superficial of the carpal tunnel. Its base is the Ret-
inaculum musculorum flexorum, which, due to a partition (‘Lig.
4.10.5 Carpal tunnel and GUYON’s canal carpi palmare’) also forms the roof. Running through the
­GUYON's canal is the N. ulnaris together with the A./V. ulnaris.
On the wrists, a distinction is made between 2 spaces, which are
used as passage points by the vascular, lymphatic and nervous sys-
tems to the palm of the hand (› Fig. 4.73):
• Carpal tunnel (Canalis carpi), deep
• GUYON's canal, superficial

N. medianus M. flexor digitorum

superficialis, Tendines
Retinaculum musculorum flexorum
(Lig. carpi palmare)
M. flexor pollicis longus, Tendo
A.; N. ulnaris
Vagina tendinis musculi
flexoris pollicis longi Hamulus ossis hamati
M. flexor carpi radialis, Tendo
Vagina communis
Vagina tendinis musculi tendinum musculorum
flexoris carpi radialis flexorum
Os trapezium
Ligg. carpometa-
carpalia palmaria Os hamatum
Os trapezoideum Fig. 4.73 Carpal tunnel and
Os capitatum M. flexor digitorum penetrating structures as well
profundus, Tendines as GUYON's CANAL, right. ­
Distal view.

194
5 Lower extremity
Volker Spindler, Jens Waschke

5.1 Overview . . . . . . . . . . . . . . . . . 197 5.6 Nerves of the

lower extremity . . . . . . . . . . . 231
5.2 Pelvis . . . . . . . . . . . . . . . . . . . . 198 5.6.1 Plexus lumbosacralis . . . . . . . 233
5.2.1 Structure and form . . . . . . . . . 198 5.6.2 N. ischiadicus . . . . . . . . . . . . . 236
5.2.2 Bones of the pelvis . . . . . . . . . 199
5.2.3 Pelvic joints and 5.7 Arteries of the
ligament attachments . . . . . . 201 lower extremity . . . . . . . . . . . 238
5.2.4 Mechanics of the 5.7.1 A. iliaca externa . . . . . . . . . . . 239
pelvic joints . . . . . . . . . . . . . . . 201 5.7.2 A. femoralis . . . . . . . . . . . . . . . 239
5.7.3 A. poplitea . . . . . . . . . . . . . . . . 241
5.3 Thigh . . . . . . . . . . . . . . . . . . . . 202
5.7.4 A. tibialis anterior . . . . . . . . . . 241
5.3.1 Thigh bone . . . . . . . . . . . . . . . 202
5.7.5 A. tibialis posterior . . . . . . . . . 243
5.3.2 Hip joint . . . . . . . . . . . . . . . . . . 203
5.3.3 Mechanics of the hip joint . . . 205 5.8 Veins of the
5.3.4 Muscles of the hip joint . . . . . 205 lower extremity . . . . . . . . . . . 243
5.3.5 Fascia lata and 5.9 Lymph vessels
Tractus iliotibialis . . . . . . . . . . 209 of the lower extremity . . . . . . 245
5.4 Lower leg . . . . . . . . . . . . . . . . 209 5.9.1 Lymph vessels . . . . . . . . . . . . 245
5.4.1 Bones of the leg . . . . . . . . . . . 209 5.9.2 Inguinal lymph nodes . . . . . . 245
5.4.2 Attachments between 5.9.3 Pelvic lymph nodes . . . . . . . . 245
the Tibia and Fibula . . . . . . . . 211
5.10 Topographically important
5.4.3 Knee joint . . . . . . . . . . . . . . . . 211 aspects of the leg . . . . . . . . . . 246
5.4.4 Mechanics of the knee joint . . 214 5.10.1 Lacuna musculorum
5.4.5 Muscles of the knee joint . . . . 216 and Lacuna vasorum . . . . . . . 246
5.10.2 Femoral triangle and
5.5 Foot . . . . . . . . . . . . . . . . . . . . . 218 adductor canal . . . . . . . . . . . . 247
5.5.1 Bones of the foot . . . . . . . . . . 219 5.10.3 Gluteal region . . . . . . . . . . . . . 248
5.5.2 Joints of the foot . . . . . . . . . . 220 5.10.4 Hollow of the knee . . . . . . . . . 249
5.5.3 Mechanics of the
ankle joints . . . . . . . . . . . . . . . 221
5.5.4 The arch of the foot . . . . . . . . 223
5.5.5 Muscles of the
lower leg and foot . . . . . . . . . 225
5.5.6 Support facilities of the
musculature in the region
of the lower leg and foot . . . . 229
 CLINICAL CASE

Rupture of an Achilles tendon

Medical history Diagnosis
A 56-year-old man is brought by friends into the Accident and Right side Achilles tendon rupture.
Emergency department of the clinic. He says that every Wednesday
night, he plays volleyball with his team. On taking a powerful jump
from a squatting position, he suddenly felt an impact on the back of Treatment
his right leg. At the same time, a loud clicking noise was heard. Since
then he has had severe pain and is only able to limp. He is an avid After comprehensively informing the patient, a conservative
runner, and enjoys sport on a regular basis. He says that for a few approach is decided on. The patient receives a therapeutic shoe
days, after long runs he occasionally has pain in the back of his leg. adapted with 3 cm heel lift, so that the foot is fixed in 20° plantar
flexion position. It is immediately possible to place all his weight on
the leg. The patient is discharged with the instruction to wear the
Examination findings shoe day and night for 12 weeks. The foot must also be maintained in
a plantar flexed position if the shoe is removed, for example, for
The patient is completely conscious and the vital parameters are showering.
within the normal range. There is a noticeable swelling of the distal
third of the right leg. During the examination an indentation about
1 cm long and the width of a palm could be felt above the calcaneus. Subsequent progression
The patient is unable to stand on tiptoe on the right leg. On examina-
tion, the ankle joint is normal. After 3 weeks, physiotherapy is started. The heel wedges are
The ultrasound examination shows a rupture of the Achilles tendon. gradually reduced to 2 cm and 1 cm high. After 12 weeks, the patient
The gap between the two torn ends of the tendon is 8 mm wide. An is pain-free without the therapeutic shoe.
x-ray image in lateral beam projection reveals no evidence of
avulsion of a bone fragment at the attachment of the tendon onto the
calcaneal tuberosity, or of any fractures.

You have just started your internship and the first patient to be presented is waiting to see
the senior consultant. Fortunately, you are allowed to choose a patient for this, and since you
are also a passionate volleyball player, the decision about which patient is easy.
You make you some notes about history, admission status, previous investigations and,
so that nothing can go wrong, notes about treatment.

The head doctor visit – Take 1

Hx: 56-year-old patient, Achilles tendon rupture on right
Trigger: jump from squatting position in volleyball games,
resulting in impact lower leg rear right, noticed snapping noise.
Anamnestic after prolonged exercise (jogging)
Pain in the back of lower leg area for a couple of days
Admission status: swelling distal third right lower leg,
depression of approx. 1 cm, 1 hand width above heel bone,
Not possible to stand on the tips of the right toes, ankle unobtrusive
Further differential diagnosis: Sono: Rupture of the Achilles
tendon, gap of 8 mm
x-ray: no evidence of a vulsion bone fragment or fractures
Treatment: local decongestive measures, in the course of
conservative procedure with fixation of the foot in 20° plantar-
flexion position
 5.1 Overview

5.1 Overview The lower extremities (Membrum inferius) are subdivided into the
pelvic girdle (Cingulum pelvicum) and the leg (› Fig. 5.1). The
The upper and lower extremities are basically similar; however, leg is subdivided into the thigh (Femur), lower leg (Crus) and foot
they have different characteristics in their construction in order to (Pes). The longitudinal axes of the upper and lower thigh bones lat-
adapt to their different functions. The arm is a gripping tool de- erally form the exterior knee angle of 174°.
signed to ensure maximum freedom of movement for interacting The weight of the body is not exactly borne by the longitudinal axis
with the environment (e.g. by enabling turning movements of the of the long leg bones, instead the pressure is placed on the connect-
forearm, or by the high mobility of the thumb). Conversely, the ing line between the hip and the centre of the ankle joint (MIKU-
lower limbs with evolutionary transition to walking upright, have LICZ's line) (› Fig. 5.2). Ideally, this axis, which is designated as an
adopted the role of running and support organs. The stability axis line of the leg, runs largely through the centre of the knee joint.
needed to carry the body is ensured by the fixed coupling of the Deviations from this line of the knee joint in the frontal plane are
hips to the spine and by more bulky bones. Solid ligaments stabilise called knock knees (Genu valgum) or bow legs (Genu varum):
the joints and limit movements in such a way that it is possible to • In knock knees, the knee joint is medial of the axis line, so the
stand without becoming tired, as well as preserving mobility to exterior angle of the knee is reduced. The distance between the
enable running. In contrast to the upper limbs, the muscles of the right and left knee is reduced. In Genu valgum, the lateral com-
leg and especially those of the foot are more designed for stability partment of the knee joint carries a heavier load than the medial
(e.g. by bracing the plantar arch), rather than for fine motor skills. one.
Despite this stable construction, degenerative joint diseases such • In bow legs, this situation is reversed so that the knee joint is
as osteoarthritis and traumatic injuries (for example, fractures of positioned lateral to the axis line, the exterior angle of the knee
the neck of the femur) are extremely common and are therefore is greater and the distance between the two knee joints increases.
relevant for all doctors. In Genu varum, the medial compartment is affected as a result
of greater pressure.

Articulatio sacroiliaca

Cingulum
pelvicum Os coxae
Os sacrum
Coxa

Articulatio coxae

Shaft axis
of the femur

Femur
Femur

174°

Patella
Genu Articulatio Articulatio femorotibialis
genus Articulatio femoropatellaris
Pars libera
membri inferioris Articulatio tibiofibularis

Fibula
Stem axis of the tibia
Crus
Tibia

Articulatio talocruralis
Syndesmosis
tibiofibularis Articulatio calcaneocuboidea
Articulatio subtalaris
Tarsus, Articulatio talocalcaneonavicularis
Ossa tarsi Articulatio cuneonavicularis
Metatarsus, Articulatio cuneocuboidea
Ossa metatarsi Articulationes intercuneiformes
Pes
Digiti pedis, Articulatio tarsometatarsalis
Ossa digitorum:
– Phalanx Articulationes metatarsophalangeae
proximalis Fig. 5.1 Bones and joints of the
– Phalanx media
– Phalanx distalis Articulationes interphalangeae pedis lower extremity, Membrum
inferius, right side. Ventral view.

197
5 Lower extremity

5.2 Pelvis

Skills
After working through this chapter, you should be able to:
• indicate the composition and the main structures of the pel-
vis, and explain the differences between the male and fe-
male pelvis,
• demonstrate the connections of the pelvic bone with each
other and to the vertebral column and, in doing so, explain
the course and the function of the ligaments involved,
• explain the function of the pelvic ring for the stability of the
upright gait.

5.2.1 Structure and form

The pelvis (syn.: pelvic girdle, Cingulum pelvicum) forms the con-
Regular leg Genu valgum Genu varum nection between the legs and the torso. It is composed of the right
X-leg O-leg and left hip bone (Os coxae) and the sacrum (Os sacrum) (› Fig.
5.3). The two hip bones are attached ventrally via a synarthrosis, the
Fig. 5.2 The axis line of the leg (MIKULICZ's line). Ventral view. Nor- pubic symphysis (Symphysis pubica). The right and left hip bone
mal knee joint (left), Genu valgum (centre) and Genu varum (right).
are united dorsally with the sacrum via an amphiarthrosis, the
­sacroiliac joint (Articulatio sacroiliaca). This means that there is a
If the axis line runs through the centre of the knee joint, the right stable ring of bone, but still with a degree of flexibility.
and left sides of the knee joint are evenly loaded (indicated by ar- Cranially, the greater pelvis can be distinguished (Pelvi major)
rows in › Fig. 5.2). from the lesser pelvis (Pelvis minor) caudally. The transition from
the greater to lesser pelvis is the Linea terminalis. This runs from
the Symphysis pubica via the Pecten ossis pubis and the Linea ar-
Clinical remarks cuata to the Promontorium of the Sacrum. The lesser pelvis forms
Deviations of the knee joint from the axis line are very com- a bony ‘canal’ with an upper opening, the Apertura pelvis superior,
mon and not abnormal during growth. Thus in infants, in phys- and a lower opening, the Apertura pelvis inferior.
iological terms a Genu varum can be observed, which often
becomes a Genu valgum after a few years have elapsed. As a
rule, these deformities are ‘grown out of’ within the first de- Table 5.1 Internal female pelvis dimensions (› Fig. 5.4a).
cade of life. Severe deformities in adults can, however, lead to
Name Course Size
arthritis of the knee joint due to the ongoing incorrect loading
of the knee joint surfaces and the menisci (gonarthrosis). In Diameter vera Rear of the pubic symphysis to Promontorium 11 cm
the case of severe deformities, to ensure correction during Diameter Upper margin of the pubic symphysis to Promon­ 11.5 cm
growth a part of the growth plate such as the growth plate of ­anatomica torium
the femur is clamped (temporary epiphysiodesis, prevents the
growth of the lateral or medial bone end). Better centring of Diameter Lower margin of the pubic symphysis to Promon­ 12.5 cm
the axis line in adults may be achieved by removing a wedge ­diagonalis torium
of bone (osteotomy). Diameter Largest transversal diameter between the two 13.5 cm
transversa ­terminal lines

Promontorium

Os sacrum
Apertura pelvis
Articulatio superior
sacroiliaca

Linea
terminalis
Linea arcuata

Os ilium

Os ischii
Pecten ossis pubis
Os pubis

Apertura pelvis inferior

Symphysis pubica Fig. 5.3 Pelvis. Ventral cranial
view.

198
 5.2 Pelvis

Diameter transversa Linea terminalis Fig. 5.4 Pelvis.

a b
Diameter vera a Female pelvis.
b Male pelvis.

The pelvis of males and females differs in shape. In women, the caesarea) necessary, the pelvis can be directly measured
largest diameter of the plane of the arch of the pelvis is located hor- during the operation. This means that for a subsequent preg-
izontally (› Fig. 5.4a), whereas in men it is in a sagittal position nancy, a decision can be taken in time as to whether a vaginal
(› Fig. 5.4b). Therefore, in men the aperture is slightly heart- birth is possible or if a planned caesarean section would be
shaped, and in women it is horizontally oval. In men, the lower pu- sensible.
bic branches meet the symphysis at a relatively sharp angle (Angu-
lus subpubicus). In women, however, this angle is flat and is there-
fore referred to as the Arcus pubicus. In women the iliac wings are
also larger and more protruding. 5.2.2 Bones of the pelvis
The internal dimensions of the pelvis provide information about
the width of the lesser pelvis (› Fig. 5.4a). In women, this is im- The pelvis is made up of the sacrum (Os sacrum, › Chap. 3.3.2 )
portant for assessing whether a normal birth is possible. To do so, and 2 hip bones (Ossae coxae). The hip bone (Os coxae) is made
the dimensions provided in › Table 5.1 can be used. up of 3 bone portions (› Fig. 5.5, › Fig. 5.6):
• Iliac bone (Os ilium): forms the upper part of the hip bone
• Ischium (Os ischii): is positioned caudally and dorsal
Clinical remarks • Pubic bone (Os pubis): is located ventrally and caudal
In normal vaginal birth the child passes through the lesser The initially existing cartilage plates between the individual bones
pelvis which represents the narrowest point of the birth canal. ossify between the ages of 13 and 18 years.
A disparity between the size of the child (the diameter of its
head is relevant here) and the size of the pelvis can make nor- Os ilium
mal birth impossible. What is decisive here is primarily the
The Os ilium forms the wing of the ilium (Ala ossis ilii). Medially
­Diameter vera (clinically known as Conjugata vera), since this
represents the shortest distance between the walls of the this has a concave shape (› Fig. 5.5). The front section of the me-
lesser pelvis. During pregnancy the sacroiliac joint and Sym- dial side is indented by the Fossa iliaca, which forms the origin of
physis pubica are relaxed by hormones (e.g. relaxin). This the M. iliacus. On the dorsal side of the Fossa iliaca is the Facies sac-
leads to an enlargement of the Diameter vera by about 1 cm. ropelvica, which with the Facies auricularis is located on the ar-
In cases where there is a suspected disparity between the pel- ticular surface of the sacrum. The Tuberositas iliaca is an import-
vis and the child's head, the pelvic dimensions can be deter- ant attachment point for the ligaments of the sacroiliac joint (Artic-
mined before birth by magnetic resonance imaging (MRI). If a
ulatio sacroiliaca). At the cranial end of the iliac bone is the Crista
failure of birth progression makes a caesarean section (Sectio
iliaca. The respective abdominal muscles are attached at its Labium
internum, the Linea intermedia and the Labium externum. To the

Labium internum
Linea intermedia Tuberositas iliaca
Crista iliaca
Ala ossis ilii
Labium externum
Facies sacropelvica

Spina iliaca Facies auricularis

anterior superior
Fossa iliaca
Corpus ossis ilii Eminentia iliopubica
Spina iliaca
anterior inferior Corpus ossis pubis

Ramus superior ossis pubis

Limbus acetabuli
Acetabulum
Facies lunata Pecten ossis pubis

Facies symphysialis
Corpus ossis ischii
Foramen obturatum
Tuberculum pubicum
Tuber ischiadicum Ramus inferior ossis pubis
Ramus ossis ischii Fig. 5.5 Hip bone, Os coxae,
right. Ventral view.

199
5 Lower extremity

Labium internum
Linea intermedia Crista iliaca
Linea glutea
Labium externum
anterior
Linea glutea
Facies glutea
inferior Ala ossis ilii
Linea glutea
posterior Spina iliaca
anterior superior
Spina iliaca
posterior superior Corpus ossis ilii

Spina iliaca posterior inferior Spina iliaca anterior inferior

Incisura ischiadica major Facies lunata

Limbus acetabuli Fossa acetabuli

Pecten ossis pubis
Spina ischiadica
Tuberculum
Incisura ischiadica minor pubicum
Corpus ossis ischii Ramus inferior ossis pubis
Incisura acetabuli
Tuber ischiadicum
Ramus ossis ischii Fig. 5.6 Hip bone, Os coxae,
right. Lateral view.

front and rear, the Crista iliaca tapers into the Spina iliaca anterior originating from the Spina iliaca anterior superior (› Fig. 5.7).
superior and Spina iliaca posterior superior. Correspondingly, The inguinal ligament is therefore not a ligament in the real sense
caudal of each of these two structures there is another projection, of the word; in fact it is produced by the uniting of the M. obliquus
the Spina iliaca anterior inferior and Spina iliaca posterior infe- externus abdominis with the fascia of the M. iliopsoas. It is an im-
rior. Under the Spina iliaca posterior inferior the Incisura ischiadi- portant limitation for 2 places where vessels and nerves pass
ca major is grooved in. On the lateral side (Facies glutea) of the through:
wings of ilium the Linea glutea anterior, Linea glutea inferior and • The floor of the inguinal canal (Canalis inguinalis): the passage
Linea glutea posterior are important origins for the dorsolateral from the abdominal cavity to the external genitalia (› Chap.
hip muscles (› Fig. 5.6). 3.1.4)
• The roof of the Lacuna musculorum and Lacuna vasorum
Os ischii (› Chap. 5.10.1)
The Os ischii bears the Tuber ischiadicum. The ischium (Corpus On the Ramus superior, there is a pronounced bony ridge, the
ossis ischii) runs cranially into the Spina ischiadica and caudally Pecten ossis pubis, which continues from the Linea arcuata in the
connects the Ramus ossis ischii with the Os pubis. Under the Spi- direction of sacroiliac joint.
na ischiadica is the Incisura ischiadica minor (› Fig. 5.6). The Acetabulum is the socket of the hip joint and receives the head
of the femur. It is formed from parts of all 3 bones of the hip. The
Os pubis depression (Fossa acetabuli) is almost completely covered by a
The Os pubis is divided into Corpus, Ramus inferior and Ramus crescent-shaped area, the Fascies lunata. This is only interrupted
superior and, together with the Facies symphysialis forms the con- caudally on the Incisura acetabuli. In the Limbus acetabuli the
nection to the opposite side. Close to this joint surface, the Tuber- acetabulum is externally elevated in a ring shape.
culum pubicum serves as the attachment for the Lig. inguinale, Caudally of the Fossa acetabuli, the ramus and body of the Os ischii,
which is anatomically represented as bands of connective tissue as well as the Ramus superior and Ramus inferior of the Os pubis,

Lig. longitudinale anterius

Ligg. sacroiliaca anteriora Lig. iliolumbale

Lig. inguinale

Articulatio sacroiliaca

Lig. pubicum superius Articulatio coxae

Canalis obturatorius Lig. iliofemorale

Membrana obturatoria

Lig. Symphysis pubica,

pubicum Discus interpubicus
Angulus inferius
subpubicus Fig. 5.7 Joints and ligaments of
the pelvis. Ventral view.

200
 5.2 Pelvis

form a bony ring around the largest opening in the pelvic bone, the While the anterior ligaments bridge the joint space ventrally, the
Foramen obturatum. This is filled by a plate of connective tissue interosseous and posterior ligaments form a powerful ligamentous
(Membrana obturatoria), which serves as the origin of the muscles apparatus at the dorsal side of the joint (› Fig. 5.8).
bearing the same name (Mm. obturatorii internus and externus). An In addition, the Lig. iliolumbale joins the Procc. costales of the
opening (Canalis obturatorius) serves as an exit point for vessels two lower lumbar vertebrae with the Crista iliaca and is attached to
and nerves (A./V. obturatoria, N. obturatorius) from the small pel- parts of the Lig. sacroiliacum anterius.
vis to the leg (› Chap. 5.10.2). Caudal of the sacroiliac joint there are 2 more strong ligaments:
• Lig. sacrotuberale: the sacrotuberal ligament goes from the
­dorsal side of the Sacrum descending to the Tuber ischiadicum
Clinical remarks and Ramus inferior of the pubic bone.
The Crista iliaca can also be easily palpated even in obese • Lig. sacrospinale: this ligament runs horizontally from the dor-
people, because it is located just below the surface of the sal side of the sacrum to the Spina ischiadica, and divides the
skin. Since even in the elderly population blood-forming red opening between the hip bones (Incisurae ischiadicae major and
bone marrow is still present, in the case of disorders of blood minor), the sacrum and Lig. sacrotuberale into a cranial Fora-
formation or suspected diseases of the blood cells in the bone
men ischiadicum majus and a caudal Foramen ischiadicum mi-
marrow (e.g. in the case of leukaemia) a punch biopsy is taken
from the iliac crest (bone marrow puncture). The bone marrow nus (› Fig. 5.9).
is histologically processed and then assessed by a patholo- The Symphysis pubica is held in place by 2 ligaments:
gist. • The Lig. pubicum superius connects the two pubic bones on the
upper side of the joint.
• The Lig. pubicum inferius is located on the lower side (› Fig.
5.7).

5.2.3 Pelvic joints and ligament attachments

5.2.4 Mechanics of the pelvic joints
Three joints from the bones of the pelvis form a stable ring (› Fig.
5.7): The pelvis forms a ring with its three bones. It is connected by the
• Articulatio sacroiliaca dorsal to the right and left joints and ligaments so that, on one hand, stability is ensured, al-
• Symphysis pubica ventral lowing transfer of the body's weight onto the legs, while on the
The Articulationes sacroiliacae are a diarthrosis; conversely the ­other hand also ensuring a certain springy mobility. This is espe-
Symphysis pubica is a synarthrosis. cially important for dynamic movements such as running or jump-
In the Articulatio sacroiliaca the Facies auricularis of the hip is ing, to cushion the power surges that arise.
attached to the Facies auricularis of the sacrum. The arch-shaped The sacroiliac joint must transfer the full load of the upper half of
joint surfaces are held very tight by ligaments and as an amphiartro- the body to the hip bones. This occurs due to the strong ligaments of
sis the joint has only very limited mobility. an amphiarthrosis making only minor movements possible. These
The Symphysis pubica is formed by the two Facies symphysiales of slight movements (maximum 10°) are used to mitigate the effect of
both hips (to be more precise: the pubic bone). Both bones are strong peak loads on the joint. As can be seen from the V-shaped po-
connected by the Discus interpubicus, which is made up of fibrous sition of the sections of the powerful ligamentous apparatus of the
cartilage. Lig. sacroiliacum posterius (› Fig. 5.8), the sacrum is suspended
The following ligaments secure the Articulatio sacroiliaca: between the right and left Facies sacropelvica. Therefore, the sacrum
• Lig. sacroiliacum anterius, spans the joint space ventrally does not press the body's weight down onto the hip bones; instead it
• Lig. sacroiliacum interosseum is ‘suspended’ by means of the ligaments. This allows a distribution
• Lig. sacroiliacum posterius, runs like the Lig. sacroiliacum inter- of force over the entire Tuberositas sacroiliaca, which is subjected to
osseum dorsal of the joint space between Tuberositas iliaca and tension. Simultaneously the hip bone is pressed onto the sacrum by
the Sacrum this tension, which, together with the ligaments, prevents the sacrum
from sliding caudally.

Lig. iliolumbale

Ligg. sacroiliaca
interossea
Ligg. sacroiliaca
Lig. sacrotuberale posteriora

Lig. sacrospinale

Lig. pubicum
inferius Fig. 5.8 Joints and ligaments of
the pelvis. Dorsal view.

201
5 Lower extremity

Weight of Rotational axis Lig. sacrotuberale. The Ligg. sacroiliaca cannot do this alone due to
the body their smaller lever arm.

NOTE
The Ligg. sacroiliaca prevent the sacrum from sliding caudally,
while the Lig. sacrospinale and sacrotuberale prevent rotation in
the transverse axis.

Foramen ischia- 5.3 Thigh

dicum majus

Lig. sacro-
Skills
spinale
After working through this chapter, you should be able to:
• explain the structure of the femur and its blood supply, in
particular of a neck and head of the femur
Foramen ischiadicum minus • explain the structure and function of the hip joint as well as
Lig. sacrotuberale the course and the function of the hip joint ligaments and
show them on the skeleton
• know all the hip muscles with their origins, attachment and
function and demonstrate their course on a skeleton or dis-
Fig. 5.9 Joints and ligaments of the pelvis in an infant; mid-sagittal sected specimen
section. Medial view.

Placing a load on the Os sacrum and sacroiliac joint leads to tensile

forces being exerted at the Symphysis pubica. A separation of the
fibre cartilage is prevented by the Ligg. pubica which run transver- 5.3.1 Thigh bone
sally. The Lig. iliolumbale performs the same function for the sac-
roiliac joint. The thigh bone (Femur) is the largest bone in the human body
When standing, the body's centre of gravity is located ventral of (› Fig. 5.10). It is divided into a head (Caput), a neck (Collum)
the sacroiliac joint. This could lead to the rotation of the sacrum in and a shaft (Corpus).
the transverse axis so that the sacrum is transferred dorsally up- A small depression at the head, the Fovea capitis femoris serves to
wards and the body would tip ventrally (› Fig. 5.9, dotted ar- attach the Lig. capitis femoris. The head tapers towards the neck of
rows). This rotation is prevented by the Lig. sacrospinale and the the femur, which merges into the shaft in the area of the two tro-

Collum femoris
Fossa trochanterica Fovea capitis Caput femoris
femoris
Trochanter major Trochanter major
Caput femoris

Collum femoris Collum femoris

Crista
Linea intertrochanterica Trochanter minor intertrochanterica
Trochanter minor Linea pectinea

Tuberositas
glutea

Labium
laterale
Linea aspera
Corpus Labium
femoris mediale

Facies poplitea
Tuberculum
adductorium Tuberculum
adductorium
Epicondylus
Epicondylus Epicondylus lateralis
lateralis medialis Condylus
medialis
Condylus lateralis Fig. 5.10 Thigh bone, femur,
Facies patellaris right. a Ventral view, b dorsal
a b Fossa intercondylaris
view.

202
 5.3 Thigh

*
*

14°

120°
126°
a b
130° **
**

Fig. 5.11 Proximal end of the femur, right. a Representation of the

CCD angle, dorsal view. b Representation of the angle of antetorsion,
proximal view. a b

chanters. The greater trochanter (Trochanter major) faces dorso- Fig. 5.12 Section through the proximal end of the femur, right side.
laterally, the lesser trochanter (Trochanter minor) faces dorsome- Illustration of the structure of the spongiosa and the CCD angle.
dially. The trochanters act as an attachment point for muscles that a Coxa valga. b Coxa vara. * ‘tension bundle’, ** ‘pressure bundle’
make the hip joint move. Between the Trochanter major and Tro-
chanter minor, the Linea intertrochanterica passes on the ventral Therefore, there is a trajectorial orientation of the trabeculae,
side. On the dorsal side, the Crista intertrochanterica is more ele- which are either under tension or subject to pressure.
vated. Below the lesser trochanter, the Linea pectinea is positioned In the case of a Coxa vara, the neck of the femur to the shaft has a
as the attachment of the M. pectineus. Lateral from this is the Tu- greater bend, resulting in a higher tensile loading of the spongious
berositas glutea, the attachment for the M. gluteus maximus. trabeculae in the upper sections of the neck of the femur(* in
The femoral shaft is largely circular in diameter; only on the dorsal › Fig. 5.12b). Correspondingly, in the case of a Coxa valga, the tra-
side is there a bony ridge called the Linea aspera with a Labium me- beculae in the lower part of the neck of the femur are increasingly
diale and a Labium laterale. Distally the shaft widens to the Epicon- subject to pressure (** in › Fig. 5.12a).
dylus medialis and lateralis and ends in the two cylindrically-shaped The antetorsion angle means the twisting of the shaft in relation to
joint surfaces of the knee joint (Condyli medialis and lateralis). Be- the knee joint axis. The neck of the femur, compared to this axis, is
tween the two condyles there is a recess for the cruciate ligaments rotated by approximately 14° to the front, i.e. in an antetorsion po-
of the knee joint, the Fossa intercondylaris. The front surface of sition. This angle also varies according to age. In infants it is even
the femoral condyles is called the Facies patellaris; on the rear more pronounced at 30°. The torsion causes the kneecap to point
­surface is the Facies poplitea (› Fig. 5.10). somewhat medially. With increased antetorsion the toes point fur-
At the femur 2 angular dimensions can be distinguished: ther inwards while running, and where there is low antetorsion,
• Centrum-Collum-Diaphyseal angle (CCD angle) between the they point outwards.
neck of the femur and femoral shaft (› Fig. 5.11a).
• Antetorsion angle: between the connecting line of the two con-
dyles (equivalent to approximately the transverse axis of the
Clinical remarks
knee) and the longitudinal axis of the neck of the femur (› Fig. CCD and antetorsion angles are highly pathophysiologically
5.11b). significant. Variations of this angle lead to altered power
The CCD angle depends on age and is approximately 126° in transfer in the hip joint. Due to incorrect loading on the carti-
adults. It is 150° in newborn babies, decreasing throughout life to lage, this leads to increased wear and often contributes to the
development of coxarthrosis (osteoarthritis of the hip).
120° in old age. If the angle is more than 130°, it is referred to as a
The oblique loading of the neck of the femur predisposes it to
Coxa valga (› Fig. 5.12a), with an angle less than 120° as a Coxa fractures (‘femoral neck fractures’). These are very common,
vara (› Fig. 5.12b). especially in older people, in combination with osteoporosis.
As can be seen in › Fig. 5.2, the axis line of the leg does not run Typically, these fractures are triggered by falls. In order to avoid
along the longitudinal axis of the shaft of the femur. Through the long immobilisation of the patient, femoral neck fractures are
neck of the femur, the proximal parts of the shaft are displaced lat- often treated by the use of an artificial hip joint (total endo-
eral of the axis line, so that only the distal end of the femur remains prosthesis = TEP). A TEP consists of joint cup and joint head
with an artificial femoral head. The femoral head and neck are
in the axis line. This lateralisation is important, providing the small
fixed in place in the femoral shaft by the two trochanters.
gluteal muscles (running from the pelvic ring to the trochanter ma-
jor) with a larger lever arm. This is required, for example, to pre-
vent the pelvis from dropping down to the contralateral side when
standing on one leg; however, the ‘position’ of the Trochanter
­major has the disadvantage that the femoral shaft and, most impor- 5.3.2 Hip joint
tantly the neck of the femur, does not bear its load axially, but at an
angle. In the neck of the femur, this means that there are areas pri- The hip joint (Articulatio coxae) is a ball joint with 3 degrees of
marily subjected to compressive loading (** in › Fig. 5.12), and freedom. The cup is formed by the Os coxae, with the head of the
areas which are primarily subjected to tension (* in › Fig. 5.12). femur as its counterpart.
In order to compensate for this loading, the spongious trabaeculae The Facies lunata is lined with joint cartilage. A connective tissue
are longitudinally aligned to the arising forces (the trajectories). lip, the Labrum acetabuli, expands the articular surface and extends

203
5 Lower extremity

over the Incisura acetabularis with the Lig. transversum acetabuli. • Lig. iliofemorale: originates distally from the Spina iliaca ante-
This joint lip extends over the equator of the femoral head, so that rior inferior and runs to the Linea intertrochanterica and the
approximately two-thirds of the surface area of the ball are c­ overed Trochanter major (strongest ligament in the human body!)
by the joint cup. This is a special type of ball joint called a cotyloid • Lig. pubofemorale: runs from the Ramus superior of the Os pu-
joint (Articulatio cotylica, enarthrosis). As with the covering of the bis to the Trochanter minor
socket, the majority of the joint head is lined with cartilage. • Lig. ischiofemorale: runs from the corpus of the Os ischii to the
Trochanter major (Pars superior) and the Trochanter minor
(Pars inferior)
Clinical remarks The Lig. capitis femoris on the other hand, has no holding func-
The joint socket only reaches its final depth after birth. It is im- tion. It passes within the joint cavity from the Incisura acetabuli to
portant that the femoral head is already located in the centre the Fovea capitis femoris. The R. acetabularis of the A. obturatoria
of the flat cup in infancy. Therefore, in infants the position of runs within this ligament to the femoral head and plays a role in
the femoral head is examined using ultrasound. If there is a blood supply. In small children it is responsible for the majority of
deformity, at this stage a simple correction can be carried out,
the blood supply, but in adults only about 20–30 %. The main
just using splints for example. If hip dysplasias like these (no
covering of the femoral head by the Os coxae) remain uncor- blood supply is shared between the A. circumflexa femoris media-
rected, this can often result in osteoarthritis of the hip joint. lis and the A. circumflexa femoris lateralis (› Fig. 5.14), which
The femoral head can even exit the socket (hip dislocation) emerge from the A. profunda femoris:
and lead to the development of a new but functionally ineffi- • The A. circumflexa femoris medialis runs on the dorsal side of
cient articular surface above the acetabulum. the neck, giving rise to several branches running between the
joint capsule and the periosteum to the femoral head. It supplies
the back of the femoral neck and the majority of the femoral
The joint capsule originates from the Limbus acetabuli and spans head.
the femoral head and the largest part of the femoral neck. It is insert- • The A. circumflexa femoris lateralis runs on the ventral side of
ed at the front of the Linea intertrochanterica and behind it is at- the femoral neck, which it mainly supplies, and also provides
tached a little further proximally. Three ligaments reinforce the joint small branches to the femoral head.
capsule from outside and stabilise the hip joint (› Fig. 5.13):

Lig. sacrospinale
Lig. pubofemorale
M. rectus femoris, Canalis obturatorius
Tendo Caput reflexum M. rectus
Caput rectum femoris, Tendo
Lig. iliofemorale Lig. iliofemorale
Lig. sacro-
Membrana tuberale Collum
Lig. ischiofemorale
Trochanter major obturatoria femoris Trochanter major

Trochanter
Trochanter minor
minor

a b

Fig. 5.13 Hip joint, Articulatio coxae, with ligaments, right. a Ventral view. b Dorsal view.

A. circumflexa A. circumflexa
femoris medialis femoris lateralis

R. acetabularis R. acetabularis

A. circumflexa A. circumflexa
femoris medialis femoris lateralis

A. circumflexa A. circumflexa
femoris lateralis femoris medialis
A. profunda femoris
A. profunda
R. ascendens femoris
Fig. 5.14 Blood supply to the
R. transversus hip joint, Articulatio coxae,
a R. descendens b right. a Ventral view. b Dorsal
view.

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 5.3 Thigh

The hip socket is supplied by arteries coming from the lesser pel- Table 5.2 Range of movement in the hip joint.
vis. Branches of the A. obturatoria and the A. glutea superior are
Movement Range of movement
involved. Both vessels arise from the A. iliaca interna.
Extension/flexion 10°–0°–130°

Clinical remarks Abduction/adduction 40°–0°–30°

External rotation/internal rotation 50°–0°–40°
The fact that the femoral head is mainly supplied by blood
vessels from the femoral neck is clinically highly relevant. In
the case of fractures, particularly of the femoral neck or dislo- Table 5.3 Functions of the hip joint ligaments.
cations of the joint, these vessels are frequently damaged.
Movement Inhibition by
This can therefore result in the destruction of bone tissue and
femoral head necrosis due to insufficient blood supply to the Extension • Lig. iliofemorale
femoral head. This complication is also a reason why with • Lig. pubofemorale
femoral head fractures, a total endoprosthesis is usually im- • Lig. ischiofemorale
planted. Abduction Lig. pubofemorale
Adduction Lig. ischiofemorale
Lateral rotation Lig. pubofemorale
Medial rotation Lig. ischiofemorale
5.3.3 Mechanics of the hip joint
Internal and external rotation must be assessed with the knee joint
The hip joint can be moved in 3 axes (› Fig. 5.15, › Table 5.2): in a flexed position. By doing this, the possibility of additional rota-
• Flexion and extension in the transverse axis, bending and tion in the other leg joints is eliminated.
stretching of the thigh The hip joint can only be very slightly extended (important for sta-
• Abduction and adduction in the sagittal axis, stretching or pull- bility when standing), but can be flexed very well (important for
ing of the leg walking). This is achieved with the ligaments of the hip joint,
• Internal rotation and external rotation around the longitudinal which are all tensed in extension, but relaxed during flexion,
axis, internal rotation (kneecap pointing more medially) and ex- (› Table 5.3). This function can be explained by the spiral track of
ternal rotation (kneecap pointing laterally) of the thigh. the ligaments around the femoral head (› Fig. 5.13). In addition,
In particular, extension can only be precisely defined with a fixed the ligaments prevent excessive adduction and abduction, as well
contralateral hip joint. When trying to move the leg as far as possi- as extreme internal and external rotation.
ble dorsally when standing, the contralateral hip joint is always Securing the extension is also important when standing for longer
bent. Therefore, the extension is defined best in the prone position. periods. This pushes the hip slightly forwards, tightening the liga-
ments due to the slight extension that takes place in the hip. When
standing for a long time, these ligaments provide support, and this
130°
saves a great deal of energy.

5.3.4 Muscles of the hip joint

40°
30° There are 4 groups of muscles which affect the movement of the
hip joint:
• Ventral muscles
– M. iliacus (part of the M. iliopsoas)
– M. psoas major (part of the M. iliopsoas)
– M. psoas minor (part of the M. iliopsoas, variable)
0°
• Dorsolateral muscles
10°
– M. gluteus maximus
0°
– M. gluteus medius
a b
– M. gluteus minimus
– M. tensor fasciae latae
0° • Pelvitrochanteric (medial) muscles
– M. piriformis
40° – M. obturatorius internus
50°
– M. gemellus superior
50°
40° – M. gemellus inferior
– M. quadratus femoris
0°
– M. obturatorius externus
• Adductor group
– M. pectineus
c d – M. gracilis
– M. adductor brevis
Fig. 5.15 Range of movement in the hip joint. a Extension/flexion. – M. adductor longus
b Abduction/adduction. c, d External rotation/internal rotation. – M. adductor magnus

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5 Lower extremity

Table 5.4 Ventral muscles of the hip joint.

Innervation Origins Attachment Function

M. iliopsoas (consists of M. iliacus and M. psoas major)
Plexus lumbalis ­ • M. iliacus: Fossa iliaca Trochanter minor Lumbar spine:
(Rr. musculares) • M. psoas major: • Lateral flexion
– Superficial layer: Facies lateralis of the Hip joint:
body of the XIIth thoracic to the IVth • Flexion (most important muscle)
Intervertebral discs • Lateral rotation from medial rotation position
– Deep layer: Proc. costalis of Ist–IVth
lumbar ­vertebrae
M. psoas minor (interictal muscle)
Plexus lumbalis Body of the XIIth thoracic and Ist lumbar ver- Fascia of the M. iliopsoas, Arcus Lumbar spine:
(Rr. musculares) tebrae iliopectineus, iliopectineal arch • Lateral flexion

The adductor group also belongs to the thigh muscles, because they joint, making it the most important extensor and essential for ex-
are located medially of the femur. Other muscles of the thigh also tension from the flexed position. The cranial parts cross the hip
move the hip joint; however, since in contrast to the adductor joint above the sagittal axis, while the caudal part crosses under-
group, their main function is the movement of the knee they will neath it. Therefore, the top half of the muscle carries out abduction
be dealt with there. movements, whereas the bottom half takes part in adduction. Due
to its location on the dorsal side of the longitudinal axis, the M.
Ventral muscles gluteus maximus is the most important external rotator. In addition
All the ventral muscles together form the M. iliopsoas (› Fig. to its attachment to the femur, the M. gluteus maximus is also at-
5.16, › Table 5.4). Their joint terminal tendon is inserted at the tached to the Tractus iliotibialis. This is a reinforcement of the
trochanter minor of the Femur. The muscles run ventral to the hip thigh fascia (Fascia lata) on the lateral side, which inserts below the
joint, so their main function is the flexion of the joint. The M. ilio- Condylus lateralis of the tibia. The Tractus iliotibialis is tasked with
psoas is the most important muscle for doing this. The muscle also reducing the flexural stresses that act on the femoral neck, like a
plays a role in external rotation, especially when flexing the thigh. tension spring.

Clinical remarks
Failure of the M. iliopsoas leads to discomfort when walking,
as flexion in the hip joint is compromised. Furthermore, in the
case of bilateral paralysis of the muscle, straightening of the
upper body with the hip joint from the reclined position is no
longer possible.

M. tensor
fasciae latae

Dorsolateral muscles
The dorsolateral muscles form the superficial muscle group of the
gluteal region. The bulky M. gluteus maximus (› Fig. 5.17, › Ta-
ble 5.5) is responsible for the expression of the relief of the gluteal
M. gluteus
region. All of its fibres run dorsal to the transverse axis of the hip maximus

Tractus M. gluteus medius

iliotibialis

M. psoas major

M. iliopsoas

M. iliacus

M. obturatorius
externus
a b

Fig. 5.17 Dorsolateral muscles of the hip joint. Dorsal view. a Super-
Fig. 5.16 Ventral muscles of the hip joint. Ventral view. ficial layer. b Deep layer.

206
 5.3 Thigh

Clinical remarks swings forward (free leg). When doing so, the M. gluteus medius
and M. gluteus minimus prevent the hip from descending down to
In the case of paralysis of the M. gluteus maximus extension
the free leg, in order for the pelvic ring to remain horizontally
in the hip joint is extremely limited. This is particularly evident
when climbing stairs, because here the leg needs to be aligned.
stretched out from the flexed position. In the event of the mus-
cle malfunctioning, this is no longer possible because it is vi-
tal to lift the entire body weight.
Clinical remarks
A lesion of the N. gluteus superior can arise when an intra-
muscular injection is administered incorrectly into the gluteal
The M. gluteus medius and the M. gluteus minimus form a func- region leading to failure of the M. gluteus medius and M. glu-
tional unit and are also referred to as the ‘small gluteals’ (› Fig. teus minimus. Weakening of the muscles is the long-term ef-
fect of hip dysplasia with luxation (see above). The muscles
5.17, › Fig. 5.18, › Table 5.5). They originate to the front of and
are usually actively insufficient as they cannot be shortened
cranial to the Facies glutea of the hip and pull forward laterally to enough due to the femoral head being positioned too high.
the Trochanter major below. This makes them the most important This prevents powerful abduction. In these cases, the patients
abductors. As a majority of the fibres are located ventral to the lon- are not able to stand on the leg of the injured side (biome-
gitudinal axis, these muscles are also the most important medial chanically impossible) and when walking, they suffer primarily
rotators. from a disturbed movement pattern. The hip descends to-
The muscles are essential for walking upright. When walking, one wards the side of the contralateral (!) free leg side since, due
to muscle failure, the pelvic ring can no longer be kept in the
leg remains stable on the ground (standing leg), while the other leg
horizontal plane (TRENDELENBURG's sign). In order to com-
pensate for this descent when walking, the trunk flexes to the
side of the lesion laterally, in order to shift the body's centre
of gravity and prevent the hip from descending. This character-
istic gait is called the ‘DUCHENNE limp’.
M. gluteus minimus
M. piriformis
M. gemellus superior The M. tensor fasciae latae has a short muscle belly ending in the
M. obturatorius Tractus iliotibialis (› Fig. 5.17, › Table 5.5). Thus, the M. tensor
internus fasciae latae not only acts on the hip joint (flexion, abduction, in-
M. gemellus inferior ternal rotation), but also stabilises the knee in the extended posi-
M. quadratus femoris
tion and supports tensing.

Pelvitrochanteric (medial) muscles

The pelvitrochanteric muscles lie caudal to the M. gluteus medius
and M. gluteus minimus (› Fig. 5.18, › Table 5.6). They are all
lateral rotators of the hip joint, because they run behind the longi-
tudinal axis. Their course is sometimes very complicated. The M.
Fig. 5.18 Pelvitrochanteric muscles. Dorsal view. obturatorius internus arises on the medial side of the hip bone at

Table 5.5 Dorsolateral muscles of the hip joint.

Innervation Origins Attachment Function

M. gluteus maximus
N. gluteus inferior • Facies glutea of the Os ilium dorsal to the • Cranial part: Tractus iliotibialis Hip joint:
Linea glutea posterior • Caudal part: Tuberositas • Extension (most important muscle), external rotation
• Facies posterior of the Os sacrum ­glutea (most important muscle)
• Fascia thoracolumbalis • Cranial part: abduction
• Lig. sacrotuberale • Caudal part: adduction
Knee joint:
• Stabilisation in the extended position
• Tensing of the femur
M. gluteus medius and minimus
N. gluteus superior Facies glutea of the Os ilium: Tip of the Trochanter major Hip joint:
• M. gluteus medius: between the Lineae • Abduction (most important muscle)
gluteae anterior and posterior • Ventral portion: flexion, internal rotation ­
• M. gluteus minimus: between the Lineae (most important muscle)
gluteae anterior and inferior • Dorsal part: extension, external rotation
M. tensor fasciae latae
N. gluteus superior Spina iliaca anterior superior Via Tractus iliotibialis, tibia Hip joint:
below the Condylus lateralis • Flexion
• Abduction
• Medial rotation
Knee joint:
• Stabilisation in the extended position
• Tensing of the femur

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5 Lower extremity

the Membrana obturatoria. It enters through the Foramen ischiadi-

cum minus, redirected at the Corpus ossis ischii in the area of the
Incisura ischiadica minor and inserts at the Trochanter major. The
Mm. gemelli adhere to it.
An important orientation mark is the M. piriformis. It is always
recognisable due to its conical shape, after dissecting the M. gluteus
maximus. Above and below the muscle there are 2 openings, the
Foramen suprapiriforme and Foramen infrapiriforme, which are M. pectineus
used by various vessels and nerves as an exit point from the lesser
pelvis (› Chap. 5.10.3). The cranially lying M. piriformis is ab- M. adductor brevis
ducted in the hip joint while the caudally located M. quadratus M. adductor longus

femoris and the M. obturatorius externus are involved in adduc-

tion. The M. obturator externus is assigned in developmental terms
to the adductor group (see below) and therefore is the only muscle M. adductor magnus

innervated by the Plexus lumbalis. M. gracilis

NOTE
All pelvitrochanteric muscles are for external rotation. Hence fail-
ure of these muscles results in weakened movement; however, the
most important external rotator is the M. gluteus maximus.

Adductor group
The adductor muscles with their origin occupy the entire lower por-
tions of the hip bones around the Foramen obturatum (› Fig. 5.19,
› Table 5.7). In addition to their main function, the adduction of the
hip joint, all the muscles contribute to flexion and external rotation,
Fig. 5.19 Adductor muscles of the hip joint. Ventral view.
because they run ventrally and medially over the hip joint to the rear
of the femur. Only the dorsal portions of the M. adductor magnus are
behind the transverse axis, so that they stretch into the hip joint. The two attachments of the M. adductor magnus (Labium mediale of
M. gracilis is the only twin-articulated muscle of this group so that it the Linea aspera and medial femoral epicondyle) there is an open-
also operates the knee joint (flexion, internal rotation). The adductor ing. This Hiatus adductorius is used by the A. and V. femoralis as
group has an important function for balance when standing on one the passage to the hollow of the knee.
leg. The forces which are exerted by the abductors are balanced out,
and are therefore also essential when walking.
The various muscles of the adductor group are not easy to differ-
Clinical remarks
entiate. Furthest lateral and cranial is the small M. pectineus. Me- The adductor muscles can be irritated and injured by sudden,
dial and caudal from it is the M. adductor longus, followed by the extreme abduction movements (e. g. lunging tackle in foot
M. gracilis. Behind the M. adductor longus are the M. adductor ball), which is often referred to as ‘groin strain’. Permanent
brevis (cranial) and the M. adductor magnus (caudal). Between the

Table 5.6 Pelvitrochanteric muscles of the hip joint.

Innervation Origins Attachment Function

M. piriformis
Plexus sacralis Facies pelvica of the Os sacrum Tip of the Trochanter major Hip joint:
(Rr. musculares) • Lateral rotation
• Abduction
M. obturatorius internus
Plexus sacralis Bony margin of the Foramen obturatum, Tip of the Trochanter major Hip joint:
(Rr. musculares) medial fascia of the Membrana obturatoria • External rotation
Mm. gemelli superior and inferior
Plexus sacralis • M. gemellus superior: Spina ischiadica Tendon of the M. obturatorius Hip joint:
(Rr. musculares) • M. gemellus inferior: Tuber ischiadicum internus • External rotation
M. quadratus femoris
Plexus sacralis Tuber ischiadicum Crista intertrochanterica Hip joint:
(Rr. musculares) • External rotation
• Adduction
M. obturatorius externus
N. obturatorius Bony margin of the Foramen obturatum, Fossa trochanterica Hip joint:
Facies lateralis of the Membrana obturatoria • External rotation
• Adduction

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 5.4 Lower leg

Table 5.7 Adductor of the hip joint.

Innervation Origins Attachment Function

M. pectineus
N. femoralis and Pecten ossis pubis Trochanter minor and Linea Hip joint:
N. obturatorius ­ ectinea of the femur
p • Adduction
• Flexion
• External rotation
M. gracilis
N. obturatorius Corpus ossis pubis, Ramus inferior ossis Condylus medialis of the tibia Hip joint:
pubis (‘Pes anserinus superficialis’) • Adduction
• Flexion
• External rotation
Knee joint:
• Flexion
• Inner rotation
M. adductor brevis
N. obturatorius Ramus inferior ossis pubis Proximal third of the Labium Hip joint:
mediale of the Linea aspera • Adduction
• Flexion
• External rotation
M. adductor longus
N. obturatorius Os pubis up to the symphysis Middle third of the Labium Hip joint:
­mediale of the Linea aspera • Adduction
• Flexion
• External rotation
M. adductor magnus1
• Main part: • Main part: Ramus inferior ossis pubis, • Proximal two thirds of the Hip joint:
N. obturatorius Ramus ossis ischii ­Labium mediale of the Linea • Adduction
• Dorsal part: tibial • Dorsal part: Tuber ischiadicum aspera, • External rotation
­portion of the • Epicondylus medialis of the • Main part: flexion
N. ischiadicus femur, • Dorsal part: extension
• Septum intermusculare
vastoadductorium
1
An incomplete proximal splitting of the M. adductor magnus is known as the M. adductor minimus

contraction (spastic paralysis) of the adductor muscles can be 5.4 Lower leg

observed, e.g. after neonatal brain damage (e. g. LITTLE’s
­disease). This results in standing and walking no longer being
possible.
Skills
After working through this chapter, you should be able to:
• show the bony structures of the leg as well as the structure
and function of the knee joint in a dissected specimen
5.3.5 Fascia lata and Tractus iliotibialis • describe the course of internal and external ligaments of the
knee joint and their positioning to the joint capsule, as well
as the symptoms and principles of clinical tests in cases of
The Fascia lata surrounds the muscles of the gluteal region and the damage to these ligaments
thigh. This very stable connective tissue sheath is attached proxi- • explain the functions of the ligaments in relation to the posi-
mally at the pubic bone, at the inguinal ligament, iliac crest and on tion of the knee joint
the sacrum. It extends distally over the knee joint and passes over • understand the design, function and blood supply of the
the muscle fascia of the lower leg, the Fascia cruris. On the outside menisci as well as their relationship with the collateral liga-
it is reinforced by the radiation of the end tendons of the M. glute- ments
• show all of the muscles of the knee joint with their origin, at-
us maximus and M. tensor fasciae latae. This cord, called the Trac-
tachment and function on a skeleton or dissected specimen
tus iliotibialis, inserts lateral to the tibia and works on the princi-
ple of tension (see above).
Two strong septa of connective tissues as part of the Fascia lata
­divide the flexor side from the extensor side on the upper thigh: the
Septum intermusculare femoris mediale is located medially, the 5.4.1 Bones of the leg
Septum intermusculare femoris laterale forms the septum on the
outside. The end tendon of the M. adductor magnus radiates into As on the forearm, the skeleton of the lower leg (Crus) is formed
the Septum intermusculare vastoadductorium which is involved in by 2 bones (› Fig. 5.20):
the limitation to the adductor canal (› Chap. 5.10.2). • Shin bone (Tibia)
• Fibula

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5 Lower extremity

Articulatio tibiofibularis, and the Margo anterior lie just beneath the skin and are easily pal-
Lig. capitis fibulae anterius pated. The Tuberositas tibiae acts as the attachment of the M. quadri-
Caput fibulae ceps femoris via the Lig. patellae. There is a crest located on the Fa-
Tuberositas tibiae cies posterior with the Linea musculi solei as the origin for the M.
soleus. The ‘tibial plateau’ is formed by both tibial condyles
(Condylus medialis and lateralis). On the upper side there is an
elevation, the Eminentia intercondylaris with the Tuberculum in-
tercondylare mediale and laterale. In the front middle of the plateau
lies the Area intercondylaris anterior, behind the Area intercon-
Membrana
dylaris posterior. Both condyles together bear the Facies articu-
interossea cruris laris superior at the top as a joint surface for the knee joint. At the
distal end of the tibia, the articular surface for the ankle (Facies
­articularis inferior) is found. Medially, the inner ankle (Malleolus
medialis) can be well palpated; its Facies articularis malleoli medi-
alis also plays a role in the structure of the ankle joint.

Fibula
The fibula like the tibia, has 3 sides and 3 edges (Facies lateralis,
medialis and posterior; Margines anterior, posterior and inter-
osseus). Proximal of the corpus there is a neck section (Collum
Malleolor fork
fibulae) and the fibular head (Caput fibulae). This articulates with
the Condylus lateralis of the tibia. The distal end of the fibula is
Malleolus medialis formed by the outer ankle (Malleolus lateralis), which bears the
Malleolus lateralis Syndesmosis tibiofibularis, Facies articularis malleoli lateralis of the upper ankle joint.
Lig. tibiofibulare anterius

Fig. 5.20 Bones of the lower leg and joint connections. Ventral view. Clinical remarks
The superficial position of the tibia is used in emergency med-
Proximally, both bones are connected by the Articulatio tibiofibu- icine to administer fluids via an intraosseous access. If large
laris, and distally connected by the Syndesmosis tibiofibularis. calibre venous access is not possible, in an emergency the
Both bones come together to form the ankle joint (Articulatio ta- ­tibia distal to the Tuberosita tibiae, can be drilled into and a
cannula can be inserted. The fibula is used as a bone substi-
locruralis).
tute material in oral and maxillofacial surgery. Since the fibu-
la is not a part of the knee joint and the axial line of the leg
Tibia generally only passes through the tibia, the proximal and mid-
The tibia is in cross-section a triangular bone, which is flat and dle sections are expendable. For example, these can be used
runs proximally. On the shaft (Corpus) 3 surfaces can be distin- to substitute parts of the lower jaw, which have to be removed
guished, (Facies lateralis, medialis and posterior) and 3 edges due to a carcinoma of the oral cavity.
(Margines anterior, lateralis and interosseus). The Facies medialis

Rotational axis

Femur

Tuberculum
adductorium
Epicondylus
Epicondylus lateralis medialis femoris
transverse axis
Patella
Articulatio femoropatellaris
Condylus lateralis femoris
Condylus medialis femoris
Condylus lateralis tibiae
Condylus medialis tibiae
Articulatio tibio-
fibularis proximalis Articulatio
femorotibialis
Caput fibulae

Tuberositas tibiae

Fibula Tibia
Fig. 5.21 Knee joint, Articulatio
genus, right. Ventral view.
[E460]

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 5.4 Lower leg

5.4.2 Attachments between the Tibia and Fibula the Lig. patellae, which is attached to the Tuberositas tibiae. Thus
the patella is a sesamoid bone and serves as a hypomochlion for the
Proximally, the tibia and fibula are linked via a true joint, the Artic­ tendon of the M. quadriceps femoris. Thus, it gains greater distance
ulatio tibiofibularis (› Fig. 5.20). Due to its 2 ligaments (Ligg. from the transverse axis of the knee joint, so the torque of the mus-
capitis fibulae anterius and posterius) this joint is an amphiar- cle is significantly increased by the extended virtual lever arm.
throsis and does not have a wide range of movement. When standing, the patella is positioned on the Facies patellae of
The tibia and fibula are coupled with each other via the flat Mem- the femoral condyles and thus largely above the joint gap between
brana interossea cruris. This spans the two Margines interosseae the femur and the tibia.
of both bones. The distal end of the membrane closes the gap at the
contact surface between the tibia and fibula, called the distal tibio- Joint capsule
fibular joint. Therefore, this is a syndesmosis (Syndesmosis tibio- The joint capsule surrounds the cartilage-coated parts of the joint
fibularis). This is also reinforced by 2 ligaments, the (Ligg. tibio- surfaces of the femur and tibia, creating a space of a few millime-
fibularia anterius and posterius) by the connection of the ankle to tres around it. The knee cap with the Lig. patellae is embedded in
the ‘fork’ of the malleolus. the front wall of the capsule. The capsule extends ventrally upwards
under the tendon of the M. quadriceps femoris (Recessus supra-
patellaris). Strictly speaking, this is a bursa (Bursa suprapatellaris),
5.4.3 Knee joint but is usually found directly connected with the joint capsule. The
Membrana fibrosa and Membrana synovialis are points not
In the knee (Articulatio genus) joint one of the femoral condyles is closely linked at all points; instead they are separated by large
articulated with the tibial condyles and the other with the rear sur- ­sections (› Fig. 5.23). At the front beneath the patella, the space
face of the Patella. Thus the knee joint can be divided into 2 parts, between the two layers is filled by a fat body (Corpus adiposum
referred to as the Articulatio femorotibialis and Articulatio fem- ­infrapatellare, HOFFA's fat pad). Outwardly this has folds (Plicae
oropatellaris (› Fig. 5.21). The joint capsule encloses both parts alares) and is connected via the strap-shaped Plica infrapatellaris to
of the joint. the anterior cruciate ligament. Also dorsally the two sheets of the
The cylindrical femoral condyles are not round when viewed from joint capsule differ from each other. The Membrana synovialis
the side, they are horizontally ovoid (› Fig. 5.22). The curvature passes deep into the joint up to the anterior cruciate ligament. Thus,
of the articular surface is towards dorsal. This means that in the ex- the cruciate ligaments are positioned extrasynovially between the
tended position, the contact area towards the tibia is greater than two sheets of the joint capsule.
in a flexed position.
The joint surfaces of the two tibial condyles are shaped differently.
The Condylus medialis is slightly recessed (concave), whereas the
Clinical remarks
Condylus lateralis is flat or even slightly convex in shape. Knee joint effusion, i.e. increased fluid in the joint capsule, is
This poor fit (congruence) between the curved joint surfaces of the relatively common. It can exist, for example, due to acute inju-
femur and its counterpart of the ‘tibial plateau’ is balanced out by ry (fractures, meniscal lesions), inflammation (e.g. rheuma-
the menisci composed of fibrous cartilage (› Fig. 5.22). toid arthritis) or degenerative processes (arthrosis). In order
to confirm joint effusion by clinical examination, firstly the Re-
cessus suprapatellaris is stretched out from proximal to distal.
Knee cap (Patella) Where large amounts of fluid have collected, this leads to the
The patella is shaped somewhat like a tear drop, with its tip point- phenomenon of the ‘floating patella’ (› Fig. 5.24). When ap-
ing distally (Apex patellae) and a proximally located curved Basis plying pressure on the kneecap, momentary resistance is felt
patellae (› Fig. 5.21). The posterior side has a Facies articularis in as the patella ‘swims’ on the articular effusion. Smaller effu-
order to connect with both condyles of the femur. With its Facies sions can be detected reliably by ultrasound.
anterior it is embedded in the terminal tendon of the M. quadri-
ceps femoris. Distally from the patella, the tendon is referred to as

M. quadriceps Femur
femoris, tendo
Epicondylus
medialis
Patella
Front, superficial
part of the collateral ligament
tibiale (free running) Meniscofemoral fibres of the rear,
deep part of the
Lig. patellae Lig. collaterale tibiale
(fused with Meniscus medialis)
Meniscus medialis Lig. collaterale
tibiale
Tuberositas tibiae Meniscotibial fibres of
the rear, deep part of the
Lig. collaterale tibiale
Tibia Fibula (fixed to the bone)

a b

Fig. 5.22 Knee joint, Articulatio genus, right. Medial view. a Extended position, b flexed position.

211
5 Lower extremity

Lig. cruciatum Lig. patellae

anterius
Corpus adiposum
Retinaculum infrapatellare
patellae mediale
Retinaculum
patellae laterale
Meniscus medialis
(attachment) Meniscus lateralis
(attachment)
Lig. collaterale fibulare
Lig. collaterale tibiale
M. popliteus, Tendo
Lig. cruciatum posterius

Membrana synovialis Fig. 5.23 Schematic represen-

Capsula articularis
Membrana fibrosa tation of the joint capsule of the
knee joint. Proximal view. [L126]

anterius and posterius by the cruciate ligaments. It is not fused with

the lateral collateral ligament of the knee. On the ventral side, both
menisci are joined by the Lig. transversum genus.
The ‘tibial plateau’ is enlarged into a joint surface by menisci joined
together by ligaments, and has 2 cup-like indentations.
The menisci are supplied by branches of the A. poplitea (› Fig.
5.26a). The Aa. inferiores lateralis and medialis genus and the A.
Effusion
media genus are of particular significance here. The vessels and its
branches form a perimeniscal vascular network which enters from
the outside into the meniscus. The vessels particularly supply the
thicker edge zone of the menisci, whereas the internal sections are
fed by diffusion via the synovial fluid (arrows in › Fig. 5.26b).

Clinical remarks
Due to its strong attachment and its inhomogeneous shape,
Fig. 5.24 Clinical examination of an articular effusion of the knee the internal meniscus is more susceptible to injury. Typically,
Lateral view. [L126] injuries arise due to a sudden rotation in the flexed position
(e.g. the twisting of skis in a squatting position on the slopes),
in which the stronger fixed inner meniscus cannot deal with
Menisci
the sliding movement needed for the rotation. This creates
The menisci, primarily made up of fibrous cartilage, are designed new fissures or pre-existing degenerative changes increase to
to reduce irregularities between the joint surfaces of the knee. become fissures (› Fig. 5.27). Less commonly, even whole
From a proximal view the Meniscus medialis is somewhat oval fragments may shear off and for example, can prevent the ex-
and shaped like a big ‘C’, whereas the smaller Meniscus lateralis is tension of the joint by becoming trapped between the joint
more rounded (› Fig. 5.25). Viewed in cross-section, the menisci bodies. Knee arthroscopy is required to remove the fragments.
are wedge-shaped, with the thicker edged zone on the outside run- When the inner meniscal lesion is combined with other injuries,
these are often lesions of the internal ligaments and the anterior
ning into the flat internal zone. The thickness of the lateral menis-
cruciate ligament and referred to as the ‘unhappy triad’.
cus is largely the same; however the medial meniscus in its rear Transverse and longitudinal tears can also appear due to de-
sections (posterior horn) is much thicker than at the front (anterior generative changes. Small tears may become bigger over
horn). The ends of the medial meniscus are attached to the Tuber- time. If there is a tear in the well-perfused marginal zone, it is
cula intercondylaria of the Eminentia intercondylaris and to the often still possible for spontaneous healing to take place. In
Areae intercondylaria. The corresponding fibres are also referred to the more poorly-supplied internal areas, this is more unlikely.
as ‘Ligg. meniscotibialia anterius and posterius’. The medial menis- Meniscal lesions may lead to osteoarthritis of the knee joint
(gonarthrosis); however, in the case of degenerative changes,
cus is also fused together with the medial collateral ligament of
whether an operation to (partially) remove the menisci im-
the knee joint. The lateral meniscus with its horns is also attached proves clinical outcomes is still currently under discussion.
to the Areae intercondylaria and via the Ligg. meniscofemoralia

(Lig. meniscotibiale anterius) Lig. patellae

Lig. transversum genus

Lig. cruciatum
anterius
Meniscus medialis

Meniscus lateralis

(Lig. meniscotibiale
posterius)
Ligg. meniscofemoralia
Lig. cruciatum posterius anterius and posterius Fig. 5.25 Menisci. Proximal
view.

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 5.4 Lower leg

A. media genus, Lig. cruciatum anterius Meniscus

(R. anterior)

A. media genus,
(R. posterior)
Lig. collaterale tibiale
M. popliteus, Tendo

A. inferior Lig. collaterale fibulare Membrana

medialis genus
A. poplitea A. inferior lateralis genus fibrosa

Lig. cruciatum posterius

a b

Fig. 5.26 Blood supply to the menisci. a Proximal view. b Cross-section. [L126]

Ligaments of the knee joint

Differentiation is made between 3 groups of ligaments:
• Cruciate ligaments (inner ligaments)
• Collateral ligaments (outer ligaments)
• Additional ligaments to strengthen the capsule

Cruciate ligaments
The cruciate ligaments (Ligg. cruciata) are positioned within the
joint gap between the femur and tibia (› Fig. 5.28); however, they Meniscus medialis Meniscus lateralis
are not freely exposed within the joint cavity but are surrounded by
the Membrana synovialis of the joint capsule. Thus they are posi- Fig. 5.27 Lesions of the inner meniscus. Proximal view. [L126]
tioned between the two sheets of the joint capsule. Therefore, its
position is referred to as intracapsular but extrasynovial (› Fig. Additional ligaments to strengthen the capsule
5.23). Multiple ligaments reinforce the Membrana fibrosa of the joint
The anterior cruciate ligament (Lig. cruciatum anterius) runs capsule:
from the inner surface of the lateral femoral condyle to the Area • The Lig. patellae extends the tendon of the M. quadriceps femo-
intercondylaris anterior to the tibia and, therefore, runs from the rear ris tibae from the patella to the Tuberositas tibae.
lateral above to ventromedial below (like a hand in a coat pocket). • The Retinacula patellae (mediale and laterale) are split-offs
The posterior cruciate ligament (Lig. cruciatum posterius) runs from the tendon of the M. quadriceps femoris on each side of
from the inner surface of the medial femoral condyle to the Area the patella (› Fig. 5.29) and have superficial longitudinal and
intercondylaris posterior of the tibia therefore, from frontal medial deep transverse parts.
above to rear lateral below. • The Lig. popliteum obliquum is a split-off from the terminal
tendon of the M. semimembranosus and runs on the dorsal side
NOTE of the capsule from medial above to lateral below.
Course of the cruciate ligaments: • The Lig. popliteum arcuatum also runs in an arched shape on
• Lig. cruciatum anterius: ‘Like a hand in the coat pocket’ (poste­rior the rear wall of the capsule to the Caput fibulae.
lateral top to ventromedial below)
• Lig. cruciatum posterius: in the opposite direction (ventromedial
top to posterior lateral below)

Collateral ligaments
The collateral ligaments (Ligg. collateralia) are located on the out- Lig. cruciatum
side of the knee (› Fig. 5.29). posterius
The Lig. collaterale tibiale (inner ligament, medial ligament) is Condylus lateralis
Condylus medialis
relatively wide and runs from the Epicondylus medialis of the fe-
mur to the medial surface of the tibial plateau (also › Fig. 5.22). It Meniscus lateralis Meniscus medialis
is joined both to the joint capsule and to the interior meniscus.
The narrow Lig. collaterale fibulare (outer ligament, lateral liga- Lig. capitis
Lig. cruciatum
anterius
ment) connects the lateral epicondyle of the femur with the head of fibulae anterius

the fibula. In contrast to the medial collateral ligament, it is joined Lig. transversum
genus
neither to the meniscus nor to the joint capsule. The gap between
capsule and the ligament is filled by the M. popliteus and the Lig.
popliteum arcuatum (› Fig. 5.23). An additional ligament from
the lateral epicondylus of the femur to the Condylus lateralis of the
tibia is called the anterolateral ligament (ALL). Fig. 5.28 Cruciate ligaments, Ligg. cruciata, right. Ventral view in
knee flexion.

213
5 Lower extremity

Clinical remarks
Femur
Heavy loads placed on the knee, e.g. jobs requiring frequent
kneeling (tilers, road construction etc.) can lead to inflamma-
M. articularis genus
tion of the synovial bursae (bursitis). Chronic bursitis is rec-
Bursa suprapatellaris
ognised as an occupational disease. Also chronic joint inflam-
mation such as that found in rheumatic diseases can cause
M. quadriceps
enlargement or the fusion of bursae, which appear as swollen
M. quadriceps
femoris, Tendo masses in the popliteal fossa as (BAKER's cysts).
femoris

Patella
5.4.4 Mechanics of the knee joint
Retinaculum The knee joint is a bicondylar joint. Movements in the joint is pos-
patellae laterale
sible in 2 different axes (› Fig. 5.31a, › Table 5.8):
Corpus adiposum Retinaculum • Transversal axis: flexion/extension
infrapatellare patellae mediale
• Longitudinal axis: internal/external rotation
Lig. collaterale
Lig. patellae This means that functionally it is a hinge-pivot joint. Unlike the hip
fibulare
joint, flexion here does not mean bending ventrally but dorsally.
Bursa infra-
patellaris profunda
Lig. collaterale
tibiale
When rotated externally the toes point laterally and when they are
rotated inwards, medially.
The bending movement is a combination of rolling and turning. At
Caput fibulae Tuberositas tibiae
the beginning of bending (for example, for the first 25°) the femo-
rial condyles roll on the tibia (like a car tyre on tarmac). Thus the
femur moves backwards in relation to the tibia. In the case of
strong flexion, the femoral condyle then turns on the spot (like a
Fig. 5.29 Lateral ligaments, Ligg. collateralia, right. Ventral view. ‘spinning’ tyre). The result of this combination of sliding and rota-
tional motion is that during the deflection movement the transverse
Bursae of the knee joint axis does not stay in its position and moves backwards (› Fig. 5.31c).
In the knee region there are many synovial bursae (Bursae synovia- As the radius of curvature of the femoral condyles is smaller dor-
les) (› Fig. 5.30). These bursae serve as bearings and as a rule un- sally than ventrally, ultimately an arc-shaped displacement of the
derpin the tendons of the muscles. Some are associated with the axis occurs. Further dorsal displacement of the femoral is prevent-
joint capsule, such as the Bursa suprapatellaris under the tendon ed by the cruciate ligaments (› Table 5.9). Particularly in a flexed
of the M. quadriceps femoris or the Bursa subpoplitea beneath the position, the lateral portions of the cruciate ligaments are
M. popliteus. Additionally, other bursae act as shock absorbers stretched. The collateral ligaments are relaxed (› Fig. 5.32b).
when bearing a load, e.g. when kneeling (Bursa subfascialis prepa- During flexion both menisci glide dorsally together with the femur
tellaris in front of the patella or the Bursa infrapatellaris profunda condyles on the plateau. Here, the lateral meniscus travels the larg-
under the Lig. patellae) or as slide bearings for origin and attach- est distance.
ment tendons (Bursa m. semimembranosi, Bursae subtendineae The movements of the femur in relation to the tibia are not the
musculi gastrocnemii medialis and lateralis). same in both compartments. In the lateral condyle, rolling pre-
dominates and the medial condyle primarily performs a twisting
motion. This is also a result of the more strongly fixed medial me-
niscus (fused at the medial collateral ligament) reducing the sliding
Bursa suprapatellaris movement dorsally.
M. quadriceps
The shape of the joint surfaces should make an extension possible
femoris, Tendo without any problem. The two outer ligaments › Table 5.9 are the
primary reason for the very small range of extension (5°). Because
Lig. collaterale (Bursa subfascialis these pass behind the transverse axis with their major attachments,
fibulare prepatellaris) they are stretched to the maximum in the extended position due to
Bursa the larger ventral radius of curvature of the femoral condyles, so
Lig. patellae
subpoplitea preventing overextension, and additionally, they prevent abduction
M. popliteus, Meniscus lateralis and adduction movement and rotation (see below) (› Fig. 5.31,
Tendo
Bursa infra-
› Fig. 5.32a). At the same time, the medial components of the cru-
Lig. popliteum patellaris profunda ciate ligaments are stretched. An extension of over 5° is referred to
arcuatum as ‘Genu recurvatum’ and can be caused, for example, by weak liga-
M. biceps ments.
femoris, Tendo

Table 5.8 Range of movement in the knee joint.

Movement Range of movement

Extension/flexion 5°–0°–140°
External rotation/internal rotation 30°–0°–10°
Fig. 5.30 Bursae of the knee joint, right side. Lateral view.

214
 5.4 Lower leg

0° 0° 30° 10° 0°

5°
0°

140°

a b

Anterior radius of curvature Anterior radius of curvature

Posterior radius
of curvature

Lig. collaterale Lig. patellae

fibulare
Fig. 5.31 Range of movement in
the knee joint. a Extension/flex-
ion. b External rotation/internal
c rotation. c Displacement of the
transverse axis.

The rotational axis of the knee joint runs somewhat eccentrically whereas increased mobility dorsally (posterior drawer) indi-
through the Tuberculum intercondylare mediale (› Fig. 5.21). No cates an (old) rupture of the posterior cruciate ligament.
rotation can be carried out in the extended position as the collater- Examination of the collateral ligaments must be carried out in
al ligaments effectively prevent this from occurring; however, in a the extended position, because the collateral ligaments must
flexed position the collateral ligaments are slack due to the smaller be held under tension. Adduction (enlargement of the exterior
dorsal radius of curvature of the femoral condyles, making rotation knee angle, lateral tilt) is indicative of a lesion of the Lig. col-
possible. laterale fibulare. Conversely, strengthened abduction (reduc-
tion of the knee exterior angle with a medial tilt) indicates a
In internal rotation the cruciate ligaments wrap tightly around
lesion of the Lig. collaterale tibiale (› Fig. 5.33b).
each other and in external rotation away from each other. Therefore,
the scope of external rotation is wider than medial rotation. The
collateral ligaments are only tensed in the case of major external
rotation, and prevent any further rotation (› Table 5.9).
Where there is complete stretching in the knee joint, so-called final
rotation can occur. Here parts of the anterior cruciate ligament
tighten, and the tibia rotates outwards by approximately 5–10°.
Table 5.9 Functions of the ligaments of the knee joint.

Clinical remarks Movement Inhibition by

A simple method for the functional testing of the cruciate lig- Extension • Collateral ligaments
ament is the drawer test (LACHMAN test). With the knee in a • Cruciate ligaments (medial parts)
slightly flexed position (to relax the collateral ligaments) and the Flexion • Cruciate ligaments (lateral parts)
foot in a fixed position, the examiner moves the proximal calf
Medial rotation • Cruciate ligaments
forward or backward in relation to the femur (› Fig. 5.33a). An
• Collateral ligaments (in the extended knee)
abnormal ability to relocate forwards (anterior drawer)
­indicates an (old) injury to the anterior cruciate ligament External rotation • Collateral ligaments (in the extended and
flexed knee)

Lig. cruciatum
posterius
Lig. cruciatum
Lig. collaterale
anterius
fibulare Fig. 5.32 Stabilisation of the
Lig. collaterale knee joint by cruciate and col-
tibiale
lateral ligaments, right. Ventral
view. Tensed parts of ligaments
are shown in red. a Extended
a b position. b Flexed position.
[L126]

215
5 Lower extremity

Lig. cruciatum anterius

Lig. cruciatum posterius

“Positive” anterior
drawer

Lig. collaterale Lig. collaterale

fibulare tibiale (ruptured)

Fig. 5.33 Clinical tests to inves-

tigate the functioning of the lig-
aments at the knee joint.
a Examination of the anterior
cruciate ligament (drawer
a b signs). b Examination of the
internal ligament. [L126]

5.4.5 Muscles of the knee joint tendons attached to the patella and the Lig. patellae to the Tuberosi-
tas tibiae. In addition, attachments are located over the Retinacula
The muscles for movement in the knee joint are positioned at the patellae lateral to the Tuberositas tibiae. Only one part of the
thigh mainly ventrally or dorsally. Only the M. popliteus and parts M. quadriceps femoris, the M. rectus femoris, is a double-hinged
of the M. triceps surae are located on the lower leg. In the latter muscle, and in addition, performs flexion in the hip joint.
muscle, its main function is seen in the movement of the foot,
hence the M. triceps surae will be discussed there. NOTE
Since the M. quadriceps femoris is mainly supplied by spinal cord
Ventral muscles segment L3 , it is a reference muscle for damage to this segment.
The ventral group is made up of only 2 muscles (› Fig. 5.34, In addition, if the patellar reflex is reduced, an impact onto the Lig.
› Table 5.10): patellae will trigger an extension movement in the knee.
• M. quadriceps femoris
• M. sartorius The M. sartorius is a long lean muscle, which goes from lateral
The most important movement performed by the M. quadriceps above at an oblique angle to medially down to the Condylus medi-
femoris is the extension of the knee. It is the only muscle capable of alis of the tibia (› Fig. 5.34, › Table 5.10). Together with a muscle
performing this function. Its 4 sections make up the majority of the coming from dorsal, the M. semitendinosus, and the M. gracilis
thigh's muscle mass. It is inserted predominantly via its terminal (from the adductor group), its end tendon forms a tendon com-

Table 5.10 Ventral muscles of the knee joint.

Innervation Origins Attachment Function

Quadriceps femoris
N. femoralis M. rectus femoris: • Patella F: Hip joint (only M. rectus femoris): flexion
• Spina iliaca anterior inferior • Tuberositas tibiae over Lig. Knee joint: extension (sole extensor!)
• Cranial edge of the acetabulum patellae
M. vastus medialis: • Areas to the side of the Tuber-
• Labium mediale of the Linea aspera ositas tibiae over Retinacula
M. vastus lateralis: patellae
• Trochanter major
• Labium laterale of the Linea aspera
M. vastus intermedius:
• Facies anterior of the femur
M. sartorius
N. femoralis Spina iliaca anterior superior Condylus medialis of the tibia Hip joint:
(‘Pes anserinus superficialis’) • Flexion
• External rotation
• Abduction
Knee joint:
• Flexion
• Medial rotation

216
 5.4 Lower leg

M. tensor
M. rectus fasciae latae
femoris

M. vastus
medialis M. sartorius
M. quadriceps
femoris
M. vastus
intermedius
Tractus
M. vastus iliotibialis
lateralis

Lig. patellae

Fig. 5.34 Ventral muscles of the

knee joint, right. Ventral view.
a b a M. quadriceps femoris.
b M. sartorius.

partment, also known as the Pes anserinus superficialis. Through its

oblique course it crosses over all the movement axes of the hip and
knee joints. It flexes and abducts in the hip joint and rotates exter-
nally. In the knee joint it plays a role in flexion and medial rotation.

Clinical remarks
In the case of a malfunction of the M. quadriceps femoris it is
no longer possible to flex the knee. This is particularly evident
in climbing stairs, as this cannot be performed. Even a slight
drop of the knee cannot be stopped and the patient buckles M. semitendinosus
backwards in an uncontrolled way. Impaired function of the M.
sartorius is functionally insignificant, as for all of the move-
ments it performs there are stronger muscles available.
Caput longum
M. biceps
Caput breve femoris
Dorsal muscles
On the dorsal side there are 4 muscles (› Fig. 5.35, › Table 5.11): M. semimem-
branosus
• M. biceps femoris
• M. semitendinosus
• M. semimembranosus
• M. popliteus
The M. biceps femoris (Caput longum), M. semitendinosus and
M. semimembranosus are double-hinged muscles which run from the
Tuber ischiadicum to the lower leg. Therefore, they are also referred
to collectively by the term ischiocrural muscles. All 3 muscles bend
in the hip joint and flex in the knee joint. The M. biceps femoris runs
lateral to the Caput fibulae, and is the most effective external rotator. Fig. 5.35 Dorsal muscles of the knee joint, right side. Dorsal view.
The M. semitendinosus and M. semimembranosus run medially to
the Condylus medialis of the tibia. Both muscles are also medial ro- Clinical remarks
tators, with the M. semimembranosus being the strongest. The broad
attachment of this muscle is also known as Pes anserinus profundus. When there is a functional failure of the ischiocrural muscles,
The M. popliteus is also considered as one of the deep muscles of the bending and external rotation of the knee are impaired. Walk-
ing, standing and climbing stairs are however possible as long
leg (› Fig. 5.50b) due to its innervation by the tibial nerve; however,
as the M. gluteus maximus is not affected (most important ex-
it only affects the knee and here is a medial rotator. It can also stretch
the joint capsule, as its tendon is embedded in the Membrana fibrosa.

217
5 Lower extremity

Table 5.11 Dorsal muscles of the knee joint.

Innervation Origins Attachment Function

M. biceps femoris
• Caput longum • Caput longum: Tuber ischiadicum Caput fibulae Hip joint:
(twin-articulated): • Caput breve: Labium laterale of the • Extension
tibial part of the Linea aspera • External rotation (most important muscle), adduction
N. ischiadicus Knee joint:
• Caput breve • Flexion
­(single-articulated): • External rotation
fibular part of the
N. ischiadicus
M. semitendinosus
Tibial portion of the Tuber ischiadicum Condylus medialis of the tibia Hip joint:
N. ischiadicus (‘Pes anserinus superficialis’) • Extension
• Medial rotation
Knee joint:
• Flexion
• Medial rotation
M. semimembranosus
Tibial portion of the Tuber ischiadicum Condylus medialis of the tibia Hip joint:
N. ischiadicus (‘Pes anserinus profundus’) • Extension
• Medial rotation
Knee joint:
• Flexion (most important muscle)
• Medial rotation (most important muscle)
M. popliteus
Tibial portion of the Condylus lateralis of the femur, posterior Facies posterior of the tibia Knee joint:
N. ischiadicus horn of the outer meniscus above the Linea musculi solei • Medial rotation
• Prevents the meniscus from getting trapped

tensor in the hip); however, use of the M. quadriceps femoris 5.5 Foot

preponderantly on the ventral side results in overstretching in
the knee joint, Genu recurvatum.
Skills
After working through this chapter, you should be able to:
In summary, the following muscles are involved in the respective • indicate the bones of the foot skeleton with its main struc-
movements of the knee joint (most important muscle in bold type): tures
• Extension: • explain the construction, range of movement and mechanics
of the ankle joint and the other joints of the foot
– M. quadriceps femoris
• explain the course and the function of ligaments for secur-
• Flexion: ing the ankle and the basic characteristics of the ligaments
– M. semimembranosus of the other joints of the foot
– M. semitendinosus • know the structure and the importance of the arch of the
– M. biceps femoris foot, including the necessary ligaments and muscles
– M. gracilis • know the muscles of the leg with origin, attachment and
– M. sartorius function, and also show them on the skeleton or dissected
specimen, and name the short foot muscles and their inner-
• External rotation:
vation
– M. biceps femoris
– M. tensor fasciae latae
• Internal rotation On the foot a differentiation is made between the tarsus (Tarsus),
– M. semimembranosus the mid-foot (Metatarsus) and the toes (Digiti pedis).
– M. semitendinosus The big toe is called the Hallux (Digitus primus [I]). The other toes
– M. popliteus are numbered accordingly. The second toe is the Digitus secundus
– M. sartorius (II), the third is Digitus tertius (III), the fourth is Digitus quartus
– M. gracilis (IV) and the little toe is referred to as the Digitus minimus (V).
The sole of the foot (Planta pedis) has a concave shape in relation
NOTE to the floor. A distinction is made between a longitudinal arch and
The M. quadriceps femoris is the only extensor of the knee joint. All a transverse arch. The characteristics of the arches involve the
ischiocrural muscles bend in the knee joint and flex in the hip joint. shape of the bones, the tensor ligament systems, as well as tension
All muscles that have their attachment medially in the lower leg ro- by muscles.
tate inwards in the knee joint. All muscles which attach laterally ro-
tate outwards.

218
 5.5 Foot

5.5.1 Bones of the foot with the Sulcus tali located directly above forms a tunnel, the Sinus
tarsi. Medially a protrusion stands out, the Sustentaculum tali.
The skeleton of the foot is divided into the tarsal bones (Ossa tar- The calcaneus has a total of 4 joint surfaces: at the front is the Fa-
si), the metatarsal bones (Ossa metatarsi) and the toe bones (Ossa cies articularis cuboidea, top ventral the Facies articularis talaris
digitorum, Phalanges) (› Fig. 5.36). Just as in the wrist, a proxi- anterior and facies articularis talaris media and top dorsal, the Fa-
mal and a distal row can be distinguished in the tarsal bones: cies articularis talaris posterior.
• Proximal row (2 bones):
– Ankle bone (Talus)
– Heel bone (Calcaneus)
Clinical remarks
• Distal row (5 bones): At the Proc. medialis of the Tuber calcanei, an osteophyte can
– Os naviculare form at the attachment of the plantar aponeurosis as a heel or
– 3 sphenoid bones: calcaneal spur. Load-related inflammatory changes to this cal-
– Os cuneiforme mediale caneal spur can lead to severe pain.
– Os cuneiforme intermedium
– Os cuneiforme laterale
– Cuboid bone (Os cuboideum) The Os naviculare lies medially and articulates distally with the 3
The talus is part of both the upper ankle joint and a joint body for sphenoid bones and laterally with the cuboid bone which, in turn,
the lower ankle. Above it bears the talar dome (Trochlea tali) as articulates with the calcaneus bone. The narrow end of the sphe-
the articular surface for the upper ankle. The head (Caput), neck noid bones faces plantar, creating an important requirement for the
(Collum) and body (Corpus) can be distinguished. Below is the formation of the transverse arch of the foot.
Sulcus tali, the dividing line between the front and rear chamber of With the 5 metatarsal bones (Ossa metatarsi) the toes are num-
the lower ankle joint. At the front on the head is the Facies articu- bered from medial to lateral, from I–V. As with the hand, a dis­
laris navicularis, below are the Facies articularis anterior and Facies tinction is made between the Basis, Corpus and Caput. A special
articularis media, and dorsal the Facies articularis posterior, all feature is that underneath Os metatarsi I, there are typically 2 sesa-
providing joint surfaces for the lower ankle joint. moid bones located under the metatarsal bones. The Tuberositas
The rear section of the elongated calcaneus is called the Tuber cal- ossis metatarsi I serves as an attachment for the M. tibialis anterior;
canei. It has 2 raised areas, the Proc. lateralis tuberis calcanei and the Tuberositas ossis metatarsi V forms the attachment for the M.
the Proc. medialis tuberis calcanei. The Sulcus calcanei, together fibularis brevis.

Tuberositas phalangis distalis

Phalanx distalis
Phalanx media

Phalanx distalis
Phalanx proximalis
Phalanx media
II
I III Phalanx proximalis I
II
IV Caput phalangis
III
Caput ossis
metatarsi Corpus phalangis IV
V
Ossa digitorum
Corpus ossis Basis phalangis [Phalanges] V
metatarsi
Basis ossis
metatarsi
Articulationes
tarsometatarsales Os cuneiforme Ossa meta-
(LISFRANC laterale tarsi I–V
joint) Os cuneiforme
mediale
Os cuneiforme Tuberositas ossis
mediale Os cuneiforme
metatarsi quinti
Tuberositas ossis intermedium
Os cuneiforme Os cuboideum metatarsi quinti
intermedium Os cuneiforme laterale
Articulatio tarsi Sulcus tendinis musculi Tuberositas ossis
Os naviculare transversa (CHOPART’s fibularis longi navicularis
joint)
Caput tali Os cuboideum Os naviculare
Talus Proc. lateralis tali Caput tali
Calcaneus
Trochlea tali

Calcaneus Talus

Proc. lateralis
a b tuberis calcanei Sustentaculum tali

Proc. medialis
I Hallux [Digitus primus] II Digitus secundus III Digitus tertius tuberis calcanei
IV Digitus quartus V Digitus minimus [quintus]

Fig. 5.36 Skeleton of the foot, right. a Dorsal view. b Plantar view.

219
5 Lower extremity

Clinical remarks wide Lig. collaterale mediale; It is often referred to as the deltoid
ligament (Lig. deltoideum) (› Fig. 5.37). It has 4 parts:
A disease often occurring in pubescent girls is KÖHLER's dis-
• Pars tibionavicularis
ease II, in which an aseptic necrosis of generally the 2nd or
3rd metatarsal head occurs. Necrosis of the Os naviculare is • Pars tibiocalcanea
called KÖHLER's disease I. • Pars tibiotalaris anterior
• Pars tibiotalaris posterior
On the lateral side, there are 3 weaker individual ligaments (› Fig.
The Hallux consists of the proximal phalanx and distal phalanx 5.38):
(Phalanx proximalis and Phalanx distalis), whereas toes II–V, as • Lig. talofibulare anterius
with the fingers of the hand, are made up of 3 bones (Phalanx • Lig. talofibulare posterius
proxi­malis, Phalanx media and Phalanx distalis). Here, too for, • Lig. calcaneofibulare
each phalanx basis, corpus and caput can be distinguished. They are collectively known as the Lig. collaterale laterale, but in
contrast to the deltoid ligament, do not represent a single unit.
Strictly speaking, a secure attachment is only made by the ligament
5.5.2 Joints of the foot parts between the tibia and the fibula and the tibia and the talus ex-
cept for the upper ankle. The other ligaments also stretch over the
The two large joints of the foot are lower ankle, thus providing additional stability.
• Upper ankle (Articulatio talocruralis) The interlocking of the tibia and fibula via the Membrana interos-
• Lower ankle (consisting of the Articulatio subtalaris and the sea cruris and the Ligg. tibiofibularia is also crucial for the stability
Articulatio talocalcaneonavicularis) of the upper ankle joint.
Clinically, these two joints are abbreviated to UAJ and LAJ. The
other joints of the tarsus and of the midfoot are referred to by the
interrelated bones (Articulatio talonavicularis, Articulatio calca-
Clinical remarks
neocuboidea, Articulatio cuneonavicularis, Articulationes intercu- Fractures in the region of the joint surfaces of the UAJ are
neiformes, Articulatio cuneocuboidea, Articulationes tarsometa- among the 5 most common fractures. They often affect the
tarsales and Articulationes intermetatarsales). distal end of the fibula. The commonly used classification ac-
The Articulatio tarsi transversa (between the proximal and distal cording to WEBER (› Fig. 5.39) categorises the breaks ac-
cording to the position of the fracture of the fibula in relation
rows of tarsal bones) is also known as CHOPART’s joint line. The
to the distal tibiofibular joint (Syndesmosis tibiofibularis):
Articulationes tarsometatarsales between the tarsus and midfoot • WEBER A: fracture in the outer ankle distal of the syndesmo-
form LISFRANC’s joint line (› Fig. 5.36a). The lines have a cer- sis; syndesmosis intact
tain relevance in amputations. • WEBER B: fracture at the level of the syndesmosis with injury
The toe joints are referred to as: to the tibiofibular ligaments; even the syndesmosis itself
• Articulationes metatarsophalangeae can be injured
• Articulationes interphalangeae pedis • WEBER C: fracture proximal to the syndesmosis, tear in the
Membrana interossea, generally including the dislocation of
the syndesmosis.
Upper ankle joint Additional fractures, e.g. of the talus and the distal tibia, can
The upper ankle joint (Articulatio talocruralis) is the connection also occur.
between the lower leg and the foot. Here the Malleolus medialis of The severity of injury increases from A to C. WEBER A fractures
the tibia and the Malleolus lateralis of the fibula and the distal end can often be treated conservatively with just a splint. It is es-
of the tibia articulate with the talus. The talus is slightly wider ven- sential to have a stable upper ankle (joint space in the x-ray
trally than dorsally, which is important for the stability of the ankle image is of the same width, ability to stand on tip-toe).
joint. ­WEBER C fractures on the other hand, are highly unstable and
must always be treated by an operation.
A differentiation is made between the medial and lateral liga-
ments, which stabilise the upper ankle joint. Located medial is the

Fibula
Pars tibiotalaris posterior
Lig. collaterale mediale Pars tibiocalcanea Tibia
[deltoideum] Pars tibiotalaris anterior
Pars tibionavicularis

M. tibialis anterior, Lig. tibiofibulare

tendo posterius

M. tibialis
posterior, tendo

Lig. calcaneonavi-
culare plantare

Ligg. tarsometa-
tarsalia plantaria

Lig. calcaneo- Lig. plantare longum

naviculare plantare Fig. 5.37 Upper ankle with liga-
ments, right. Medial view.

220
 5.5 Foot

Lig. tibiofibulare
anterius Lig. talocalcaneum laterale
Lig. talofibulare Lig. talocalcaneum interosseum
anterius
Ligg. tarsi dorsalia
Malleolus lateralis

Ligg. metatarsalia dorsalia

Lig. calcaneofibulare

Tendo
calcaneus

Ligg. metatarsalia
transversa profunda
Lig. plantare longum Lig. calcaneo- Lig. calcaneo-
Ligg. tarsometatarsalia dorsalia
naviculare cuboideum
M. fibularis [peroneus]
Lig. bifurcatum Fig. 5.38 Upper ankle with liga-
brevis, Tendo
ments, right. Lateral view.

Lower ankle joint simply, a distinction is made between the ligaments on the dorsal
The lower ankle joint is articulated by the talus, calcaneus and the side (Ligg. tarsi dorsalia), and on the plantar side (Ligg. tarsi
Os naviculare. The joint is complicated and consists of 2 individual plantaria) and the ligaments between the bones (Ligg. tarsi inter-
joints, which are separated by the Sinus tarsi (› Fig. 5.40): ossea). The Lig. bifurcatum is bifurcated (› Fig. 5.38) and bridg-
• Articulatio subtalaris (dorsal) es the CHOPART’s joint line (Lig. calcaneonaviculare and Lig. cal-
• Articulatio talocalcaneonavicularis (ventral) caneocubideum).
In the Articulatio subtalaris the Facies articularis calcanea poste- Dorsal, plantar and interosseous ligaments can also be distin-
rior of the talus meets the Facies articularis talaris posterior of the guished at the amphiarthroses between the tarsus and midfoot as
calcaneus. This joint is separated from the anterior joint by the Lig. well as between the metatarsal bones.
talocalcaneum interosseum, which fills the Sinus tarsi. The toes are stabilised by plantar ligaments and collateral ligaments
The Articulatio talocalcaneonavicularis has 3 articulating bony running along the sides.
joint surfaces:
• Facies articularis navicularis of the talus with the Os naviculare
• Facies articulares calcanea anterior and media of the talus with 5.5.3 Mechanics of the ankle joints
the Facies articularis talaris anterior and media of the calcaneus
When observing the skeleton of the foot from plantar (› Fig. The upper ankle joint is a hinge joint (› Fig. 5.41). Only move-
5.36b), it becomes clear that there is a gaping bony gap between the ments around one axis are possible, which runs through the tips of
calcaneus and the Os naviculare. The two bones are connected by the two ankle bones. The corresponding movements are referred to
the socket ligament (Lig. calcaneonaviculare plantare). This as dorsal extension and plantar flexion. Instead of ‘dorsal extension’
completes the socket of the lower ankle joint (› Fig. 5.40). As this in some books the term dorsiflexion can also be found. The upper
ligament forms part of the articular surface, its upper surface is ankle does not have equal stability in all positions. This results
covered with cartilage like the other bony joint surfaces. mainly from the differing width of the trochlea as the lower articu-
The lower ankle is partially stabilised by the ligaments of the upper lar surface. This is wider ventrally compared to dorsally by up to 5
ankle joint and by the ligaments that connect the talus and calcane- mm. In the dorsiflexion position the malleolar fork is located over
us together (› Fig. 5.37, › Fig. 5.38). the wider anterior end of the talus. The joint surfaces of the Malle-
olus lateralis and Malleolus medialis sit firmly on the talus on both
Other joints of the foot sides. To do this, the Ligg. tibiofibularia must also yield somewhat
The remaining joints of the tarsus are mainly amphiarthroses and and the ‘dovetailing’ of the forks are slightly spread. In the plantar-
are tightly braced. The corresponding ligaments generally run be- flexion position the malleolar fork is located over the narrower dor-
tween two adjacent bones and so are named after these bones. Put sal end of the Trochlea tali. The joint surfaces are no longer held

Fibula
Tibia
Membrana interossea
cruris

Syndesmosis tibiofibularis
(Lig. tibiofibulare)
Malleolus
Malleolus medialis
lateralis Fig. 5.39 WEBER classification
of fibular fractures with involve-
ment of the ankle joint. From
WEBER A WEBER B WEBER C left to right WEBER A, WEBER B
and WEBER C fracture.

221
5 Lower extremity

Ligg. tarsometatarsalia dorsalia

Os metatarsi II
Os metatarsi IV
Os metatarsi I Os metatarsi V

Ligg. tarsi dorsalia Tuberositas ossis

metatarsi quinti
Os cuboideum
Lig. calcaneonaviculare Lig. bifur-
Os naviculare
Lig. calcaneocuboideum catum
Lig. calcaneonaviculare M. fibularis [peroneus] brevis, Tendo
plantare Facies articularis talaris anterior
Facies articularis talaris media Articulatio talocalcaneonavicularis
Lig. talocalcaneum interosseum Articulatio subtalaris

Facies articularis talaris posterior

Calcaneus
Fig. 5.40 Lower ankle joint,
­distal surface, right. Proximal
view.

taut on the talus, allowing a little more play. Stability is reduced by through the Tuber calcanei (› Fig. 5.41c). Functionally, the joint
the poor closure of the joint in this position. is therefore best described as an atypical pivot joint. Movement
around this oblique axis is referred to as inversion and eversion.
When looking at the axis from the rear, inversion means turning
Clinical remarks clockwise, with the rear foot being medially rotated. Conversely,
Injuries of the upper ankle joint are very common. Usually this eversion, means anticlockwise rotation with lateral rotation of the
is the classical ‘sprained ankle’, whereby the joint is ‘twisted’ foot.
laterally. Due to its poor stability, this ‘twisting’ frequently Inversion and eversion are not to be confused with pronation and
takes place in the plantar flexion position, such as when walk- supination (› Fig. 5.41). Pronation means the lifting of the lateral
ing down hills or wearing high-heeled shoes. Here external
margin of the foot, while supination is the lifting of the medial
ligaments are frequently damaged (especially the Lig. talo­
fibu­lare anterius). Depending on the severity of injury, conser- margin of the foot. Whereas inversion/eversion only occurs around
vative treatment is sufficient, otherwise the ligament injury the axis of the lower ankle joint, for pronation/supination, addi-
must be surgically treated. tional movements are required in the other, mostly tightly com-
pressed joints of the tarsus and midfoot. The Articulatio tarsi
transversa (‘CHOPART’s joint’) is not an amphiarthrosis but has
Movement in the lower ankle joint always takes place in both greater mobility.
compartments at the same time, functionally fitting together to These additional joints as a whole allow the foot to twist in the sag-
make a unit (› Fig. 5.41, › Table 5.12). The joint has one degree ittal axis (e.g. through the second toe ray). This means that the
of freedom. The axis runs forwards and medially from the front to front and rear sections of the foot can easily be turned against each
the rear through the Os naviculare and Talus posterior laterally other. In addition, there is an elastic bone plate which exists as a

ion
lex
rs al f 30°
Do
Pl
an 50°
ta
rf
a lex
ion

UAJ axis
Pron Fig. 5.41 Axes and ranges of
ation
30° movement of the upper and low-
ion er ankle joints.
b in at c
60° LAJ axis a Dorsal flexion/plantar flexion.
Sup
b Pronation/supination and
35° 20°
Inversion Eversion eversion/inversion. c Axes of
the upper and lower ankle.

222
 5.5 Foot

Table 5.12 Range of movement in the ankle joints. Hallux “Deviation

[digitus primus] laterally”
Joint Movement Range of movement
Os sesamoideum
Upper ankle Dorsal extension/plantar 30°–0°–50°
mediale
flexion
Lower ankle Eversion/inversion 20°–0°–35°
Os sesamoideum
Lower ankle and other Pronation/supination 30°–0°–60° laterale
joints of the tarsus and
metatarsus “Deviation
medially” M. adductor hallucis

Os metatarsi I

result of the tightly securing ligaments of this joint, especially in

M. extensor hallucis
the area of the metatarsus, which is also able to compensate for un- longus
even floors.
M. flexor hallucis longus
The metatarsophalangeal joints are ball joints; however, due to the
M. abductor hallucis
tightly securing ligaments, movement is only possible in 2 axes
(› Fig. 5.42, › Table 5.13), no rotation takes place: Fig. 5.43 Distal foot with Hallux valgus, right. Dorsal view. [L126]
• Dorsal flexion/plantar flexion
• Abduction/adduction
Table 5.13 Scope of movement of the toe joints.
Abduction, means spreading of the toes, whereas with adduction,
the movement of the toes is to the midline of the foot. Especially in Movement Range of movement
the base joint of the hallux, dorsiflexion is possible and at least pas-
Dorsal flexion/plantar flexion 60°–0°–40°
sively very far (often over 90°). This is important for the rolling
Abduction/adduction 10°–0°–20°
movement when walking.
The middle and distal interphalangeal joints of the toes are hinge
joints. The movement is limited to relatively limited dorsiflexion
and plantarflexion (› Fig. 5.42, › Table 5.13). 5.5.4 The arch of the foot

When standing, the weight of the body is transferred via the ankle
Clinical remarks to the remaining part of the foot skeleton. Put simply, a medial and
Hallux valgus is a common deformity of the big toe (› Fig. lateral strand can be distinguished, and these spread the load
5.43). It leads to a valgus position in the first metatarsopha- (› Fig. 5.44). The talus acts as a distributor, because the entire
langeal joint, i.e., the angle between the longitudinal axis of weight is placed on it via the upper ankle joint and the Trochlea
metatarsal I and the Phalanx proximalis of the big toe increas- tali. The medial metatarsal bones radiate out and run over the Os
es. This goes hand in hand with an enlargement of the angle
naviculare, Ossa cuneiforma and Ossi metatarsi I–III to the first
between the longitudinal axis of Os metatarsi I and II. Thus,
the head of the metatarsal protrudes painfully medially and three toes. The 4th and 5th metatarsal bones form the lateral strand
the tip of the big toe overlays or underlays the second toe. Of- through the calcaneus, the Os cuboideum and the Ossa metatarsi
ten this deformity is triggered by a predisposition and the con- bones IV and V to the two outer toes.
tinuous wearing of footwear which is too tight with a widened The midfoot and tarsus are curved in a concave sense in a plantar
forefoot (generally because of splayed foot). The modified direction. Whereas the heads of the Ossa metatarsi are positioned
muscle structure assists the pathology even more by the ten- largely flatly, the Corpus and Basis rise up towards the tarsal bones.
sion of the long muscle tendon of the big toe reinforcing the
The apex of the longitudinal arch is the talus. The calcaneus, the
valgus position. As a result of lateralisation of the medial ses-
amoid bone, the M. abductor pollicis may even become an ad- anterior attachments of which are also raised, descends dorsally to
ductor in the base joint. Larger deformities and resulting pain form the posterior end of the arch. Viewed in cross-section an
must be treated by an operation. arch is most strongly formed in the area of the cuneiform bones
and the cuboid bone (apex of the transverse arch: Os cuneiforme
intermedium). These arches mean that in the normal p ­ osition, only
3 bone points are in contact with the ground (­ › Fig. 5.44b):
Abduction • Tuber calcanei
20° • Head of the Os metatarsi I
10°
Addu
ction
• Head of the Os metatarsi V
Adduction
The arches of the foot are formed in the course of growth with in-
a 20° creasing requirements for standing and walking. In infants, the
Abd
ucti 10° arch is only very slightly pronounced. Only during the first years of
on
life does the foot skeleton elevate and completely form the trans-
60° verse and longitudinal arches.
The arches of the foot are maintained in place both passively by lig-
b aments and actively by muscles (› Fig. 5.45, › Fig. 5.46). The
40° longitudinal arch is stabilised by 3 ligament systems arranged in
layers:
Fig. 5.42 Range of movement of the toe joints. a Abduction/adduc- • Upper layer: socket ligament (Lig. calcaneonaviculare plan-
tion. b Dorsal flexion/plantar flexion. tare); from the Sustentaculum tali to the Os naviculare

223
5 Lower extremity

I II III I
IV
V III II
IV
V

Ossa cunei- Ossa cuneiformia

formia
Os navi- Os cubo- Os cuboideum Os naviculare
culare ideum

Talus Talus
Calcaneus Calcaneus

Contact points Fig. 5.44 Bone of the arch,

a b to the floor right. a Dorsal view. b Plantar
view.

M. tibialis posterior, Tendo Tendo Table 5.14 Stabilisation of the arch of the foot.
M. flexor hallucis calcaneus
longus, Tendo Passive stabilisation Active stabilisation
Longitudinal arch
• Lig. calcaneonaviculare • M. flexor hallucis longus
• Lig. plantare longum • M. flexor digitorum longus
• Plantar aponeurosis • M. tibialis posterior
Lig. calcaneonaviculare • Short foot muscles
plantare
Transverse arch
Short plantar ligaments between the • M. fibularis longus
bones of the tarsus and metatarsus • M. tibialis posterior
• M. adductor hallucis

Short foot muscles Aponeurosis

Lig. plantare longum plantaris
tendons at the Tuber calcanei, counteracts the calcaneus from be-
ing in an excessively steep position (and thereby strengthening the
Fig. 5.45 Longitudinal arch of the foot, right side. Medial view.
longitudinal arch). Thus, it is possible by actively tensing the mus-
[L126]
cles to fine tune the arch and make adjustments to loadings.
The transverse arch is passively held in place by the short liga-
Os cuneiforme mediale ments between the bones of the tarsus and the midfoot on the
Os cuneiforme intermedius plantar side. Also contributing to its active support are the M. fibu-
Os cuneiforme laterale laris longus and the M. tibialis posterior (› Fig. 5.46) as well as
the individual short foot muscles of the M. adductor hallucis
(› Table 5.14). The M. fibularis longus is deflected at the lateral
Os cuboideum side of the cuboid bone towards the sole of the foot. It crosses un-
derneath the foot at an angle and sets the radius of curvature at the
medial ray of the foot ray so that its tension reinforces the trans-
M. tibialis verse arch.
posterior, Tendo M. fibularis [peroneus] By the formation of the arch, the load transferred to the talus is
longus, Tendo
shared and transferred to the support points. This is particularly
clear in the example of the longitudinal arch, where the forces in
Fig. 5.46 Transverse arch of the foot, right. [L126]
the Tuber calcanei and the metatarsal bones are dissipated (› Fig.
5.45). Thus, the structures spanning the longitudinal arch are held
• Middle layer: Lig. plantare longum; from underneath the calca- under tension (horizontal arrows). This ensures that the arch of the
neus to the Os cuboideum and the bases of Ossi metatarsi II–V foot performs a certain amount of the shock absorber function,
• Lower layer: plantar aponeurosis (Aponeurosis plantaris); and thus can absorb force peaks.
stretches between the Tuber calcanei and the heads of the Ossi
metatarsi
The short foot muscles on the plantar side are important for the ac-
Clinical remarks
tive tension on the longitudinal arch (› Fig. 5.45). Also the ten- Flattened sections of the arch due to a failure of passive and
dons of all deep lying calf muscles (M. flexor hallucis longus, M. active tension mechanisms are common diseases, which, due
flexor digitorum longus and M. tibialis posterior) work against flat- to incorrect weight bearing leading to a reduction in shock ab-
tening of the longitudinal arch (› Table 5.14). The opposing mus- sorber function, can lead to severe pain and degenerative
changes. A flattening of the longitudinal arch leads to falling
cle here is the M. triceps surae which, by tensing via the Achilles

224
 5.5 Foot

of the calcaneus and the talus, referred to as flat feet or fallen well as the bones of the leg. In particular, the extensor compart-
arches (Pes planus). Often in this case, the talus buckles me- ment (Compartimentum anterius) is very taut and does not allow
dially, splay foot (Pes valgus). much extra expansion.
A flattening the transverse arch is due to the descent of the
Ossi metatarsalia II–IV. This leads to a broadening of the fore-
foot (splay foot, Pes transversoplanus). In addition to the of- Clinical remarks
ten painful additional stress of the middle metatarsal bone, it
often results in Hallux valgus (see above). A strong curvature An increase in pressure in one of the compartments is referred
of the foot is referred to as Pes cavus (Pes excavatus). to as compartment syndrome. Often the extensor compart-
A congenital club foot is the most common foot malformation ment is affected (Tibialis anterior compartment syndrome). For
(Pes equinovarus). Here the unstressed foot remains in the example, this can occur as a result of excessive stress (long
plantarflexion position and is supinated. This is the normal periods of running), or haemorrhage after a fracture or an op-
intrauterine position but up to the time of birth the foot gener- eration. Increased pressure results in compression of the ar-
ally reverts to the position found in normally developed feet. teries and nerves passing through the compartment, which
can ultimately lead to necrosis of the muscles. Therefore, it
may be necessary to separate the fascia in an emergency.

5.5.5 Muscles of the lower leg and foot All the long muscles pass over the upper and lower ankle joint,
with most of them being inserted into the front sections of the tar-
Muscles of the talocalcaneonavicular joint sus. Thus all the muscles contribute to both flexion/extension (up-
The muscles that move the foot in the joints are located in the low- per ankle joint) as well as in pronation and supination movements
er ankle. Here, three groups can be distinguished: (lower ankle and other joints of the foot). So the function of each
• Ventral group (dorsal extensors) muscle is dependent on the course of its end tendon (› Fig. 5.47).
• Lateral group (fibularis or peroneus group, pronators)
• Dorsal group (plantar flexors) NOTE
In the plantar flexors a superficial group is differentiated from a All muscles with end tendons coursing ventral of the flexion/exten-
deep group: sion axis of the upper ankle joint are dorsal extensors (left figure in
• Ventral group (from medial to lateral) › Fig. 5.47, red). Muscles whose tendons course dorsally to this
– M. tibialis anterior axis are plantar flexors (left figure in › Fig. 5.47, blue). Muscles
that course medial to the axis of the lower ankle joint, are supina-
– M. extensor hallucis longus tors (lifting the medial margin of the foot, right figure in › Fig.
– M. extensor digitorum longus 5.47, blue). All muscles whose end tendons course laterally to the
• Lateral group (from proximal to distal) axis act as pronators (lifting the lateral margin of the foot) (right
– M. fibularis longus figure in › Fig. 5.47, red).
– M. fibularis brevis
• Dorsal superficial group
– M. triceps surae Ventral group
– M. plantaris The most important of all the extensors is the M. tibialis anterior
• Dorsal deep group (from medial to lateral) (› Fig. 5.48, › Table 5.15). It originates from the lateral side of
– M. flexor digitorum longus the tibia and therefore has to overlap the tibia in its distal course.
– M. tibialis posterior Due to its attachment medial to the skeleton of the foot, it is also a
– M. flexor hallucis longus supinator. Conversely, the terminal tendons of the other muscles
Each group runs in a separate osteofibrous canal, referred to in its course further laterally, so they are pronators (› Fig. 5.47, ›­ Ta-
entirety as the Compartimenta cruris. These muscle compartments ble 5.15).
are made up of the lower leg fascia (Fascia cruris), its divisions, as

Extension Eversion

Inversion
M. extensor hallucis longus

M. tibialis anterior M. extensor digitorum longus

M. fibularis longus,
M. tibialis posterior
M. fibularis brevis
Fig. 5.47 Effect of the muscles
M. flexor digitorum longus of the lower leg on the ankle
M. flexor hallucis longus joints. Dorsal view. Course of
the end tendons for the axis of
Flexion M. triceps surae the ankle joint (left) and of the
lower ankle joint (right). [L126]

225
5 Lower extremity

Table 5.15 Ventral group of the lower leg muscles.

Innervation Origins Attachment Function

M. tibialis anterior
N. fibularis profundus Facies lateralis of the tibia, Fascia cruris, Os metatarsi I, Os cuneiforme • Upper ankle joint: dorsal extension (most important
(N. ischiadicus) Membrana interossea mediale muscle)
• Lower ankle: supination (weak)
M. extensor hallucis longus
N. fibularis profundus Facies medialis of the fibula, Membrana Distal phalanx of the Hallux • Upper ankle: dorsal extension
(N. ischiadicus) interossea, Fascia cruris • Lower ankle: pronation (weak)
• Joints of the big toe: extension
M. extensor digitorum longus
N. fibularis profundus Condylus lateralis of the tibia, Margo anterior Dorsal aponeurosis of the • Upper ankle: dorsal extension
(N. ischiadicus) of the fibula, Membrana interossea cruris, 2nd–5th toes • Lower ankle: pronation
Fascia cruris • Toe joints: extension

The M. extensor hallucis longus and M. extensor digitorum longus Clinical remarks
are primarily responsible for dorsal flexion in the toe joints. An oc-
casionally occurring separation of the M. extensor digitorum lon- When there is damage to the muscles of the ventral group,
dorsiflexion is no longer possible and the foot hangs down
gus muscle with an attachment to the Os metatarsi V is referred to
slackly (equine foot position). Patients have to compensate by
as the M. fibularis tertius. raising the thigh higher when walking, in order to avoid drag-
ging the slack foot on the floor (drop foot gait).
NOTE
The M. tibialis anterior is a reference muscle for segment L4 and
the M. extensor hallucis longus for spinal cord segment L5. In the
case of injury to L5 (e.g. as a result of a hernia), this leads to a Lateral group
weakening of extension of the Hallux. The M. fibularis longus derives proximally on the fibula and is lo-
cated dorsal to the M. fibularis brevis (› Fig. 5.49, › Table 5.16).
Both muscles run dorsally from the outer ankle to the foot. The M.
fibularis longus in the area of the Os cuboideum transfers from the
lateral margin of the foot to the sole of the foot, crosses (as viewed
from plantar) under all the muscles running there and is inserted
at the medial margin of the foot skeleton. It is the strongest pronator

M. tibialis
anterior

M. extensor
digitorum longus

M. extensor
hallucis longus
M. fibularis [peroneus]
longus

M. fibularis [peroneus]
brevis

Fig. 5.48 Ventral group of muscles of the lower leg, right side. Ven- Fig. 5.49 Lateral group of muscles of the leg, right side. Lateral
tral view. view.

226
 5.5 Foot

Table 5.16 Lateral group of the lower leg muscles.

Innervation Origins Attachment Function

M. fibularis (peroneus) longus
N. fibularis superficialis Caput fibulae, proximal two thirds of the Tuberositas ossis metatarsi I, Os • Upper ankle: plantar flexion
(N. ischiadicus) ­fibula, Fascia cruris cuneiforme mediale • Lower ankle: pronation (most important muscle)
M. fibularis (peroneus) brevis
N. fibularis superficialis Distal half of the fibula Tuberositas ossis metatarsi V • Upper ankle: plantar flexion
(N. ischiadicus) • Lower ankle: pronation

and due to its course crossing over the sole area, it is involved in strongest and thickest tendon of the human body. It is twisted in a
tension of the transverse arch. In addition to pronation, both mus- spiral and inserts flatly onto the bottom edge of the Tuber calcanei.
cles contribute to plantar flexion. A bursa (Bursa tendinis calcanei) supports the tendon in its
course along the rear edge of the calcaneus.
The M. triceps surae is the strongest plantar flexor and also the
Clinical remarks strongest supinator (the Achilles tendon inserts medial to the axis of
A malfunction in the fibularis group leads to the supination the lower ankle joint!).
position of the foot due to the predominance of the antagonis-
tic muscles. NOTE
The M. triceps surae is the reference muscle for the S1 segment.
When this segment is injured, the Achilles tendon reflex fails soon
afterwards. Normally, hitting the Achilles tendon with a reflex ham-
Dorsal group mer results in the contraction of the Triceps surae and hence, plan-
tar flexion.
The calf muscles are positioned dorsally. The dorsal superficial
compartment is largely enclosed by the muscle bellies of the M. tri-
ceps surae, made up of the two heads of the M. gastrocnemius and Its largest part, the M. gastrocnemius, originates at the thigh bone
the M. soleus (› Fig. 5.50a, › Table 5.17). All the end tendons and can therefore also flex in the knee joint. The lateral portion of
converge to the Achilles tendon (Tendo calcaneus). This is the the M. soleus originates at the fibula, and its medial part at the tib-
ia. Both origins are connected by a tendinous arch (Arcus tendine-
us m. solei), under which dorsal vessels and nerves of the leg (A./V.
posterior tibialis and N. tibialis) course.
M. plantaris The M. plantaris, which is sometimes absent, only has a very short
muscle belly and a long end tendon, which also radiates into the
Achilles tendon. It also originates from the femur, which is why it
is able to bend the knee joint weakly (› Table 5.17). Due to its ex-
M. popliteus ceptional wealth of muscle spindles (receptors for the measuring
Caput
the length of a muscle) it is accorded a role in the orientation of the
M. gastro- laterale body in space (proprioception).
cnemius Caput
mediale M. tibialis
posterior Clinical remarks
M. flexor
digitorum longus A failure of the M. triceps surae alone occurs with the rupture
of the Achilles tendon. A chronically damaged Achilles ten-
don, after suffering many small injuries, can often tear under
acute stress (e.g. jumping up high when playing badminton),
which can clearly be heard as a bang.
M. flexor
hallucis longus In the event of malfunction of the M. triceps surae walking is
difficult. In particular, standing on tip-toe is no longer possi-
M. soleus ble, as this cannot be compensated for by the deep flexors. In
addition, the arch of the foot is reinforced by the predomi-
nance of the muscles located on the sole of the foot (Pes ca-
vus).
Chiasma cruris

Tendo Chiasma plantare After removal of the superficial group, the relatively slender deep
calcaneus
flexor group (in comparison to the M. triceps surae) is visible be-
tween the tibia and fibula (› Fig. 5.50b, › Table 5.18). The M. flex-
or digitorum longus originates furthest medially, in the middle is
the M. tibialis posterior and lateral the M. flexor hallucis longus.
a b The M. flexor hallucis longus and the M. flexor digitorum longus
flex all the phalangeal joints. The M. tibialis posterior is a strong
Fig. 5.50 Dorsal group of muscles of the leg, right side. Dorsal view. supinator and braces the longitudinal and transverse arch of the
a Superficial plantar flexors. b Deep plantar flexors. foot.

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5 Lower extremity

Table 5.17 Dorsal superficial group of lower leg muscles.

Innervation Origins Attachment Function

M. triceps surae1
N. tibialis ­ • M. gastrocnemius, Caput mediale: Tuber calcanei • Knee joint flexion (only M. gastrocnemius)
(n. ischiadicus) ­Condylus medialis of the femur • Upper ankle joint: plantar flexion (most important
• M. gastrocnemius, Caput laterale: ­muscle)
­Condylus lateralis of the femur • Lower ankle joint: supination (most important muscle)
• M. soleus: proximal third of the fibula,
Facies posterior of the tibia (Linea musculi
solei), Arcus tendineus musculi solei
M. plantaris
N. tibialis Condylus lateralis of the femur Tuber calcanei • Knee joint: flexion
(N. ischiadicus) • Upper ankle joint: plantar flexion
• Lower ankle joint: supination
1
The broad tendon of the M. triceps surae is known as the Achilles tendon (Tendo calcaneus).

Clinical remarks To summarise, the following muscles are involved in the respective
movements of the ankle (most important muscle highlighted in
A malfunction of the M. tibialis posterior (e.g. as a result of a
bold):
ruptured tendon) results in the foot being in a pronation posi-
tion, because the supinator's counterbalance to the pronators Dorsal extension:
is reduced. • M. tibialis anterior
A malfunction of all flexors (deep and superficial) leads to a • M. extensor digitorum longus
rise in the tip of the foot due to the predomination of the dorsal • M. fibularis tertius
extensors (Pes supinatus). Walking and standing are more diffi- • M. extensor hallucis longus
cult, rolling up of the foot is no longer possible. Patients can Plantar flexion:
only move forwards on the calcaneus. When standing, it is even
• M. triceps surae
impossible to crouch slightly, since the failure of the flexors
means that it is not possible to halt the descending movement. • M. flexor hallucis longus
• M. tibialis posterior
• M. flexor digitorum longus
• M. fibularis longus
All deep flexors run along the medial side of the leg and behind the • M. fibularis brevis
inner ankle to the sole of the foot. On the way they cross over each Supination:
other (› Fig. 5.50b): at the distal lower leg (as seen from the dorsal • M. triceps surae
side) the M. flexor digitorum longus crosses over the M. posterior • M. tibialis posterior
tibialis (Chiasma crurale). At the sole of the foot it then crosses • M. tibialis anterior
over the M. hallucis longus (Chiasma plantare). Before attaching • M. flexor digitorum longus
to the final phalanges, the M. flexor digitorum perforates the divid- • M. flexor hallucis longus
ed ­attachment tendons of the M. flexor digitorum brevis. Pronation:
• M. fibularis longus
NOTE • M. fibularis brevis
Chiasma crurale: M. flexor digitorum longus crosses over M. tibialis • M. extensor digitorum longus
posterior • M. fibularis tertius
Chiasma plantare: M. flexor digitorum longus crosses over the • M. extensor hallucis longus
M. flexor hallucis longus.

Table 5.18 Dorsal deep group of the lower leg muscles.

Innervation Origins Attachment Function

M. tibialis posterior
N. tibialis Membrana interossea, tibia and fibula Tuberositas ossis navicularis, • Upper ankle joint: plantar flexion
(N. ischiadicus) plantar aspect of the Ossa cunei- • Lower ankle joint: supination
formia I–III, Ossa metatarsi II–IV
M. flexor digitorum longus
N. tibialis Facies posterior to the tibia Distal phalanx of the 2nd–5th • Upper ankle joint: plantar flexion
(N. ischiadicus) toes • Lower ankle joint: supination
• Toe joints: flexion
M. flexor hallucis longus
N. tibialis Distal facies posterior to the fibula, Distal phalanx of the big toe • Upper ankle joint: plantar flexion
(N. ischiadicus) ­Membrana interossea • Lower ankle joint: supination
• Joints of the big toe: flexion

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 5.5 Foot

Short muscles of the foot Conversely there are two muscles that do not have an equivalent in
The short foot muscles originate at the foot skeleton and have no the hand:
function in the ankle joints. Their main function is seen less in the • M. flexor digitorum brevis: it runs from the Tuber calcanei to
movement of the toes than in the bracing of the plantar arch. This the middle phalanges 2–5, thus corresponding to the M. flexor
is clearly different in the hand where the short muscles of the hand digitorum superficialis in the forearm.
are essential for the fine motor skills of the fingers. • M. quadratus plantae: it runs from the calcaneus in the rear half
The short foot muscles can be differentiated into 4 groups: of the sole of the foot to the tendon of the M. flexor digitorum
• Muscles of the dorsum of the foot (› Table 5.19) longus, and supports it.
• Muscles of the big toes (› Table 5.20)
• Muscles of the centre of the sole of the foot (› Table 5.21)
• Muscles of the little toes (› Table 5.22) 5.5.6 Support facilities of the musculature in the
The individual muscles of each group can be taken from the muscle region of the lower leg and foot
tables. The functions of the toes generally correspond to the name
of their respective muscle. As in the hand, the long muscles of the foot are also guided by
The muscles of the dorsum of the foot assist dorsiflexion in the strengthening bands (Retinacula) of muscle fascia, in this case the
toe joints (› Fig. 5.51), but do not run to the little toe. All plantar Fascia cruris. The retinacula prevent the muscle tendons from de-
muscles assist with plantar flexion of the toe joints and prevent tip- taching from their base. In addition, the long foot muscles with
ping forward in the toe joints when the upper body is bent for- their final tendons run in tendon sheaths. These are formed par-
wards (› Fig. 5.52). In addition, they can adduct or abduct. The ticularly in the area of the retinacula.
muscles of the foot, in their course, function and innervation, cor- The Retinaculum musculorum extensorum spans the muscles of
respond to those of the hand; however, the Mm. interossei plantar- the extensor compartments ventrally at the level of the ankle joint,
es run to toes 3–5 (and not 2, 4 and 5, as in the hand), and the Mm. each of which is surrounded by its own tendon sheath (› Fig.
interossei dorsales insert on both sides of the 2nd toe (instead of on 5.51).
the 3rd finger).

Table 5.19 Muscles of the instep (dorsum) of the foot.

Innervation Origins Attachment Function

M. extensor digitorum brevis
N. fibularis profundus Facies dorsalis of the calcaneus Dorsal aponeurosis of the Toes II–IV: extension
(N. ischiadicus) 2nd–4th toes
M. extensor hallucis brevis
N. fibularis profundus Facies dorsalis of the calcaneus Phalanx proximalis of the big toe First metatarsophalangeal joint: extension
(N. ischiadicus)

M. tibialis anterior, Tendo

M. extensor hallucis longus

M. extensor digitorum longus

Retinaculum musculorum extensorum

Retinaculum musculorum
fibularium [peroneorum]

M. extensor digitorum brevis

M. fibularis [peroneus] M. tibialis anterior, Tendo

tertius, Tendo
M. extensor hallucis
M. extensor digitorum longus, Tendo
longus, Tendines
M. extensor
M. abductor digiti minimi
hallucis brevis

Mm. interossei dorsales

Fig. 5.51 Muscles of the dor-

sum of the foot. Dorsal view.

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5 Lower extremity

Table 5.20 Medial muscles of the sole of the foot.

Innervation Origins Attachment Function

M. abductor hallucis
N. plantaris medialis Proc. medialis of the Tuber calcanei, Aponeu- Medial sesamoid bone of the First metatarsophalangeal joint: abduction, flexion, tens-
(N. tibialis) rosis plantaris, Retinaculum musculorum first metatarsophalangeal joint, ing of the medial longitudinal curvature of the foot
flexorum proximal phalanx of the big toe
M. flexor hallucis brevis
• Caput mediale: Plantar aspect of the Ossa cuneiformia, plan- • Caput mediale: medial sesa- First metatarsophalangeal joint: flexion, tensing of the
N. plantaris medialis tar ligaments moid bone of the first metatar- medial longitudinal curvature of the foot
(N. tibialis) sophalangeal joint, proximal
• Caput laterale: phalanx of the big toe
N. plantaris lateralis • Caput laterale: lateral sesa-
(N. tibialis) moid bone of the first metatar-
sophalangeal joint, Phalanx
proximalis of the big toe
M. adductor hallucis
N. plantaris lateralis • Caput obliquum: Os cuboideum, Os cunei- Lateral sesamoid bone of the Base big toe joint: adduction for 2nd toe, flexion, tension
(N. tibialis) forme laterale, plantar ligaments capsule of the first metatarso- of the longitudinal foot and transverse arch
• Caput transversum: capsules of the base phalangeal joint, base phalanx of
joints of the 3rd–5th toes, Lig. metatarsale the big toe
transversum profundum

Table 5.21 Muscles of the centre of the sole of the foot.

Innervation Origins Attachment Function

M. flexor digitorum brevis1
N. plantaris medialis Plantar surface of the Tuber calcanei, Middle phalanx of the 2nd–5th Base and middle joints of the toes: flexion, extension of
(N. tibialis) ­Aponeurosis plantaris toes the longitudinal curvature of the foot
M. quadratus plantae
N. plantaris lateralis Plantar surface of the calcaneus, Lig. plantare Lateral margin of the tendon of Supports the M. flexor digitorum longus
(N. tibialis) longum the M. flexor digitorum longus
Mm. lumbricales pedis I–IV
Nn. plantares medialis M. lumbricalis pedis: tendons of the M. flexor Medial side of the proximal Base joints of the toes: flexion, adduction
(I) and lateralis (II–IV) digitorum longus ­ halanx of the 2nd–5th toes
p
(N. tibialis) • I: single-headed
• II–IV: double headed
Mm. interossei plantares pedis I–III
N. plantaris lateralis Plantar surface of the Ossa metatarsi III–V, Medial side of the proximal Base joints of the toes: flexion, adduction to the 2nd toes
(N. tibialis) Lig. plantare longum ­ halanx of the 3rd–5th toes
p
Mm. interossei dorsales pedis I–IV (twin-headed muscles)
N. plantaris lateralis Facing sides of the Ossa metatarsi I–V, Proximal phalanx of the 2nd–4th Base joints of the toes: flexion, abduction of the 2nd toe
(N. tibialis) Lig. plantare longum toes (2nd on both sides, 3rd and medially, the 3rd and 4th toes laterally
4th toes laterally)
1
The tendons of this muscle are perforated by the tendons of the M. flexor digitorum longis shortly before their attachment

Table 5.22 Lateral plantar muscles.

Innervation Origins Attachment Function

M. abductor digiti minimi
N. plantaris lateralis Proc. lateralis of the Tuber calcanei, Aponeu- Tuberositas ossis metatarsi V, Proximal joint of the 5th toe: abduction, flexion, tensing
(N. tibialis) rosis plantaris proximal phalanx of the 5th toe of the longitudinal curvature of the foot
M. flexor digiti minimi brevis
N. plantaris lateralis Base of the Os metatarsi V, Lig. plantare Proximal phalanx of the 5th toe Proximal joint of the 5th toe: flexion, tensing of the longi-
(N. tibialis) ­longum tudinal curvature of the foot
M. opponens digiti minimi (inconstant muscle)
N. plantaris lateralis Base of the Os metatarsi V, Lig. plantare Os metatarsi V Proximal joint of the 5th toe: opposition, flexion, tensing
(N. tibialis) ­longum of the longitudinal curvature of the foot

230
 5.6 Nerves of the lower extremity

Vaginae tendinum
digitorum pedis

Mm. lumbricales Vaginae tendinum

M. flexor hallucis
pedis I–IV digitorum pedis
longus, Tendo

M. flexor
M. adductor hallucis,
hallucis brevis
caput transversum
M. interosseus
M. adductor hallucis,
plantaris III
caput transversum
M. abductor
M. abductor M. flexor digitorum
digiti minimi
hallucis brevis, Tendines M. flexor
hallucis brevis
M. flexor digiti Mm. lumbricales pedis I–IV
minimi brevis
M. flexor digiti minimi brevis M. flexor digitorum
M. flexor digi- M. abductor digiti minimi longus, Tendo
torum brevis
M. interosseus plantaris III M. flexor hallucis
longus, Tendo
Aponeurosis M. interosseus
plantaris dorsalis pedis IV
M. fibularis [peroneus]
longus, Tendo M. abductor hallucis

M. quadratus plantae
a Tuber calcanei

M. abductor digiti minimi M. flexor

digitorum brevis
b

Fig. 5.52 Plantar muscles, right. Plantar view. a After removal of the plantar aponeurosis. b After removal of the M. flexor digitorum brevis.

Laterally, the Retinaculum musculorum fibularium spans the dis- The actual nerves of the leg, the pelvic floor and the caudal sections
tance between the outer ankle and the calcaneus, and fixes the two of the abdominal wall arise from this plexus.
fibularis muscles together, mostly in a common tendinous sheath. The following nerves ensure the sensory innervation of the skin of
On the medial side the malleolar canal forms a tunnel (tarsal tun- the lower limbs and the perineal region (› Fig. 5.53a and b):
nel), which originates as a result of the bridging of the gap between • Plexus lumbalis:
the inner ankle and calcaneus by the Retinaculum musculorum – N. iliohypogastricus
flexorum. The 3 deep plantar flexors pass through this, also in – N. ilioinguinalis
their own tendon sheaths, along with the vessels and nerves of the – N. genitofemoralis
sole of the foot (A./V. tibialis posterior, N. tibialis). – N. cutaneus femoris lateralis
– N. femoralis
– N. obturatorius
5.6 Nerves of the lower extremity • Plexus sacralis:
– N. cutaneus femoris posterior
– N. ischiadicus
Skills – N. pudendus
After working through this chapter, you should be able to: In addition, the lateral branches of the Rr. posteriores of segments
• explain the structure of the Plexus lumbosacralis and ex- L1–L3 as the Nn. clunium superiores, and segments S1–S3 as the
plain the symptoms associated with plexus lesions Nn. clunium medii, sensorily innervate the buttock area. As in the
• know the course, function and the exact symptoms associ- arm, the skin areas on the leg are usually innervated by the over-
ated with loss of major nerves in the lower extremity and
lapping skin branches of a variety of nerves.
show these on a dissection specimen
Also the dermatomes of the leg (› Fig. 5.53c and d) run in a sim-
ilar way to the arm along the longitudinal axis. The dermatomes of
The innervation of the lower limbs involves the spinal nerves T12– the lumbar spinal nerves on the ventral side of the leg run from
S4. The Rr. anteriores of the spinal nerves T12–L4 form the Plexus ­lateral descending obliquely to medial. The dorsal side of the leg,
lumbalis, which is amalgamated with the Plexus sacralis (L4–S5, together with the lateral margin of the foot, is innervated by the
Co1) into the Plexus lumbosacralis. sacral spinal nerves. The dermatomes run almost longitudinally
here.

231
5 Lower extremity

N. iliohypogastricus,
R. cutaneus lateralis N. iliohypogastricus,
Nn. lumbales,
R. cutaneus lateralis
N. cutaneus Nn. clunium superiores
femoris lateralis
N. iliohypogastricus, Nn. sacrales,
N. genito- R. femoralis R. cutaneus anterior Nn. clunium medii
femoralis
R. genitalis N. cutaneus
N. ilioinguinalis,
Nn. scrotales anteriores femoris posterior,
N. cutaneus
Nn. clunium inferiores
femoris lateralis
N. femoralis, N. cutaneus
N. obturatorius,
Rr. cutanei anteriores femoris posterior
R. cutaneus
N. obturatorius,
R. cutaneus

N. saphenus, N. fibularis communis,

R. infrapatellaris N. saphenus, N. cutaneus surae lateralis
(N. femoralis) Rr. cutanei cruris (N. ischiadicus)
N. fibularis communis,
mediales (N. femoralis)
N. cutaneus surae N. saphenus,
lateralis (N. ischiadicus) Rr. cutanei cruris mediales
N. suralis, N. cutaneus (N. femoralis)
dorsalis lateralis N. suralis
N. cutaneus dor- (N. ischiadicus)
salis intermedius N. fibularis
N. fibularis profundus, superficialis
N. cutaneus (N. ischiadicus)
Nn. digitales dorsales dorsalis medialis
pedis (N. ischiadicus)

a b

Nn. lumbales N. iliohypogastricus N. genitofemoralis N. obturatorius N. fibularis

Nn. sacrales N. cutaneus femoris lateralis N. femoralis N. cutaneus femoris posterior N. suralis

T12
T12
L1
L1 S2
S3 L2
S4
L2 L3
S5
S2

L3 L4

L4
S1
L5

L5

S1
L4 L5 L4
L5
S1

c d

Fig. 5.53 Cutaneous nerves and segmental innervation of the lower extremity. a Cutaneous nerves, right, ventral view. b Cutaneous nerves,
right, dorsal view. c Dermatomes, right, ventral view. d Dermatomes, right, dorsal view.

232
 5.6 Nerves of the lower extremity

NOTE 5.6.1 Plexus lumbosacralis

• Ventral side of the leg: L1–L5 (descending obliquely from the in-
guinal ligament to the foot)
• Medial margin of the foot: L4 The Plexus lumbalis (T12 – L4) and the Plexus sacralis (L4–S5,
• Big toe and the second toe: L5 Co1) are amalgamated to form the Plexus lumbosacralis. The spi-
• Little toe and the lateral margin of the foot: S1 nal nerves of L4 and L5 form the Truncus lumbosacralis, constitut-
• Dorsal side of the leg: S1–S5 (from the lateral margin of the foot ing the connection between the two nerve plexus. The branches of
ascending longitudinally to the buttocks) the Plexus lumbalis run ventral to the hip joint and course to the
anterior side of the leg. Conversely, the branches of the Plexus sa-
cralis are dorsal to the hip joint and run to the back of the leg.
Clinical remarks
Slipped discs occur principally in the discs between the 4th Clinical remarks
and 5th lumbar vertebrae and between the 5th lumbar vertebra
and the sacrum. After a rupture of the Anulus fibrosus, the The Plexus lumbosacralis can be damaged by tumours (e.g. of
­Nucleus pulposus protrudes forwards into the vertebral canal the uterus), by bruising (haematomas in the fascia of the M.
and compresses one or more nerve roots. In addition to pain in iliopsoas) or by fractures of the pelvis. A plexus lesion should
the area of the lesion, this results in discomfort in the respective be considered if the clinical picture is not limited to the mal-
dermatome and malfunctioning of the reference muscle of the function of a single nerve:
corresponding nerve root. When there is compression of L5, it • Where there is a lesion of the Plexus lumbalis (T12–L4),
is typical for there to be pain symptoms radiating into the leg there is pain and disruption to the sensory system on the
as far as the foot. This is accompanied by a loss of sensitivity of front side of the thigh (› Fig. 5.54a). Bending and adduction
the skin and a weakness when extending the big toe (reference are affected in hip and knee extensions. Standing and walk-
muscle L5: M. extensor hallucis longus). ing are difficult.

from
N. iliohypogastricus Th12
L1
N. ilioinguinalis
N. genitofemoralis L2

L3
N. cutaneus
femoris lateralis
L4

N. femoralis L5

N. obturatorius
Pain with
Truncus radiation on
lumbosacralis the front of the
thigh

from
L4

L5

S1
N. gluteus superior

N. gluteus inferior S2

S3

S4
Pain with
radiation on
the back of the
N. ischiadicus N. pudendus thigh Fig. 5.54 Structure of the Plex-
N. cutaneus us lumbosacralis and symptoms
b femoris posterior associated with lesions.
a Tumour in the Plexus lumbalis.
b Lesion in the Plexus sacralis.
left [L126 ]; right [L238]

233
5 Lower extremity

• Lesions of the Plexus sacralis (L4–S5, Co1) are recognisable the M. obliquus internus abdominis and M. transversus abdominis.
due to pain and sensory deficits in the dorsal thigh (› Fig. The R. cutaneous lateralis supplies the skin above the iliac crest,
5.54b) as well as in the lower leg. It damages extension and and the R. cutaneus anterior supplies an area of skin medially
abduction (TRENDELENBURG’s signs positive, see below) in above the inguinal ligament.
the hip, as well as flexion of the knee, and all the muscles of
The N. ilioinguinalis (L1, › Fig. 5.53a, › Fig. 5.55) runs further
the lower leg and the foot. Autonomic disturbances can
arise because the branches of the Plexus sacralis parasym- caudal than the N. iliohypogastricus and innervates the same ab-
patheticaly supply the pelvic viscera and the external geni- dominal muscles. Its terminal branch is attached to the spermatic
talia. This may result in loss of erection in the penis or im- cord (runs outside) and runs with it through the inguinal canal. It
paired filling of the erectile tissue of the clitoris. A malfunc- supplies the skin of the external genitalia via the Rr. scrotales and
tion in the innervation of the pelvic floor can be expressed Rr. labiales anteriores.
as urinary and faecal incontinence.
An isolated lesion of both plexus attachments is however rare.
In most cases, both the Plexus lumbalis and Plexus sacralis Clinical remarks
are affected.
Due to the physical proximity of the N. iliohypogastricus and
N. ilioinguinalis, inflammatory processes in the kidneys or re-
nal capsule can lead to pain in the innervation area of these
Plexus lumbalis two nerves (e.g. in the inguinal region).
The Rr. anteriores of the spinal nerves of T12–L4 form the Plexus
lumbalis (› Fig. 5.55). They exit through the Foramina interverte-
bralia between the origins of the M. psoas major and form the fol- The N. genitofemoralis (L1–L2, › Fig. 5.53a, › Fig. 5.55) pene-
lowing nerves: trates the M. psoas major and runs downwards on the anterior side
The Rr. musculares (T12–L4) are short, purely motor branches to (important identification sign). It crosses underneath the ureter
the M. iliopsoas and M. quadratus lumborum and Mm. intertrans- and is divided into:
versarii. • R. genitalis: it courses medially through the inguinal canal and
The N. iliohypogastricus (L1, › Fig. 5.53a, b, › Fig. 5.55) runs runs in the spermatic cord to the scrotum. In men, it innervates
behind the kidneys, penetrates the M. transversus abdominis, and the M. cremaster, and together with the N. ilioinguinalis, senso-
courses forwards between here and the M. obliquus internus ab- rily innervates the anterior parts of the external genitalia.
dominis along the inguinal ligament. Its Rr. musculares innervate

LI M. psoas major
N. iliohypogastricus
LII
N. ilioinguinalis LIII
N. genitofemoralis LIV M. iliacus
N. cutaneus femoris lateralis N. obturatorius

R. genitalis, (N. genitofemoralis) N. femoralis

R. cutaneus lateralis, M. sartorius

(N. iliohypogastricus) M. pectineus
R. femoralis, (N. genitofemoralis) M. adductor longus
R. cutaneus anterior, M. rectus femoris
(N. iliohypogastricus) M. obturatorius externus
N. cutaneus femoris lateralis N. obturatorius
N. saphenus (N. femoralis)
R. femoralis, (N. genitofemoralis) M. adductor brevis

N. ilioinguinalis Rr. cutanei anteriores (N. femoralis)

M. adductor longus
R. genitalis, (N. genitofemoralis) M. vastus intermedius
M. vastus lateralis
M. gracilis R. cutaneus, (N. obturatorius)

M. adductor magnus M. sartorius

M. vastus medialis

N. saphenus (N. femoralis)

Fig. 5.55 Course and target

areas of the nerves of the Plex-
us lumbalis.

234
 5.6 Nerves of the lower extremity

• R. femoralis: it runs in the Lacuna vasorum below the inguinal on the front of the thigh and on the medial side of the leg.
ligament lateral to the vessels and sensorily supplies the skin be- Deficits also arise during flexion in the hip joint (most import-
low the inguinal ligament. ant muscle: M. iliopsoas) as well as during extension of the
The N. cutaneus femoris lateralis (L2–L3, › Fig. 5.53a, b, › Fig. knee joint (single muscle: M. quadriceps femoris).
5.55) is the only purely sensory nerve of the Plexus lumbalis and
courses laterally through the Lacuna muscularum, exits medial to the
Spina iliaca anterior superior and supplies the skin of the lateral thigh. The N. obturatorius (L2–L4, › Fig. 5.53a, b, › Fig. 5.55) inner-
vates the medial adductor group at the thigh and supplies sensory
innervation to a small area of skin medially above the knee. It
Clinical remarks courses medially to the M. psoas major and downwards slightly be-
Lesions of the N. genitofemoralis lead to malfunction of the low the ovary, then passes through the obturator canal (Canalis ob-
cremaster muscle reflex when brushing the medial thigh. turatorius) to the inside of the thigh. It innervates the M. obturato-
The wearing of overtight trousers and overtightened belts may rius externus and is divided into:
lead to Meralgia paraesthetica (‘Skinny jeans syndrome’). ­Here, • R. anterior: runs in front of the M. adductor brevis and provides
compression of the N. cutaneus femoralis lateralis under the
motor innervation to the M. pectineus, M. gracilis and Mm. ad-
inguinal ligament causes pain and discomfort at the lateral
thigh (› Fig. 5.56). ductor brevis and longus and sensory innervation to the medial
skin of the thigh (R. cutaneus) down to the knee
• R. posterior: is located behind the M. adductor brevis and
­innervates the M. adductor magnus as well as the knee joint
The N. femoralis (L2–L4, › Fig. 5.53a, b, › Fig. 5.55) innervates ­capsule
the ventral muscle group of the thigh and supplies sensory inner-
vation to the front of the entire leg. It lies medial in the Lacuna
musculorum to the Trigonum femorale, where it splits into its ter-
Clinical remarks
minal branches approximately 5 cm below the inguinal ligament: Tumours or inflammatory processes of the ovaries can lead to
• Rr. musculares: innervate the M. iliopsoas, M. sartorius, deficits of the N. obturatorius due to their physical proximity
M. pectineus and M. quadriceps femoris and pain in the inner thigh and the knee (ROMBERG's knee
• Rr. cutanei anteriores: sensorily innervate the anterior aspect of phenomenon). An injury to the nerve is also possible in pelvic
fractures or femoral hernia. Where there is a complete failure,
the thigh
adduction is no longer possible in the hip joint; the legs can-
• N. saphenus: this terminal branch of the N. femoralis accompa- not be crossed on top of each other.
nies the A. femoralis into the adductor canal and breaches the
Septum intermusculare vastoadductorium, to course epifascially
with the V. saphena magna towards the foot. With a R. infrapa-
tellaris, it supplies the skin below the knee cap, and with the Rr. Plexus sacralis
cutanei cruris mediales supplies the medial side of the lower leg. The Rr. anteriores of the spinal nerves of L4–S5 , Co1 form the
sacral plexus (› Fig. 5.57). They pass through the Foramina inter-
vertebralia (L4–L5) via the Truncus lumbosacralis or via the Fo-
Clinical remarks ramina sacralia anterioria of the Sacrum to the lesser pelvis where
As the N. femoralis divides immediately beneath the inguinal they form the plexus. The branches of the plexus largely exit the
ligament, complete malfunctions (e.g. due to incision wounds lesser pelvis through the Foramen ischiadicum majus to the Regio
on the thigh) are rare. It can still be damaged before it branch- glutealis. The following branches are formed:
es, e.g. during hernia operations. Sensory deficits can be seen Muscle branches to the pelvitrochanteric muscles (M. piriformis,
M. obturatorius internus and Mm. gemelli superior and inferior,

Spina iliaca
anterior superior

Compression of the
N. cutaneus
femoralis lateralis

Numbness and formication

on the front outer side of the thigh

Fig. 5.56 Meralgia paraestheti-

ca. [L238]

235
5 Lower extremity

M. gluteus medius
M. gluteus maximus
LIV M. gluteus minimus
Lig. sacrotuberale LV Foramen suprapiriforme
SI M. tensor fasciae latae
N. pudendus SII N. gluteus superior
SIII
M. piriformis
SIV
Rr. musculares for N. gluteus inferior
SV Foramen infrapiriforme
Pelvitrochanteric muscles
M. gemellus superior
N. ischiadicus M. obturatorius internus
M. gemellus inferior
Foramen ischiadicum M. quadratus femoris
minus

N. cutaneus femoris
posterior
M. biceps femoris

M. semitendinosus

M. semimembranosus

N. tibialis
N. fibularis communis Fig. 5.57 Course and target
area of the nerves of the Plexus
sacralis.

M. quadratus femoris) reach the muscles through the Foramen in- minus under the Lig. sacrotuberale in the Fossa ischioanalis. Here
frapiriforme. it runs on the M. obturator internus, ventrally covered by its fascia
The N. gluteus superior (L4–S1, › Fig. 5.57) runs through the (= ALCOCK's canal). It has three branches:
Foramen suprapiriforme between the Mm. gluteus medius and • Nn. rectales inferiores: supply the M. sphincter ani externus and
­gluteus minimus and innervates them. In addition, it supplies the the perianal skin
M. tensor fasciae latae. • Nn. perineales:
The N. gluteus inferior (L5–S2, › Fig. 5.57) passes through the – Nn. scrotales/labiales posteriores to the skin of the external
Foramen infrapiriforme and innervates the M. gluteus maximus. genitalia
– Rr. musculares to supply the perineal musculature (Mm. tran-
serversus perinei profundus and superficialis, M. bulbospon­
Clinical remarks giosus, M. ischiocavernosus)
Both Nn. glutei can be damaged by an incorrectly performed • N. dorsalis penis/clitoridis for the sensory supply of the penis or
intramuscular injection: clitoris.
• A failure of the N. gluteus superior leads to TRENDELE-
BURG's sign. When standing on the leg on the injured side,
the pelvis drops to the opposing, healthy side, as it can no Clinical remarks
longer be held in the horizontal plane due to failure of the
Mm. gluteus maximus et minimus. When walking this leads The failure of the N. pudendus is characterised by urinary and
to the DUCHENNE limp where the trunk of the patient leans faecal incontinence (failure of the voluntary sphincter mus-
to the affected side, in order to compensate for the drop. cles) as well as by disorders in sexual function.
• A failure of the N. gluteus inferior results in severe impair-
ment of extension and lateral rotation of the hip joint. Climb-
ing stairs and getting up from a squatting position are im- The Nn. splanchnici pelvici (S2–S4) are preganglionic parasympa-
possible since the M. gluteus maximus is the most import-
thetic nerve fibres supplying the pelvic viscera (sacral section of the
ant extensor of the hip joint.
parasympathetic nervous system).
The Rr. musculares (S3–S4) innervate the pelvic floor muscles (M.
levator ani and M. ischiococcygeus).
The N. cutaneus femoris posterior (S1–S3, › Fig. 5.53b, › Fig. Small sensory branches (S2–S5, Co1) innervate the skin over the
5.57) exits through the Foramen infrapiriformis and provides the Tuber ischiadicum (N. cutaneus perforans) and the skin between
Nn. clunium inferiores for sensory innervation of the lower but- the anus and coccyx (N. coccygeus).
tock region and the Rr. perineales for the perineal region. It cours-
es subfascially up to the middle of the posterior thigh, passes
through the fascia here and supplies the skin of the back of the 5.6.2 N. ischiadicus
thigh.
The N. ischiadicus (L4–S3) is the strongest nerve in the human The thickest nerve of the human body supplies all of the dorsal
body (› Chap. 5.6.2). muscles of the upper and lower leg and foot muscles; it sensorily
The N. pudendus (S2–S4, › Fig. 5.57) exits through the Foramen innervates the calf and the entire foot. It passes through the Fora-
infrapiriforme and then runs through the Foramen ischiadicum men infrapiriforme and, initially covered by the M. gluteus maxi-

236
 5.6 Nerves of the lower extremity

mus, passes over the pelvitrochanteric muscles and then continues An intense pain in the supply area of the N. ischiadicus occurs
distally under the M. biceps femoris. It divides mostly at the tran- during LASÈGUE’s test. The examiner raises the extended leg
sition to the distal femur into: of the supine patient, creating tension on the ­N. ischiadicus.
• The N. fibularis communis (L4–S2) The resulting pain sensation can indicate a slipped disc with
compression of L5 or S1, as well as an infection of the menin-
• The N. tibialis (L4–S3) ges (meningitis).
Even before the bifurcation two separate parts are present and
these are connected only by a sheath of connective tissue. There-
fore, the corresponding innervation areas above the division point
can also be distinguished: N. fibularis communis
• Fibularis portion: innervates the Caput breve of the M. biceps After the division, the N. fibularis communis runs along the M. bi-
femoris ceps femoris at the edge of the hollow of the knee and the head of
• Tibialis portion: supplies the remaining ischiocrural muscles the Fibula (› Fig. 5.58). It delivers the N. cutaneus surae lateralis
(M. semitendinosus, M. semimembranosus, Caput longum of the for the sensory innervation of the lateral calf and has a connection
M. biceps femoris) and the dorsal part of the M. adductor magnus to the N. cutaneus surae medialis (N. tibialis) via the R. communi-
The division of the N. ischiadicus can also occur far proximally cans fibularis. It then runs underneath the M. fibularis longus and
(before leaving the Foramen infrapiriforme) (high division in ap- divides again into:
proximately 10% of cases). Here, the N. fibularis communis mostly • N. fibularis superficialis: it runs distally in the fibularis com-
penetrates the M. piriformis, whereas the N. tibialis takes the stan- partment and with its Rr. musculares, it supplies the Mm. fibu-
dard route. lares longus and brevis. It penetrates the fascia at the distal lower
leg and, as the N. cutaneus dorsalis medialis and intermedius
supplies the skin of the dorsum of the foot.
Clinical remarks • N. fibularis profundus: enters the extensor compartment and
The N. ischiadicus, like the N. gluteus superior, can be dam- with its Rr. musculares, it supplies the ventral muscles of the an-
aged by wrongly administered injections. A lesion leads to a kle joint. Its sensory terminal branch penetrates the fascia far
malfunction in the ischiocrural muscles (loss of extension in distal on the dorsum of the foot, supplying only the skin between
the hip joint, loss of flexion and rotation in the knee joint) and the big toe and the second toe.
in addition, to symptoms of failure in the terminal branches of
the N. tibialis and the N. fibularis communis (see below).
The high division of the N. ischiadicus can cause irritation Clinical remarks
when passing through the M. pirifomis and cause symptoms
similar to those of a slipped disc. The most common issues are lesions of the N. fibularis com-
munis in the region of the fibular head. This can be easily pal-
pated directly under the skin, so the highly exposed nerve can
be very easily damaged here. Typically, this occurs in fractures
of the fibula or due to chronic pressure injury arising from con-
stant crossing of the legs (‘crossed legs palsy’).
M. biceps femoris, A failure of the N. fibularis communis leads to the equine foot
caput breve
position due to loss of the extensors with compensatory drop
N. ischiadicus foot (stronger hip flexion when walking, in order to avoid drag-
ging the foot on the floor). A malfunction in the fibularis group
leads to the supination position. Sensory innervation of the
skin of the dorsum of the foot and the lateral calf is compro-
N. fibularis communis mised.
An isolated lesion of the N. fibularis profundus occurs with
N. cutaneus compartment syndrome of the extensor compartment (see
surae lateralis above) with equinus foot position and drop foot. A malfunc-
M. tibialis anterior tion of the sensors in the first toe is often the first indication of
R. communicans the onset of a compartment syndrome, but it can also arise
fibularis due to compression beneath the Retinaculum musculorum
N. cutaneus surae extensorum (‘anterior tarsal tunnel syndrome’), with no mis-
medialis (N. tibialis) alignment of the foot. This means that the sensitivity in this
area must be regularly checked following surgery on the lower
M. fibularis longus N. fibularis leg or after placing the lower leg in a plaster cast! The sensitiv-
superficialis
ity of the rest of the foot remains normal.
M. fibularis brevis
An isolated lesion of the N. fibularis superficialis is very rare,
N. fibularis profundus since the nerve is protected between the two fibularis mus-
cles. What is conspicuous here is the supination position of
N. suralis (N. tibialis) M. extensor the foot, as well as the non-operational sensors of the dorsum
digitorum longus
of the foot (apart from the first toe!).
N. cutaneus N. cutaneus dorsalis medialis
dorsalis intermedius (N. fibularis superficialis)
(N. fibularis superficialis)
M. extensor
hallucis brevis N. tibialis
M. extensor
digitorum brevis The N. tibialis continues the course of the N. ischiadicus through
the hollow of the knee (› Fig. 5.59). It runs superficially from the
N. cutaneus dorsalis
lateralis (N. tibialis) N. fibularis profundus A. and V. poplitea, passes between the heads of the M. gastrocne-
mius and under the tendinous arch of the M. soleus distally, and
Fig. 5.58 Course of the N. fibularis communis, right. Lateral view. runs in the lower leg between the superficial and deep calf muscles

237
5 Lower extremity

side of the lateral 1½ toes and their distal phalanges dorsally. It

corresponds to the N. ulnaris on the hand. It innervates the mo-
tor functions of:
M. semitendinosus M. biceps femoris, – all the muscles of the little toe
caput longum – at the big toe, the M. adductor hallucis and the Caput laterale
M. semimembranosus
N. ischiadicus of the M. flexor hallucis brevis
– the Mm. lumbricales II–IV
N. tibialis
M. plantaris – M. quadratus plantae
The N. plantaris medialis and lateralis innervate together the entire
M. gastrocnemius N. fibularis communis short foot muscles on the plantar side.

M. popliteus
Clinical remarks
N. tibialis
N. cutaneus surae
A high lesion of the N. tibialis (e.g. in the hollow of the knee)
medialis (N. tibialis) M. tibialis posterior
leads to failure of all of the flexors of the leg. If the foot is ex-
M. flexor digitorum M. flexor hallucis tended dorsally (Pes supinus) and in the pronation position,
longus longus
standing on tip-toe is impossible.
M. soleus
M. gastrocnemius A claw foot is formed due to a malfunction of the plantar mus-
N. suralis (N. tibialis) cles. There is no sensitivity at the medial calf, the heel, the
sole of the foot and the lateral margin of the foot. The nerve is
also often injured at the distal lower leg when passing through
the malleolar canal under the Retinaculum flexorum (‘posteri-
Malleolar canal or tarsal tunnel syndrome’) or in the event of the ankle joint
Retinaculum musculorum
being damaged. Here, the symptoms are limited to the mal-
flexorum function of sensors on the sole of the foot and paralysis of the
short foot muscles.
N. plantaris medialis N. plantaris lateralis
(N. tibialis) (N. tibialis)

5.7 Arteries of the lower extremity

Fig. 5.59 Course of the N. tibialis, right. Dorsal view.

along with the A./V. tibialis posterior. Distal of the medial malleo-
Skills
lus it divides into two branches for the sole of the foot. After working through this chapter, you should be able to:
In its course, the N. tibialis divides into a total of 5 branches: • know all the arteries of the lower extremity and identify
• Rr. musculares for the innervation of all calf muscles them on dissection specimens
• N. interosseus cruris: runs distally on the Membrana interossea • know the right places to take the pulse
• explain vascular anastomoses in the hip region
and together with the Rr. calcanei mediales supplies the skin
over the inner ankle and heel
• N. cutaneus surae medialis: skin branch, runs together with the The lower extremities are supplied with blood by the A. iliaca
V. saphena parva and, together with the R. communicans fibu- communis. The buttock region and the intestines mainly receive
laris (from the N. fibularis communis), forms the N. suralis. blood from the parietal branches of the A. iliaca interna. As it is
This supplies the skin of the dorsal lower leg, with the Rr. calca- also responsible for supplying the pelvic organs, it is discussed in
nei laterales supplies the skin above the outer ankle and with the (› Chap. 8.8.2).
R. cutaneous dorsalis lateralis supplies the skin of the lateral mar- The artery responsible for the leg is the A. iliaca externa (› Chap.
gin of the foot. 5.7.1). After it passes underneath the inguinal ligament, it contin-
While still in the malleolar canal, the N. tibialis splits into its 2 ter- ues into the A. femoralis (› Fig. 5.60, › Chap. 5.7.2 ). This
minal branches: changes to the dorsal side of the leg to the hollow of the knee,
• N. plantaris medialis: is positioned in the centre of the sole where it becomes the A. poplitea (› Chap. 5.7.3). As it continues,
along the M. quadratus plantae and is divided into 3 Nn. digitales it is divided into an artery for supplying the front side of the lower
plantares communes each with 2 Nn. digitales plantares propriae. leg and the dorsum of the foot (A. tibialis anterior, › Chap. 5.7.4)
It supplies sensory innervation to the plantar side of the medial and an artery supplying the back and the sole of the foot (A. tibi­
3½ toes and the skin over the corresponding distal phalanges. alis posterior, › Chap. 5.7.5 ).
Hence the nerve corresponds to the N. medianus on the hand. It
supplies the motor function to the following muscles:
– Most of the muscles of the big toe (except for M. adductor
Clinical remarks
hallucis and the lateral head of the M. flexor hallucis brevis) The pulse can be palpated in the following places on the leg:
– the M. lumbricalis I • A. femoralis: in the groin
– the M. flexor digitorum brevis • A. poplitea: in the hollow of the knee
• N. plantaris lateralis: runs to the lateral side of the sole of the • A. dorsalis pedis: at the dorsum of the foot lateral to the
­tendons of the M. extensor hallucis longus
foot and divides again into R. superficialis and R. profundis. The
• A. tibialis posterior: behind the inner ankle
superficial branch forms the Nn. digitales plantares communes
and Nn. digitales plantares propriae for supplying the plantar

238
 5.7 Arteries of the lower extremity

A. glutea inferior
A. femoralis
A. circumflexa
femoris lateralis A. circumflexa
femoris medialis
R. ascendens
A. profunda femoris
R. descendens Aa. perforantes
(I; II; III) Aa. perforantes
(I; II; III)
Canalis adductorius
A. descendens genus

R. saphenus A. poplitea

R. articularis
A. superior lateralis genus
A. superior
A. superior lateralis genus A. superior
medialis genus A. suralis
medialis genus
Rete articulare genus A. media genus
A. inferior lateralis genus A. suralis
A. inferior A. inferior lateralis genus
medialis genus A. inferior medialis
genus (A. recurrens tibialis
A. recurrens tibialis anterior posterior)
A. tibialis posterior
A. tibialis anterior
A. tibialis anterior
A. fibularis

A. fibularis, r. perforans A. malleolaris

A. malleolaris anterior lateralis anterior medialis Rr. malleolares mediales Rr. malleolares laterales
A. tarsalis medialis
A. tarsalis lateralis A. plantaris medialis
A. dorsalis pedis A. plantaris lateralis
A. arcuata
Aa. metatarsales Arcus plantaris profundus
dorsales

a b

Fig. 5.60 Overview of the arteries of the leg, right. a Ventral view. b Dorsal view.

Palpation of the pedal pulse provides important evidence • A. circumflexa ilium profunda: it runs on the inside at the in-
about which section of the leg arteries has succumbed to a guinal ligament and laterally at the iliac crest and anastomoses
blockage of an artery, for example due to arteriosclerosis or a with the A. iliolumbalis (from the A. iliaca interna).
blood clot.
Clinical remarks
If the anastomosis between the A. epigastrica inferior and
5.7.1 A. iliaca externa A. obturatoria is highly developed, it can be damaged during
inguinal or femoral hernia operations. Since in earlier times,
The vessel is formed from the A. iliaca communis after branching this was often fatal due to heavy bleeding, this variant was
­referred to as ‘Corona mortis’. In 20% of cases, the A.
into the A. iliaca interna (› Fig. 5.61). The A. iliaca externa runs
­obturatoria does not originate from the A. iliaca interna, but
medial to the M. psoas major to the inguinal ligament, which it from the A. epigastrica inferior.
crosses underneath the Lacuna vasorum. Prior to this, it delivers 2
branches:
• A. epigastrica inferior: it runs cranially along the rear of the
M. rectus abdominis in a fold which is visible from the abdomi-
nal cavity (Plica umbilicalis lateralis). It anastomoses with the 5.7.2 A. femoralis
A. epigastrica superior (A. thoracica interna).
– R. pubicus: a medial branch which enters into an anastomosis The A. femoralis begins after leaving the Lacuna vasorum beneath
with the A. obturatorius along with the R. obturatorius the inguinal ligament (› Fig. 5.61). Here it runs between the
– A. cremasterica: a thin artery in men for the testicular sheath, N. femoralis (lateral) and V. femoralis (medial). The vessel runs
passes through the inguinal canal through the adductor canal and switches to the dorsal side of the
– A. ligamenti teretis uteri: corresponding artery in women, leg. The A. femoralis divides into 5 branches (› Fig. 5.62):
passes through the inguinal canal along with the Lig. teres • The A. epigastrica superficialis runs epifascially as a thin vessel
uteri cranially over the inguinal ligament.

239
5 Lower extremity

Aorta, bifurcatio aortae

A. iliaca communis

A. iliaca externa
A. iliaca interna
A. circumflexa ilium profunda
A. epigastrica superficialis A. epigastrica inferior

A. circumflexa ilium superficialis R. obturatorius

A. femoralis Lig. inguinale

Aa. pudendae externae
R. ascendens et R. transversus
R. acetabularis
R. ascendens
R. anterior
A. profunda femoris
R. posterior
A. circumflexa femoris lateralis
A. obturatoria
R. transversus
R. acetabularis
A. circumflexa femoris medialis
R. profundus
R. descendens
Aa. perforantes Fig. 5.61 Arteries of the pelvis,
right. Ventral view.

A. circumflexa A. epigastrica
• The A. descendens genus branches off into the adductor canal
ilium superficialis superficialis and forms Rr. articulares to the knee joint and a R. saphenus,
which accompanies the N. saphenus approximately to the knee.
N. femoralis

V. femoralis Clinical remarks

The A. femoralis is easily accessed due to its superficial posi-
R. ascendens tion under the inguinal (palpable pulse!). It is therefore used,
R. transversus A. circumflexa like the A. radialis in the arm, to draw blood for an arterial
femoris medialis blood gas analysis. It is also a standard access route for cardi-
A. circumflexa
femoris lateralis A. profunda ac catheterisation.
femoris
R. descendens
A. femoralis
A. perforans
prima
A. profunda A profunda femoris
femoris
The A. profunda femoris is the most important vessel for supply-
A. perforans ing the thigh, including the femoral head. It enters approximately
secunda
5 cm below the inguinal ligament into the depths and continues
­distally, running parallel to the A. femoralis. On its way it divides
into 3 branches (› Fig. 5.62):
• A. circumflexa femoris medialis: it runs medial and posterior,
and continues to divide into:
Septum
intermusculare – R. ascendens for the anterior parts of the adductors
vastoadductorium – R. profundus to the posterior portions of the adductors, the
A. descendens
ischiocrural muscles and the femoral head
genus – R. acetabularis to the hip joint; connects to the R. acetabularis
of the A. obturatoria and runs in the Lig. capitis femoris to the
R. saphenus
femoral head
• A. circumflexa femoris lateralis: it runs laterally under the
M. rectus femoris and has the following branches:
Rete articulare – R. ascendens proximally to the gluteal muscles and the femo-
genus
ral neck; anastomoses with the A. circumflexa femoris media-
lis and the Aa. glutae superior and inferior
Fig. 5.62 A. femoralis. Ventral view after removal of M. sartorius and – R. transversus laterally to the M. vastus lateralis
parts of the M. rectus femoris. [S010-2-16] – R. descendens to the M. quadriceps femoris
• Aa. perforantes (typically 3): at right angles to the course of the
• The A. circumflexa ilium superficialis also runs epifascially under A. profunda femoris, they penetrate the adductor muscles and the
the inguinal ligament laterally to the Spina iliaca anterior superior. ischiocrural muscles, supplying these and the femoral shaft.
• The Aa. pudendae externae run medially and supply the exter- In approximately 20% the Aa. circumflexae femoris medialis and lat-
nal genitalia (Rr. labiales/scrotales anteriores). eralis each originate directly from the A. femoralis. They form an
• The A. profunda femoris is the strongest branch (see below). arterial ring around the neck of the femur (also › Fig. 5.14) and

240
 5.7 Arteries of the lower extremity

supply these and large parts of the femoral head. This creates an anas- 5.7.4 A. tibialis anterior
tomosis network made up of branches of the A. iliaca interna (Aa.
glutea superior and inferior, A. obturatoria) and branches of the The vessel penetrates the Membrana interossea cruris and runs
A. profunda femoris (A. circumflexa femoris medialis) (› Fig. 5.63). along this in the extensor compartment distally (› Fig. 5.64b). It
is then accompanied by the N. fibularis profundus. It forms the
A. dorsalis pedis at the level of the ankle joint. At the lower leg the
Clinical remarks A. tibialis anterior divides into 4 branches:
These vascular anastomosis networks vary enormously in their • Aa. recurrentes tibialis anterior and posterior: run before and
characteristics, and they can ensure the supply of the leg in after the passage through the Membrana interossea back to the
the case of acute occlusions or constriction of the A. femoris knee joint
proximal to branching of the A. profunda femoris. • Aa. malleolares anteriores medialis and lateralis to the vascu-
lar network on the inner and outer ankle

NOTE A. dorsalis pedis

The A. profunda femoris supplies the thigh, both front and back! It continues the direction of the A. tibialis anterior to the medial
side of the dorsum of the foot, and divides into a total of 4 branches
(› Fig. 5.64b):
• Aa. tarsales medialis and lateralis to the medial and lateral
5.7.3 A. poplitea margin of the foot.
• A. arcuata: it arches over the bases of the metatarsal bones and
With the exit from the adductor canal in the Hiatus adductorius, divides into the Aa. metatarsales dorsales, which are involved in
the A. femoralis extends to the A. poplitea (› Fig. 5.64a). This supplying the toes via the Aa. digitales dorsales.
transverses the hollow of the knee (Fossa poplitea) until it divides • A. plantaris profunda: it penetrates the first interphalangeal
at the level of the tibial condyles into the Aa. tibiales anterior and space and anastomoses with the Arcus plantaris profundus of
posterior. It gives up another 6 branches and forms a vessel net- the sole of the foot.
work with these anterior to the knee joint (Rete articulare genus):
• A. superior medialis and lateralis genus around the medial/
lateral femoral condyle
Clinical remarks
• A. media genus to the knee joint A non-palpable pulse of the A. dorsalis pedis with simultane-
• A. inferior medialis and A. lateralis genus around the proximal ous palpable pulse of the A. poplitea and the A. tibialis poste-
tibia/the head of the fibula rior indicates an occlusion of the A. tibialis anterior. This can
• Aa. surales to the calf muscles be caused by arteriosclerosis, as well as by compartment syn-
drome of the extensor compartment (see above).

Clinical remarks
Despite their many tributaries, the anastomoses of the Rete
articulare genus are not usually sufficient to be able to ensure
the supply of the leg if the A. poplitea is compromised.

M. gluteus minimus
M. gluteus maximus

A. glutea superior,
R. profundus, rami
A. glutea R. profundus
superior R. superficialis M. gluteus medius
M. piriformis

N. ischiadicus
A. glutea inferior
A. circumflexa femoris
Lig. sacrotuberale medialis, R. profundus

A. pudenda interna A. perforans prima

A. circumflexa femoris
medialis, R. profundus Fig. 5.63 Parietal branches of
the A. iliaca interna right, anas-
A. perforans secunda tomosis region with branches of
the A. femoralis. Lateral view
after removal of parts of the
Mm. gluteus maximus and
medius. [S010-2-16]

241
5 Lower extremity

A. poplitea N. tibialis

A. superior A. superior
medialis genus lateralis genus

A. suralis medialis A. suralis lateralis A. superior

M. gastrocnemius, N. suralis lateralis
Rete articulare
caput mediale genus
A. inferior lateralis genus
genus A. inferior
A. inferior medialis
lateralis
genus
N. fibularis [peroneus] genus A. recurrens
communis tibialis anterior
M. soleus
A. tibialis anterior M. tibialis anterior
A. tibialis
posterior
A. tibialis anterior
A. fibularis
[peronea]
M. extensor
digitorum
longus

M. extensor
hallucis longus
A. fibularis
[peronea], A. dorsalis pedis
R. perforans
A. malleolaris
Rr. malleolares Aa. tarsales mediales
A. fibularis [peronea] anterior lateralis
mediales
A. tarsalis lateralis A. plantaris
Rr. malleolares profunda
N. tibialis A. arcuata
laterales
Aa. meta-
Rr. calcanei tarsales
Rr. calcanei dorsales
Rete calcaneum Aa. digitales
dorsales
a b

Fig. 5.64 Arteries of the leg, right. a Dorsal view. b Ventral view. [S010-2-16]

A. tibialis
posterior A. tibialis
posterior

Aponeurosis
plantaris
M. flexor digitorum
brevis A. plantaris
A. plantaris lateralis
medialis, A. plantaris
Rr. superficiales lateralis A. plantaris
medialis
Arcus plantaris

Aa. metatar-
sales plantares

Mm. interossei
Aa. digitales
plantares A. metatarsalis
A. metatarsalis plantaris I
communes Aa. digitales
plantaris I
plantares
communes

Aa. metatarsales
plantares Aa. digitales
plantares propriae
Aa. digitales Aa. digitales
a plantares propriae b plantares propriae

Fig. 5.65 Arteries of the sole of the foot, right. Plantar view. a Superficial vessels following removal of the plantar aponeurosis. b Deep vessels
following removal of the long and short flexors. [S010-2-16]

242
 5.8 Veins of the lower extremity

5.7.5 A. tibialis posterior is carried by branches of the V. iliaca interna (› Chap. 8.8.3) and
by branches of the V. iliaca externa into the V. iliaca communis.
The A. tibialis posterior continues the course of the A. poplitea The branches of the V. iliaca externa (V. epigastrica inferior and
(› Fig. 5.64a). It accompanies the N. tibialis between the deep and V. circumflexa ilium profunda) correspond to the arteries in terms
superficial calf muscles distally behind the inner ankle, which it of their name and course.
supplies with Rr. malleolares mediales, and divides into the Rr. The blood from the whole leg is collected via the V. femoralis.
calcanei to the medial side of the heel. It runs through the neuro- Here, a distinction is made between a superficial system (epifas-
vascular passageway of the malleolar canal towards the sole of foot cial) and a deep system (that accompanies the artery). Both sys-
The main branch is the: tems are connected by perforans veins (Vv. perforantes) (› Fig.
• A. fibularis: it runs along behind the Fibula parallel to the A. tibi- 5.66). These veins have valves, which only allow blood to flow from
alis posterior distally and divides into the Rr. malleolares laterales the superficial to the deep system. Ultimately therefore, the majori-
to the external ankle and Rr. calcanei to the lateral side of the heel. ty of the blood from the leg (85%) travels through the deep system.
On the sole of the foot, the A. tibialis posterior is divided into its Among the numerous perforating veins, 3 groups are clinically
two terminal branches: significant:
• A. plantaris medialis (› Fig. 5.65a): it runs medial to the M. flex- • DODD veins: on the medial side of the thigh
or digitorum brevis and connects to the Arcus plantaris profundus. • BOYD veins: on the inner side of the proximal lower leg
• A. plantaris lateralis: it runs underneath the M. flexor digito- • COCKETT veins: on the medial side of the distal lower leg
rum brevis and forms the Arcus plantaris profundus (› Fig. The veins of the deep system accompany the arteries. Therefore, as
5.65b). This deep arch (a superficial arch is not usually formed) with the arm, the arteries and veins have the same name (› Fig.
is located below the bases of the Ossi metatarsi and divides into 5.67). On the lower leg and foot, typically 2 veins accompany the
the Aa. metatarsales plantares. With the Aa. digitales plantares corresponding artery. The V. poplitea as well as the veins of the
communes and the Aa. digitales plantares propriae, they supply thigh, generally only occur as single veins.
the underside of the toes.
V. iliaca externa
V. circumflexa ilium
5.8 Veins of the lower extremity superficialis
V. epigastrica superficialis
Saphenofemoral
Vv. pudendae externae
Skills junction
V. circumflexa
V. circumflexa
After working through this chapter, you should be able to: femoris medialis
femoris lateralis
• understand the basic principle of the venous outflow of the V. saphena accessoria
V. profunda femoris
lower extremity
• know the large epifascial veins and show them on a dissec- V. femoralis
V. saphena magna
tion specimen

The venous blood of the lower extremity drains via the V. iliaca
communis into the inferior vena cava. Blood from the hip region
V. poplitea

V. saphena parva
V. saphena magna
Vv. tibiales posteriores
Superficial vein
Vv. fibulares
Venous valve Connecting vein
Vv. tibiales anteriores

Venous valve
V. saphena parva
Perforating vein

Deep vein Fascia V. saphena magna

Rete venosum
dorsale pedis

Fig. 5.66 Classification principle of the venous outflow in the leg,

superficial and deep leg veins with valves. Fig. 5.67 Veins of the lower extremity, right side. Ventral view.

243
5 Lower extremity

Clinical remarks proximally on the medial side of the leg. It enters an opening in the
Fascia lata (Hiatus saphenus) just below the inguinal ligament in
In deep vein thrombosis, a blood clot blocks a vein of the
the depth and culminates in the V. femoralis. This arch-shaped
deep system (› Fig. 5.68). The V. poplitea, V. femoralis at the
confluence of the V. saphena magna or the iliac veins are fre- confluence is clinically referred to as ‘cross’. At the Hiatus saphenus
quently involved. Possible causes are coagulation disorders the V. saphena magna or the veins of the front hip region include
(intensified coagulation of the blood), immobilisation (long what are known as ‘venous star’:
plane journeys, being bed ridden, operation) and oral contra- • V. epigastrica superficialis
ceptives (‘the pill’, particularly in combination with smoking). • V. cirumflexa ilium superficialis
In 30% of cases it leads to a life-threatening pulmonary embo- • V. saphena accessoria
lism. When this occurs, parts of the thrombus in the veins of
• Vv. pudendae externae
the legs will break off and are then transported via the right
ventricle of the heart into the pulmonary circulation, blocking The V. saphena parva originates at the lateral margin of the foot
a branch of the A. pulmonalis. A blockage of major arteries and passes behind the outer ankle to the rear of the lower leg. Here
causes right cardiac stress (acute Cor pulmonale), which it runs epifascially further proximally and penetrates the Fascia
can lead to heart failure and death. Due to under-perfusion of cruris in order to flow into the V. poplitea in the hollow of the
the lungs, acute respiratory distress almost always occurs. knee.

The superficial system consists of 2 large vein stems and a wide va-
Clinical remarks
riety of side branches (› Fig. 5.67) If the venous valves cease to function the blood returning to
• V. saphena magna the torso in an upright posture is reduced. The resulting knot-
• V. saphena parva ty, enlarged veins of the superficial system are known as vari-
Both veins start at the foot and are fed primarily by vessels of the cose veins (varicosis). In cases of failure of the valves of the
perforating veins or relocation of the deep veins after a deep
dorsum of the foot (Rete venosum dorsale pedis and Arcus veno-
vein thrombosis, this may cause flow reversal in these vessels
sus dorsalis pedis). Further on their course, the blood vessels pass (the blood then flows from the deep vessels to the superficial
through subcutaneous fat until they penetrate through the fascia system), and this can contribute to varicosis of the superficial
and culminate in the deep vein system. veins.
The V. saphena magna is formed at the medial margin of the foot,
runs in front of the inner ankle to the lower leg and continues

Embolism in branches
Haemorrhagic
of the A. pulmonalis
pulmonary infarct

V. cava Embolism in Truncus

inferior pulmonalis and
Thrombus in Vv. iliacae Aa. pulmonales
V. iliaca externa et interna
communis

Thrombus in V. femoralis

Thrombus in V. poplitea

Thrombus in Vv. iliacae Fig. 5.68 Deep vein thrombosis

externa et interna possibly resulting in an embo-
lism. [L266]

244
 5.9 Lymph vessels of the lower extremity

5.9 Lymph vessels of the lower extremity • The dorsolateral bundle runs along with the V. saphena parva
proximally and culminates in the superficial lymph nodes in the
area of the hollow of the knee (Nodi lymphoidei poplitei superfi-
Skills ciales) and also via the Nodi lymphoidei poplitei profundi to the
After working through this chapter, you should be able to: deep system and the deep inguinal lymph nodes. The dorsolateral
• know the principles of lymphatic drainage of the lower ex- bundle drains the dorsal lower leg and the outer margin of the foot.
tremity The deep system drains the lymph of the deep leg regions directly
• explain the lymph nodes of the leg and pelvis with their into the deep popliteal and inguinal lymph nodes. The collectors
drainage areas
share their course with the major vessels. Because there are so few
lymph vessels, less lymph is carried via the deep lymph system than
the superficial system.

5.9.1 Lymph vessels NOTE

The epifascial system (via the superficial inguinal lymph nodes) and
The large lymph vessels (collectors) of the lower extremity mainly the subfascial system run together in the Nodi lymphoidei inguinales
run along the large veins. Therefore, here also the superficial (epi- profundi. This means that almost the entire lymph of the free lower
fascial) system can be differentiated from the deep (subfascial) sys- extremity is routed through the deep inguinal lymph nodes!
tem. Accordingly, superficial and deep lymph node groups can be
found on the leg.
The majority of lymph from the leg is transported by the superfi- 5.9.2 Inguinal lymph nodes
cial system. It consists of 2 large collector bundles (› Fig. 5.69):
• The ventromedial bundle runs along the V. saphena magna to The lymph nodes are divided into the epifascial Nodi lymphoidei
the superficial lymph nodes in the area of the linguinal ligament inguinales superficiales and the subfascial Nodi lymphoidei ingui-
(Nodi lymphodei inguinales superficiales). These transfer the nales profundi.
lymph further into the deep inguinal lymph nodes (Nodi lym- There are up to 25 superficial lymph nodes on the Fascia lata, posi-
phoidei inguinales profundi). The ventromedial collector bun- tioned lateral and medial on the inguinal ligament (superolateral
dle drains the majority of the lymph of the leg, apart from the and superomedial group) as well as in the area of the Hiatus sa-
dorsal lower leg and the lateral side of the foot. phenus (inferior group) (› Fig. 5.70). In addition to the lymph of
the leg, in the superficial lymph nodes, there is also the lymph from
the lower parts of the abdomen and back, from the external genita-
lia, the perineum as well as the lower segments of the vagina and the
anal canal (› Fig. 5.70). In addition, in women the lymph vessels
are connected via the Lig. teres uteri from the cranial sections of the
uterus (Fundus uteri and the ‘tube angle’), to the superficial inguinal
Nodi
lymph nodes. Efferent lymph vessels transfer the lymph, especially
lymphoidei
inguinales to the deep inguinal lymph nodes.
superficiales

V. saphena
Clinical remarks
magna
Enlargement of the superficial lymph nodes can be caused by
many different things. These include injury to or inflammation
Nodi lymphoidei of the leg, as well as deep-seated rectal and anal carcinomas or
poplitei super-
ficiales
even tumours of the external genitalia or the uterus (endometri-
al cancer). A thorough palpation of the inguinal region for en-
larged lymph nodes must be part of all clinical examinations.

Ventromedial
collector bundle
V. saphena
parva The 1–3 deep inguinal lymph nodes are below the Fascia lata in
Dorsolateral the area of the Hiatus saphenus and transport the lymph to the
collector
bundle
­pelvic lymph nodes in the area of the V. iliaca externa (Nodi lym-
phodei iliaci externi).

5.9.3 Pelvic lymph nodes

Along the major vessels in the pelvis, there are 3 lymph node sta-
tions (› Table 5.23) into which the lymph from the pelvic region,
as well as the lymph from the leg, is transported (› Chap. 8.8.4):
a b • Nodi lymphoidei iliaci externi along the V. iliaca externa, re-
ceive the lymph from the deep inguinal lymph nodes as well as
from the viscera of the lesser pelvis.
Fig. 5.69 Superficial lymph vessels of the leg, right. a Ventral view. • Nodi lymphoidei iliaci interni along the V ­ . iliaca interna also
b Dorsal view. drain the pelvic viscera.

245
5 Lower extremity

Nodi lymphoidei iliaci interni

Nodi lymphoidei iliaci externi
A.; V. iliaca interna
Rectum
Ovarium
A.; V. iliaca externa
Tuba uterina
Uterus

Nodi lymphoidei inguinales Vesica urinaria

superficiales, Nodi superolaterales

Lig. inguinale
Nodi lymphoidei inguinales
Nodi lymphoidei inguinales profundi
superficiales, Nodi superomediales

Nodi lymphoidei inguinales Fig. 5.70 Superficial inguinal

Hiatus saphenus superficiales, nodi inferiores lymph nodes and drainage
areas, right.

Table 5.23 drainage areas and drainage passages of the lymph nodes of the lower extremity, from distal to proximal.

Nodi lymphoidei Drainage area Main drainage to

Nodi lymphoidei poplitei Superficial sections of the Nodi lymphoidei poplitei profundi
superficiales • Dorsal lower leg
• Lateral margin of the foot
Nodi lymphoidei poplitei Deep sections of Nodi lymphoidei inguinales profundi
­profundi • Lower leg
• Foot
Nodi lymphoidei inguinales • Superficial portions of the leg, with the exception of the dorsal calf and the outer side of the foot Nodi lymphoidei inguinales profundi
superficiales • Lower abdominal wall
• Lower back
• Perineal region, gluteal region
• Lower anal canal
• External genitalia
• Female: lower sections of the vagina and the Fundus uteri
Nodi lymphoidei inguinales • Deep regions of the leg Nodi lymphoidei iliaci externi
profundi • Superficial parts of the leg via Nodi lymphoidei inguinales superficialis and Nodi lymphoidei
poplitei
Nodi lymphoidei iliaci externi • Pelvic viscera Nodi lymphoidei iliaci communes
• Nodi lymphoidei inguinales profundi
Nodi lymphoidei iliaci interni • Pelvic viscera Nodi lymphoidei iliaci communes
• Pelvic wall including the gluteal muscles
• Deep perineal region
Nodi lymphoidei iliaci • Nodi lymphoidei iliaci externi Nodi lymphoidei lumbales
­communes • Nodi lymphoidei iliaci interni

• Nodi lymphoidei iliaci communes around the V. iliaca commu- • explain the structure of the gluteal region, and identify the
nis receive the lymph of the Nodi lymphoidei illiaci interni and vessels and nerves penetrating the Foramina suprapiriforme
externi and transfer it to the lumbar lymph nodes (Nodi lym- and infrapiriforme
phoidei lumbales). From there, the lymph is transported via the • explain the structure of the hollow of the knee and the ar-
Trunci lumbales into the Ductus thoracicus, as the body's main rangement of the vessels and nerves that run through it
lymphatic duct (› Chap. 8.8.4).

5.10 Topographically important aspects of the leg 5.10.1 Lacuna musculorum and Lacuna vasorum

The inguinal ligament (Lig. inguinale) runs from the Spina iliaca
Skills anterior superior to the Tuberculum pubicum directly next to the
After working through this chapter, you should be able to: symphysis (› Fig. 5.71). The rough connective tissue structure is
• show the limitations and contents of the Lacuna musculo- formed from the aponeurosis of the M. obliquus externus abdomi-
rum and the Lacuna vasorum nis and the M. iliopsoas by the radiation of different fascia of the
• explain the contents and structure of the femoral triangle, abdominal wall (Fascia transversalis) and the leg and pelvic region
obturator canal and adductor canal
(Fascia lata, Fascia pelvis parietalis).
In the gap between the inguinal ligament and hip bone, the vessels
and nerves exit from the pelvis on their way to the front side of the

246
 5.10 Topographically important aspects of the leg

N. genitofemoralis,
N. cutaneus R. femoralis
femoris lateralis
A.; V. femoralis
Spina iliaca anterior superior
Septum femorale
Lig. inguinale
Nodus lymphoideus
M. iliopsoas inguinalis profundus
N. femoralis Lig. lacunare
Arcus iliopectineus Funiculus spermaticus

Tuberculum pubicum
M. pectineus
Membrana obturatoria
A.; V. obturatoria
Canalis obturatorius

N. obturatorius Fig. 5.71 Lacuna vasorum and

Lacuna musculorum, right. Ven-
tral view.

Table 5.24 Content of Lacuna vasorum and Lacuna musculorum. 5.10.2 Femoral triangle and adductor canal
Lacuna vasorum (from medial to Lacuna musculorum Femoral triangle
lateral) (from medial to lateral)
The femoral triangle (Trigonum femoris) is a triangular area on
• Deep inguinal lymph nodes and • N. femoralis the front of the thigh, in which the penetrating vessels and nerves
lymph vessels • M. iliopsoas passing under the inguinal ligament (in the Lacuna vasorum and
• V. femoralis • N. cutaneus femoris lateralis
Lacuna musculorum, see above) can continue or be divided
• A. femoralis
• R. femoralis of the N. genitofemoralis
(› Fig. 5.72a). It is delimited at the top by the inguinal ligament,
laterally by the M. sartorius and medially by the M. gracilis
(› Table 5.25). The floor is formed medially by the M. pectineus
thigh. The Arcus iliopectineus (a reinforcement of the fascia of the and laterally by the M. iliopsoas.
M. iliopsoas) separates the lateral L
­ acuna musculorum beneath When the M. pectineus is removed, underneath it (and thus dorsal
the inguinal ligament from the m ­ edially located Lacuna vasorum of the femoral triangle), the N. obturatorius and the A./V. obtura-
(› Fig. 5.71, › Table 5.24). toria become visible, having exited the pelvis through the Canalis
obturatorius, a gap in the Membrana obturatoria.
NOTE The N. femoralis is separated in the femoral triangle into its termi-
The abbreviation mVAN can help the sequence of vessels and nal branches and here the A. femoralis delivers the A. profunda
nerves to be remembered femoris to supply the thigh. Just below the inguinal ligament, the
• medial epifascial veins form the ‘venous star’, from which the V. saphena
• Vein → V. femoralis in Lacuna vasorum
magna passes into the Hiatus saphenus into the depths and flows
• Artery → A. femoralis in Lacuna vasorum
• Nerves → R. femoralis of the N. genitofemoralis in Lacuna vaso-
into the V. femoralis.
rum, N. femoralis in Lacuna musculorum, N. cutaneus femoris lat-
eralis in Lacuna musculorum Adductor canal
The A. and V. femoralis run distally at the thigh together with the
Between the V. femoralis and the medial limit of the Lacuna vaso- N. saphenus (sensory terminal branch of the N. femoralis) through
rum (Lig. lacunare, split off from the inguinal ligament) there is a the adductor canal (Canalis adductorius) to the hollow of the
gap which is sealed by a layer of connective tissue (Septum femo- knee. The canal is delimited ventrally by the Septum intermuscu-
rale). This is breached by the lymph vessels of the leg, and even lare vastoadductorium and the M. sartorius, dorsally by the M. ad-
some of the deep inguinal lymph nodes are located there. ductor longus, laterally by the M. vastus medialis, and medially by
the M. adductor magnus (› Table 5.26). The Septum intermuscu-
lulare vastoadductorium is an aponeurosis attachment of the
Clinical remarks
The Lacuna vasorum is the breach point for femoral hernias.
Thus, the Septum femorale is breached and an opening is Table 5.25 Limitation and contents of the femoral triangle.
formed, which in a similar way to the inguinal canal, is referred
Limitation Contents
to as a femoral ring (‘Anulus femoralis’). Unlike inguinal herni-
as, femoral hernias do not breach above the inguinal ligament • Cranial: inguinal ligament • Lacuna vasorum and musculorum
but below. Femoral hernias are the most common hernias in • Caudal: M. sartorius • Branching of the N. femoralis
women. They are difficult to diagnose, because only very large • Medial: M. gracilis • Branching of the A./V. femoralis with
hernias can be palpated beneath the inguinal ligament. • Dorsal: M. iliopsoas and venous star
M. pectineus • Inguinal lymph nodes

247
5 Lower extremity

Table 5.26 Limitation and content of the adductor canal. teric muscles, the Lig. sacrotuberale and the vessels and nerves are
exposed (› Fig. 5.72b). The M. gluteus minimus is located dorsal
Limitations Contents
to the M. gluteus medius and is only visible if this is detached. The
• Ventral: Septum intermusculare • A./V. femoralis M. piriformis, positioned caudally to the M. gluteus medius is
vastoadductorium (covered by the • N. saphenus
­always easily recognisable; caudal from it is the triplet consisting of
M. sartorius) • A. descendens genus
• Dorsal: M. adductor longus
the M. obturatorius internus and the two Mm. gemelli (‘M. triceps
• Lateral: M. vastus medialis coxae’). Further below is the square-shaped M. quadratus femoris
• Medial: M. adductor magnus which needs to be removed in order to demonstrate the M. obtura-
torius externus.
The M. piriformis divides the Foramen ischiadicum majus above
M. adductor magnus, runs to the M. vastus medialis and so com- the Lig. sacrospinale into 2 gaps: Foramen suprapiriforme and the
pletes the adductor canal to a tunnel. The N. saphenus breaks Foramen infrapiriforme. Both gaps are used as passages for the
through the Septum and continues to run epifascially to the lower vessels and nerves of the gluteal region, the perineal region of the
leg. In contrast, the Vasa femoralia run medially past the thigh external genitalia and of the leg (› Table 5.27).
bone dorsally and under the Hiatus adductorius into the hollow of
the knee. The Hiatus adductorius is a tendinous arch of the M. ad-
ductor magnus between its attachments to the Labium mediale of
Clinical remarks
the Linea aspera and the Epicondylus medialis. The Regio glutealis is still commonly used for intramuscular
injections, although for most injections, the M. deltoideus is
better suited. The injection should not be carried out in the
5.10.3 Gluteal region M. gluteus maximus to protect the vessels and nerves, but
should be performed ventrally in the M. gluteus medius. Using
the VON HOCHSTETTER technique, the index finger of the left
The gluteal region (Regio glutealis) is located behind the hip joint hand is placed on the Spina iliaca anterior superior, and the
between the iliac crest and the Sulcus glutealis; when standing, middle finger is braced. The injection is carried out between
there is a visible, palpable groove in the skin, running horizontally. the index and middle fingers.
This is caused by taut connective tissue and therefore does not cor-
respond to the lower margin of the M. gluteus maximus. After re-
moval of this muscle, the M. gluteus medius and the pelvitrochan-

N. cutaneus A. glutea superior, Foramen suprapiriforme

femoris lateralis N. obturatorius R. superficialis M. piriformis

N. femoralis A. femoralis Foramen infrapiriforme M. gluteus medius

M. iliopsoas M. pectineus M. gluteus maximus
M. gemellus superior
N. gluteus inferior
A. obturatoria M. obturatorius
A. circumflexa A. glutea internus
N. obturatorius
femoris lateralis inferior
M. gemellus inferior
A. profunda A. circumflexa A.; V. pudenda
femoris femoris medialis interna
N. cutaneus R. superficialis
M. sartorius (A. circumflexa
M. adductor longus femoris posterior
femoris medialis)
V. femoralis M. quadratus femoris
A. femoralis R. profundus
M. rectus femoris N. ischiadicus (A. circumflexa
N. saphenus femoris medialis)

M. adductor magnus A. perforans

Rr. musculares
Septum intermusculare (N. tibialis) M. adductor magnus
vastoadductorium M. biceps femoris, Aa. perforantes
M. gracilis caput longum

M. semitendinosus M. biceps femoris,

N. saphenus caput longum
M. vastus medialis
M. sartorius M. semimem- M. biceps femoris,
branosus caput breve
V. poplitea
N. fibularis communis
A. poplitea
N. tibialis
N. cutaneus N. cutaneus
surae medialis surae lateralis
V. saphena parva
a b M. gastrocnemius

Fig. 5.72 Topography of the hip, femur and knee joint, right. a Ventral view. b Dorsal view.

248
 5.10 Topographically important aspects of the leg

Table 5.27 Foramen isciadicum majus and minus and penetrating Table 5.28 Limitation and content of the hollow of the knee.
pathways.
Limitations Content (from superficial to deep)
Foramen Location Pathways
• Cranial lateral: M. biceps femoris • N. fibularis communis (lateral)
Foramen Between M. gluteus • N. gluteus superior • Cranial medial: M. semitendinosus • N. tibialis (central)
supra­ medius/minimus and • A./V. glutea superior and M. semimembranosus • V. poplitea
piriforme M. piriformis • Caudal: M. gastrocnemius • A. poplitea
Foramen Between M. piriformis • N. ischiadicus
Foramen infra­ and M. gemellus • N. gluteus inferior
ischiadi- piriforme ­superior • N. pudendus
two heads of the M. gastrocnemius (› Table 5.28). The major
cum • N. cutaneus femoris vessels and nerves from the thigh pass through the hollow of the
majus posterior knee on their way to the lower leg (› Table 5.28):
• Muscle branches to pel- • Most superficially positioned are the N. tibialis (middle) and the
vitrochanteric muscles N. fibularis communis (lateral).
• A./V. glutea inferior
• Below this is the V. poplitea.
• A./V. pudenda interna
• The most deep-seated is the A. poplitea. Here, it also gives rise to
Foramen ischiadicum Between Lig. sacrospinale • N. pudendus branches to supply the knee joint. Due to its deep position, the
minus and Lig. sacrotuberale • A./V. pudenda interna
pulse of the A. poplitea is often difficult to palpate.

NOTE
5.10.4 Hollow of the knee The vessels and nerves in the knee rank from superficial to deep as
follows:
The hollow of the knee (Fossa poplitea) is a diamond-shaped area • N. tibialis and N. fibularis communis
• V. poplitea
behind the knee joint (› Fig. 5.72b). At the top it is laterally delimit-
• A. poplitea
ed by the M. biceps femoris and medially by the M. semimembrano- Mnemonic: ‘NiVeA’
sus and the M. semitendinosus. The lower margin is formed by the

249
This page intentionally left blank
INTERNAL
ORGANS
6 Chest viscera
7 Abdominal viscera
8 Pelvic viscera
6 Chest viscera
Daniela Kugelmann, Jens Waschke

6.1 Heart . . . . . . . . . . . . . . . . . . . . 255 6.3 Oesophagus . . . . . . . . . . . . . . 282

6.1.1 Overview . . . . . . . . . . . . . . . . . 255 6.3.1 Overview, function
6.1.2 Function . . . . . . . . . . . . . . . . . . 255 and development . . . . . . . . . . 282
6.1.3 Development of the 6.3.2 Structure and projection . . . . 283
heart and blood vessels . . . . . 256 6.3.3 Classification . . . . . . . . . . . . . . 283
6.1.4 Prenatal and postnatal 6.3.4 Constrictions
blood circulation . . . . . . . . . . . 260 of the oesophagus . . . . . . . . . 284
6.1.5 Location and projection . . . . . 262 6.3.5 Closing mechanisms . . . . . . . 284
6.1.6 Atria and ventricles . . . . . . . . 264 6.3.6 Vessels and nerves
6.1.7 Heart wall and pericardium . . 266 of the oesophagus . . . . . . . . . 285
6.1.8 Cardiac skeleton 6.4 Thymus . . . . . . . . . . . . . . . . . . 287
and heart valves . . . . . . . . . . . 267
6.4.1 Overview, function
6.1.9 Conduction system and development . . . . . . . . . . 287
and innervation of the heart . 269
6.4.2 Structure . . . . . . . . . . . . . . . . . 288
6.1.10 Coronary blood vessel . . . . . . 271
6.4.3 Vessels and nerves
6.1.11 Veins and lymphatic of the thymus . . . . . . . . . . . . . 288
vessels of the heart . . . . . . . . 273
6.5 Thoracic cavity . . . . . . . . . . . . 288
6.2 Trachea and lungs . . . . . . . . . 274
6.5.1 Overview . . . . . . . . . . . . . . . . . 288
6.2.1 Overview and function . . . . . . 274
6.5.2 Mediastinum . . . . . . . . . . . . . . 288
6.2.2 Development
of trachea and lungs . . . . . . . . 275 6.5.3 Pleural cavities . . . . . . . . . . . . 289

6.2.3 Topography and structure 6.5.4 Breathing . . . . . . . . . . . . . . . . . 290

of the trachea and main 6.5.5 Development
bronchi . . . . . . . . . . . . . . . . . . 276 of the visceral cavities . . . . . . 291
6.2.4 Vessels and nerves of the
trachea and main bronchi . . . 277 6.6 Vessels and nerves
of the thoracic cavity . . . . . . . 294
6.2.5 Projection of the lungs . . . . . . 277
6.6.1 Overview . . . . . . . . . . . . . . . . . 294
6.2.6 Structure of the lungs . . . . . . 279
6.6.2 Arteries of the
6.2.7 Vessels and nerves thoracic cavity . . . . . . . . . . . . . 294
of the lungs . . . . . . . . . . . . . . . 281
6.6.3 Veins of the
thoracic cavity . . . . . . . . . . . . . 295
6.6.4 Lymph vessels
of the thoracic cavity . . . . . . . 296
6.6.5 Nerves of the thoracic cavity . 297
 CLINICAL CASE

Myocardial infarction (acute coronary syndrome)

Case study Preliminary diagnosis
The emergency physician is called to attend 73-year-old Klaus M., Diagnostically everything suggests an acute coronary syndrome.
who is retired. Mr. M. reports that in the morning after breakfast he Acute coronary syndrome includes myocardial infarction (heart
felt an acute onset of chest pain that radiated to the neck and left attack) with or without ST elevation in the ECG and unstable angina.
arm. In addition there was shortness of breath, sweating and Because the cell necrosis markers myoglobin and creatine kinase and
tightness of the chest. The pain was so strong, not improving with the heart muscle-specific enzyme troponin are increased, unstable
complete rest, that he called the emergency doctor. Medical history angina pectoris is ruled out. The ST elevation in the ECG indicates an
indicates known arterial hypertension, otherwise no previous cardiac ST elevation myocardial infarction. The clinical examination is most
disease is known. Mr. M. indicates he is a heavy smoker and compatible with a closure of the R. interventricularis anterior of the A.
therefore frequently has problems with his lungs. The emergency coronaria sinistra (RIVA). Differential diagnosis must exclude angina
doctor immediately brings the patient to hospital. pectoris, aortic dissection, pulmonary embolism and heart defects.

Examination results Treatment

Cold sweating, dyspnoeic patient (respiratory rate 15/min) with The cardiac catheterisation with percutaneous transluminal coronary
mainly retrosternal chest pain radiating to the left in the throat area angioplasty (PTCA) provides an angiographic confirmation of vascular
and arm. The heart rate is elevated at 120/min, blood pressure is low stenosis. The R. interventricularis anterior is expanded with a balloon
at 100/60 mmHg. On auscultation a systolic murmur with point of catheter during the same examination and a stent is implanted.
maximum impulse above the aortic valve was determined. The lungs
are inconspicuous.
Further course
Diagnostics The coronary artery can be dilated with the stent. Later the ischemia
markers decline and there are no complications. After 2 weeks the
Troponin T, myoglobin, creatine kinase (CK and CK-MB) and C-reactive patient can be referred to follow-up treatment with antithrombotic
peptide (CRP) are elevated. therapy. Overall, this is a very favourable course after myocardial
The ECG indicates pronounced signs of ischemia over the anterior infarction.
wall (ST elevation in I, aVL and V1–V6).

During your internship in A&E, you come across the following case. For the report you have to
write about the internship, you make the following notes:

In particular ACS!
(What should you do if there is chest pain?!)
Hx.: 73 year-old patient, acute chest pain since the morning,
radiating in left arm and throat area. Shortness of breath,
sweating, thoracic tightness; no complete recovery when resting
Smoker (problems with lung!), arterial hypertension (AHT)
CE: cold sweats, dyspnoea, HR 120/min, RR 100/60 mmHg
systolic with
p.m. over aortic valve, lungs free
DD.: Tropic positive, myoglobin, CK, CK-MB and CRP ↑
ECG: ST elevation in I, aVL and V1 – V6 (esp. STEMI!)
Tx: heart catheter with PTCA and Stent (RIVA)
Proc.: platelet aggregation inhibition!
 6.1 Heart

6.1 Heart pendages, known as auricles (Auricula dextra and sinistera). The

heart is absolutely essential for life as the superordinate organ of
the cardiovascular system. Its significance in medicine can,
Skills amongst other things, be recognised in that in addition to general
After working through this chapter, you should be able to: practitioners and primary care physicians, multiple disciplines,
• Explain the development of the heart with any possible mal- such as cardiologists and cardiac surgeons have specialised in heart
formations in main features diseases.
• Explain the change from foetal to post-natal circulation
• Explain on a specimen and using an x-ray the location, ori-
entation and projection of the heart with edge-forming Clinical remarks
structures
• Describe on a specimen the inner and outer structures of the Above a heart weight of 500 g blood flow to the heart muscles
heart chambers by its own supply vessels (coronary vessels) is not enough.
• Explain the wall layers of the heart and pericardial sac This increases the risk of blood flow deprivation (ischemia)
• Describe the location, structure and function of the heart and therefore death of cardiac tissue (heart attack). This
skeleton weight is known as the critical heart weight. Some pathologi-
• Explain on a specimen the structure, function and projection cal conditions may cause the heart to weigh up to 1100 g, a
of the various heart valves condition referred to as Cor bovinum (ox heart).
• Deduce heart sounds and murmurs and indicate their aus-
cultation type
• Show on a specimen the conduction system with accurate
localisation of sinu-atrial and AV nodes and understand the
anatomical basis of the ECG 6.1.2 Function
• Explain the autonomic innervation of the heart
• Indicate on a specimen the coronary arteries with all import- The heart drives the blood circulation, which can be divided into a
ant branches and describe their importance in the develop-
ment, diagnosis and treatment of coronary artery disease
small circulation (pulmonary circulation) and a large circulation
• Specify the main features of the veins and lymph vessels of (systemic circulation). The circulation serves to transport blood
the heart and distribute it throughout the body. Therefore, its functions are
identical to those of the blood.
The most important functions of the cardiovascular system are:
• Oxygen and nutrient supply of the organism (transport of respi-
ratory gases and nutrients) respectively metabolism end prod-
6.1.1 Overview ucts
• Thermal regulation (heat transfer in blood)
The heart (Cor) is a Cone-shaped, four-chambered, muscular hol- • Defence function (transport of immune cells and antibodies)
low organ. The size is roughly equivalent to the fist of the respective • Hormonal control (transport of hormones)
person and the weight is on average 250–300 g (0.45 % of body • Haemostasis (transport of blood platelets and coagulation fac-
weight, i.e. in men 280–340 g and in women: 230–280 g). The heart tors).
is divided into a left and a right half by the cardiac septum. The two Both circulations form a closed system, with the heart at the centre
halves of the heart are each divided into a right and left atrium functioning as a muscular suction and pressure pump as the driv-
(Atrium dextrum and sinistrum) as well as a right and left ventricle ing force. The heart is responsible for continuous blood circulation
(Ventriculus dexter and sinister). The atria have blind ending ap- and beats at an average of 70 times per minute. This allows blood

A. carotis communis V. jugularis interna

Venous angle, left

Venous angle, right A.; V. subclavia
A.; V. brachialis

A. pulmonalis

Atrium
sinistrum
Vv. pulmonales

Pulmonary circulation
(“small circuit”)

Atrium dextrum

Fig. 6.1 Blood flow through the

heart and lungs as part of the
cardiovascular system; blue =
Vv. hepaticae V. cava Aorta Ventriculi dexter
inferior et sinister blood low in oxygen, red = oxy-
genated blood. [L126]

255
6 Chest viscera

low in oxygen from the systemic circulation to first reach the right Vv. cardinales superiores,
atrium and then the right ventricle via the V. cava inferior and Sinus venosus
communes and inferiores
V. cava superior. From there, the blood is pumped into the pulmo- Dorsal interseg-
Saccus aorticus mental arteries
nary circulation via the Truncus pulmonalis and enriched with ox-
Amniotic sac Dorsal aorta
ygen. Saturated with oxygen, it flows through the Vv. pulmonales
A. umbilicalis
back into the left atrium and, from there, via the left ventricle and Amnion
aorta back into the systemic circulation (› Fig. 6.1).
Pharyngeal
arc arteries

6.1.3 Development of the heart and blood vessels Heart system

V. vitellina
The cardiovascular system is the first functioning organ system of A. vitellina Chorionic plate
of the placenta
the embryo (from the 3rd week of development!). Yolk sac
V. umbilicalis Body stalk

Development of the blood vessels Fig. 6.2 Early embryonic blood circulation In the 4th week (day 26).
The cardiovascular system develops out of the mesoderm. The first [E347-09]
blood vessels are formed in the 3rd week initially in the yolk sac
and the body stalk and 2 days later also in the embryo (splanchnic Clinical remarks
and somatic layer). Hemangioblasts initially develop out of the me-
soderm as precursor cells of blood vessel endothelium and red Because the modification processes for the formation of the
Vena cavae are very complex, abnormalities such as a double
blood cells (vasculogenesis) and form blood islands. New vessels
or left-sided formation of the V. cava superior or inferior may
sprout from the first simple blood vessel (angiogenesis). At first occur.
arteries and veins have no structural differences, but are only dis- Anomalies of the pharyngeal arch arteries are, e.g. a double or
tinguished based on the direction of blood flow in relation to the right-sided aortic arch and an abnormal origin of the A. sub-
heart: clavia on the right side (A. lusoria). These malformations are
• Arteries: carry the blood from the heart usually dorsal to the trachea and the oesophagus, may con-
• Veins: carry the blood to the heart strict them and become conspicuous by causing shortness of
Initially 3 paired vein stems are formed that combine to form the breath and dysphagia.
Sinus venosus of the heart (› Fig. 6.2):
• V. umbilicalis: brings oxygenated blood from the placenta back
to the embryo (also › Chap. 8.6.6) Development of the heart
• Yolk sac veins (Vv. vitellinae): transport blood low in oxygen Formation of the cardiac tube and heart loop
from the yolk sac In the 3rd week (18th day) a vascular plexus arises from the horse-
• Cardinal veins (Vv. cardinales communes superiores and inferi- shoe-shaped cardiogenic plate in the mesoderm of the upper pole
ores, Vv. subcardinales and supracardinales): collect the deoxygen- of the embryonic disc, the branches of which combine to form the
ated blood from the upper and lower body, which then form the unpaired endocardial tube. Gaps around the endocardial tube dor-
Vena cavae (Vv. cavae superior and inferior) with their tributaries sal to the cardiac system lead to the formation of the pericardial
as well as the V. azygos and V. hemiazygos cavity (› Chap. 6.5.5).
The pharyngeal arch arteries originate from the Saccus aorticus, The inner layer (intra-embryonic coeloma) of the pericardium so-
which transport the blood into the initially paired aorta, which lidifies into the myocardium, which surrounds the endocardium
then combine to form the Aorta dorsalis (› Fig. 6.2). 3 types of and forms a cardiac tube, which contracts rhythmically from the
arteries issue from the aorta: end of the 3rd week. The tube is divided into (› Fig. 6.3; › Fig.
• Aa. umbilicales (Aa. umbilicales): transport deoxygenated 6.4):
blood to the placenta • A primitive atrium with Sinus venosus as an inflow segment
• Yolk sac arteries (Aa. vitellinae): after the yolk sac is included • A ventricle with Truncus arteriosus as an outflow segment
they form the vessels for the 3 intestinal segments in the intesti- The connection of the Truncus arteriosus to the Saccus aorticus is
nal tube (Truncus coeliacus for the foregut, A. mesenterica supe- controlled by cells at the outlets of the pharyngeal arch arteries
rior for the midgut, A. mesenterica inferior for the hindgut) (secondary cardiogenic field). The Bulbus cordis bulges out of be-
• Intersegmental arteries (Aa. intersegmentales): these form the tween the ventricle and Truncus arteriosus, the distal portion of
Aa. vertebrales, the intercostal and lumbar arteries as well as the which is called the Conus cordis.
arteries for the extremities systems The epicardium arises from a small cell area on the outside of the
The pharyngeal arch arteries supply the pharyngeal arches, which Sinus venosus (proepicardium), which then surrounds the whole
form in the 4th–5th week. Of the 6 pairs of pharyngeal arch arter- cardiac tube. Through the cranial folding the heart shifts caudally
ies the first two and the 5th degenerate. Derivatives of the 3rd, 4th and ventrally to the foregut into the pericardial cavity together with
and 6th pharyngeal arch arteries are: the Septum transversum (› Fig. 6.3).
• A. carotis communis (3rd pharyngeal arch artery)
• A. subclavia (right) and aortic arch (left) (4th pharyngeal arch
artery)
Clinical remarks
• Pulmonary arteries (on both sides) and Ductus arteriosus (left) As of the end of the 3rd week the heart begins to beat. As of
(6th pharyngeal arch artery) the 5th week of pregnancy, i.e., the 7th week after the last pe-
riod, ultrasound can be used to confirm pregnancy by means
of the heartbeat.

256
 6.1 Heart

Structure of the
prosencephalon
Neural fold Foregut 1st pharyngeal arch artery

Fusing of
1st pharyngeal arch artery paired endothelial tubes
Pericardial cavity Bulbus cordis
Amnion
Myocardial
Primitive ventricle
Endothelium
hoses
Wall of the
a yolk sac b
Lumen of the Primitive atrium
yolk sac

Neural groove 2nd pharyngeal arch artery

Neural fold

1st pharyngeal
arch artery

Truncus Truncus Later left

Bulbus cordis arteriosus arteriosus ventricle

Primitive
ventricle Primitive
Later atrium
right
ventricle
Primitive
atrium V. cardinalis
communis
c Sinus d
venosus
V. umbilicalis V. umbilicalis V. vitellina

Fig. 6.3 Development of the heart and pericardial cavity in the 4th and 5th week. [E347-09]

In the 4th–5th week what will later be the right ventricle grows faster divided from the rest of the atrium by the Crista terminalis (cranial
than the other sections, creating an S-shaped heart loop (› Fig. part of the right sinus valve), which emerges from the primitive atri-
6.3c, d; › Fig. 6.4). In doing so, the atrium and Sinus venosus shift um together with the Auricula dextra and has muscle blocks (Mm.
cranially and dorsally, so that the inflow and outflow channels now pectinate). The left sinus horn becomes the Sinus coronarius,
face upwards. The Sinus venosus extends towards the right and left which, just like the mouth of the V. cava inferior, has a separate
sinus horns and has sinus valves that are designed to prevent the valve (caudal part of the right sinus valve). Similar to that on the
backflow of blood. The mouth of the sinus venosus increasingly right side, the primitive pulmonary vein is incorporated into the left
shifts towards the right. Hereby, the right sinus horn becomes larger atrium up to the point where it branches, so that now 4 Vv. pulmo-
and is incorporated into the right atrium, where it forms the Sinus nales separately enter the smooth-walled atrium. Only the left auri-
venarum cavarum. This smooth-walled part of the right atrium is cle originates from the primitive atrium.

3rd week 4th–5th week

15th day 21st day Saccus aorticus

3rd
Pharyngeal arch
4th arteries
Ventriculus Conus 6th
arteriosus;
Truncus

Atrium
Ventriculus dexter Ventriculus
sinister

Canalis
Atrium dextrum Atrium sinistrum atrioventricularis Fig. 6.4 Stages of heart devel-
opment in the 3rd–5th week.

257
6 Chest viscera

From the 8th week

Aa. carotides communes

A. subclavia Arcus aortae

A. subclavia

Ductus arteriosus
A. pulmonalis sinistra
V. cava superior
Truncus pulmonalis
Foramen ovale
Valva aortae

Valva atrioventricularis
sinistra [Valva mitralis]
Valva trunci pulmonalis
Valva atrioventricularis dextra Pars membranacea Septum inter-
[Valva tricuspidalis] ventriculare
Pars muscularis
Ventriculus sinister

V. cava inferior Ventriculus dexter Fig. 6.5 Septation of ventricle

in the 5th–7th week.

During the contraction of the heart the cells of the Sinus venosus In the 5th week the Conus cordis and Truncus arteriosus are also
have a pacemaker function and after integration of the right atrium separated by bulges that are formed by proliferation of neural crest
form the sinus nodes and AV nodes. cells (› Fig. 6.6). These bulges join together, forming the Septum
The connection between atrium and ventricle is narrowed to form aorticopulmonale, which spirally divides the outflow tract and,
the atrioventricular canal (Canalis atrioventricularis), which is di- together with the adjacent Saccus aorticus, forms the Truncus pul-
verted into the centre line and divided by endocardial cushions monalis and the aorta. In the Truncus arteriosus 3 endocardial
into a right and a left atrioventricular opening (› Fig. 6.4). The cushions form the semilunar valves of the pulmonary and aortic
endocardial cushions arise from the cardiac jelly that is formed be- valve.
tween the endocardium and the myocardium and later develops Septation of the atrium also occurs in the 5th–7th week and begins
into the cuspid valves. with the formation of the Septum primum, that grows in dorsally
During its development the heart increasingly loses its connection from above and initially leaves the Ostium/Foramen primum free
to the dorsal wall of the pericardial cavity (Mesocardium dorsale), (› Fig. 6.7a). Within the upper part of the Septum primum, the
until it is reduced to the folding of the epicardium into the pericar- Ostium/Foramen secundum is created through programmed cell
dium. The Sinus transversus pericardii forms between them. death (apoptosis) (› Fig. 6.7b). The Septum secundum then devel-
ops to the right of the Septum primum, and merges with the left
Septation of the heart sinus valve (› Fig. 6.7c, e). Both septa fuse and together enclose
In the 5th–7th week the interventricular septum (Septum inter- the Foramen ovale (› Fig. 6.7d, f).
ventriculare) develops. In a caudal position close to the tip of the The Septum primum forms the Valvula foraminis ovalis that en-
heart, first the muscular part of the septum forms (Pars muscu- ables directional flow of the blood from the right atrium into the
laris), which incompletely separates the two ventricles. They con- left atrium. After birth the Valvula foraminis ovalis closes the Fora-
tinue to communicate with each other until the end of the 7th week men ovale due to the increased blood pressure in the left atrium.
via a Foramen interventriculare, until the Pars membranacea of From the septum secundum the Limbus fossae ovalis remains.
the septum completely separates the two ventricles (› Fig. 6.5).

Saccus aorticus

Septum Truncus
aorticopulmonale pulmonalis
3rd
Pharyngeal arch arteries 4th Trunk septum
Aorta
– anterior
6th – back
Endocardial pillow
Conus septum Ostium
– upper
– right atrioventriculare
– lower
– left – dextrum
– sinistrum
Ostium
atrioventriculare
– dextrum
– sinistrum
Foramen
interventriculare
Septum
interventriculare Fig. 6.6 Septation of the out-
flow tract. [L126]

258
 6.1 Heart

Septum
spurium Ostium secundum

Septum primum

Ostium primum Ostium secundum

Sinus valves
a b

Septum
secundum
Septum secundum

Foramen ovale
Valvula venae
cavae inferioris

Septum sinus *
c d Valvula sinus
coronarii

Atrium dextrum
Sinus valves Atrium sinistrum
Septum secundum

Valvula foraminis
Septum primum ovalis

Septum atrio- Septum atrioventriculare,

ventriculare (Pars membranacea)
Foramen
primum ovale
Pars mem-
Septum inter-
branacea Septum inter-
ventriculare
Pars ventriculare
Ventriculus muscularis
sinister Fig. 6.7 Septation of the atria.
a, b in the 5th week. c, e In the
e Ventriculus dexter f 6th week. d, f In the 7th and 8th
week; ∗ cutting plane in e and f.

Clinical remarks The tetralogy of FALLOT is the most common cyanotic heart
defect and makes up 65 % of all congenital cyanotic heart de-
Congenital heart defects occur in 0.75% of all newborn babies fects (› Fig. 6.8). It is a combination of:
and are thus the most common developmental disorders. Not • Pulmonary artery stenosis
all heart defects require treatment because they are often not • ‘Overriding’ aorta
functionally relevant and some close spontaneously. Patho- • Right ventricular hypertrophy
physiologically, the most common heart defects can be divid- • Ventricular septal defect
ed into three groups: Due to the asymmetrical septation of the Conus arteriosus,
• Defects with left to right shunt are among the most com- the pulmonary valve is too narrow and in contrast the aorta is
mon congenital heart defects: ventricular septal defects too wide and displaced over the septum (‘overriding’). The
25% (most frequent congenital heart defect [› Fig. 6.8b]), narrow pulmonary valve causes right ventricular hypertrophy,
atrial septal defects 12%, open (persistent) Ductus arterio- which is responsible for the right to left shunting through the
sus 12% (› Chap. 6.1.4). Due to the increased pressure in ventricular septal defect and thus the cyanosis.
the systemic circulation the blood flows from left to right
into the pulmonary circulation. If no operative remedial ac-
tion is taken, pulmonary hypertension will lead to right heart
insufficiency.
• Defects with right to left shunt: Tetralogy of FALLOT 9%
(› Fig. 6.8a), transposition of the great vessels 5%. These
defects are characterised by a bluish tinge of the skin (cya-
nosis) because deoxygenated blood is transported from pul-
monary circulation to the systemic circulation.
• Defects with obstruction: Pulmonary valve stenosis 6%, aor-
tic valve stenosis 6%, aortic coarctation 6% (› Chap. 6.1.4,
› Fig. 6.11). This leads to hypertrophy of the respective
ventricle.

259
6 Chest viscera

Truncus
pulmonalis
Ventricular septal defect
Pulmonary “Riding” aorta with “left-right shunt”
valve
stenosis

Right heart Ventriculus

hypertrophy sinister Ventriculus sinister
Ventricular septal- Ventriculus dexter Ventriculus
dexter Fig. 6.8 a Tetralogy of FALLOT,
Defect with "right-
a left shunt" b b ventricular septal defect.
[L126]

6.1.4 Prenatal and postnatal blood circulation supply of the child is undertaken by the placenta (› Chap. 8.6.6).
Before birth the pulmonary vessels are therefore narrow and there
Prenatal circulation is no gas exchange in the lungs. The capillary bed of the still imma-
The development of the heart and blood vessels is described in ture liver also has a high flow resistance. These organs are separat-
› Chap 6.1.3. ed from the prenatal circulation by bypass pathways, so all of the
The prenatal circulation has various unusual features, which are blood does not have to pass through the organs. This is why there
based on the fact that various organs are not yet fully developed is a physiological right to left shunt in the atrium and the large
and do not have their final functions. The lungs are not yet fully vessels of the heart, and a bypass of the liver, that opens directly
unfolded because it is still filled with amniotic fluid and the oxygen into the V. cava inferior (› Fig. 6.9).

Arcus aortae Aa. pulmonales

Ductus arteriosus
Truncus pulmonalis
V. cava superior
Atrium sinistrum

Foramen ovale

Atrium dextrum Ventriculus sinister

Septum interventriculare
V. cava inferior
Ventriculus dexter

V. hepaticae
Aorta

Ductus venosus
Hepar

Vesica biliaris

V. umbilicalis

V. cava inferior

V. umbilicalis
Aa. umbilicales

A. iliaca communis

A. iliaca externa
A. iliaca interna

Placenta Vesica urinaria

Fig. 6.9 Prenatal circulation.

260
 6.1 Heart

The 3 most important structures of the prenatal bypass circula- Postnatal circulation
tion are: After birth the placental circulation is interrupted by clamping the
• The Foramen ovale: shunt at the atrial level umbilical cord. The partial pressure of CO2 in the blood of the
• The Ductus arteriosus BOTALLI: shunt between the great heart newborn increases. The respiratory centre is stimulated and the
vessels lungs assume their function. The bypass connections must now be
• The ductus venosus (clinically ARANTII): vessel bypassing the interrupted (› Fig. 6.10):
liver • As a result of the pressure increase in the left atrium the Fora-
The oxygenated blood flows from the placenta into the V. umbilica- men ovale is functionally closed. Later the Valvula foraminis
lis of the umbilical cord through the navel (Umbilicus) to the liver. ovalis grows together with the Septum secundum. The Fossa
A part of the blood is sent directly to the capillaries of the liver, but ovalis remains as a relic.
the vast majority bypasses it due to the high flow resistance of the • The Ductus arteriosus is actively closed by smooth muscle con-
liver and is transferred via the Ductus venosus (clinically ARAN- traction, which is triggered by the high level of oxygen. Four
TII) directly to the inferior vena cava (V. cava inferior) and further days after birth it has usually closed completely. In adults the
into the right atrium (liver bypass). In the V. cava inferior oxy- Ligamentum arteriosum can be found as a relic.
gen-rich blood from the placenta is already mixed with the blood • The Ductus venosus obliterates after birth into the Ligamentum
from the lower body. The valve at the bottom of the confluence of venosum.
the V. cava inferior (Valvula venae cavae inferioris) guides the • The V. umbilicalis obliterates to the Lig. teres hepatis between
blood into the right atrium directly to the Foramen ovale. The Fo- the liver and abdominal wall.
ramen ovale is a direct bypass connection in the septum between • The two Aa. umbilicales also contract to prevent blood loss. The
the right and left atrium, so that the blood can be transported di- distal part of the A. umbilicalis becomes the medial umbilical
rectly via the aorta into the systemic circulation, bypassing the ligament on both sides, which both form the basis of the Plica
lungs. A part of the blood, especially the blood from the upper half umbilicalis medialis on the inner relief of the abdominal wall.
of the body, which flows into the right atrium via the superior vena
cava (V. cava superior), enters the right ventricle. The majority of NOTE
this blood flows through the Ductus arteriosus, a direct connec- After the change from prenatal circulation
tion between the Truncus pulmonalis and the aorta, into the sys- • the Foramen ovale becomes the Fossa ovalis
temic circulation. 65% of the blood flows through the Aa. umbili- • the Ductus arteriosus becomes the Lig. arteriosum
• the Ductus venosus becomes the Lig. venosum
cales back to the placenta. The remaining 35% remains in the or-
• the Vv. umbilicalis becomes the Lig. teres hepatis
gans of the lower half of the body. • the A. umbilicalis (distal portion) becomes the Lig. umbilicale
mediale

Arcus aortae

Aa. pulmonales
Lig. arteriosum

Vv. pulmonales sinistrae

V. cava superior Atrium sinistrum
Fossa ovale Truncus pulmonalis

Atrium dextrum
Ventriculus sinister

Ventriculus dexter

Vv. hepaticae
Hepar

Lig. venosum

V. portae hepatis

Lig. teres hepatis

Aorta abdominalis

V. cava inferior

Umbilical cord

(Ligg. umbilicalia medialia)

Fig. 6.10 Postnatal circulation.

261
6 Chest viscera

Clinical remarks 6.1.5 Location and projection

Patent Ductus arteriosus: if the Ductus arteriosus does not
The heart lies in the pericardium between the pleural cavity in the
close, it creates a patent ductus arteriosus. It is more common
in females. If it is not blocked, blood from the aorta can get inferior middle mediastinum (› Chap. 6.5.2) in the pericardial
into the Truncus pulmonalis. This creates a left to right shunt. cavity (Cavitas pericardiaca) (› Fig. 6.12). It is rotated round its
Since prostaglandin E2 has a diluting effect on the ductus, an longitudinal axis, so that the right heart faces the ventral thoracic
inhibitor of prostaglandin synthesis may cause a closure and wall and the left heart more towards the left side and to the back.
possibly help avoid an operation. However, since these active Two thirds of the heart project left of the median plane, the last
substances are used to some extent as anti-inflammatory third to the right of it. In the membrane-free triangle (Trigonum
agents and analgesics, they can also cause a premature clo-
pericardiacum) a part of the cardiac sac lies directly on the ventral
sure of the foetal Ductus arteriosus in a pregnant woman.
Opening in the Foramen ovale: Approximately 20% of the thoracic wall.
adult population have a residual opening in the area of the
Foramen ovale. This is usually functionally irrelevant and
therefore not to be confused with an atrial septal defect. The
Clinical remarks
opening, however, can lead to thrombi in the form of emboli Cardiac dullness describes a weakened sound over the heart
from the leg veins entering the systemic circulation and there on percussion (tapping) of the chest. A distinction is made be-
causing organ infarction and stroke in the brain (paradoxical tween absolute cardiac dullness, which corresponds to the
embolism). percussion sound directly above the membrane-free triangle
Aortic coarctation: When the occlusion of the Ductus arterio- and relative cardiac dullness. With relative cardiac dullness,
sus encroaches upon the surrounding sections of the aortic the percussion sound is less reduced due to the lungs (Reces-
arch, a coarctation of the aorta ensues (› Fig. 6.11). This re- sus costomediastinalis) lying over the heart. Relative cardiac
sults in hypertrophy of the left heart with high blood pressure dullness can be used to determine the size of the heart.
(hypertension) in the upper part of the body. In contrast, pres- The direct location of the heart in the thorax can be used for
sure in the lower half of the body is too low. What stands out intracardiac injections in the 4th–5th intercostal space (ICS)
diagnostically is a systolic cardiac murmur between the shoul- and operative access to the heart. The location of the heart
der blades as well as radiographically visible rib defects (ero- directly on the chest is advantageous for cardiac massage
sions) due to bypass circulations of the intercostal arteries to (› Fig. 6.13). Here the heart can be compressed by the chest.
the A. thoracica interna. The stenosis must be corrected via an
operation or by dilation, because otherwise heart failure and
strokes can ensue even at a young age.

A. carotis communis

A. dorsalis scapulae
Truncus brachio-
cephalicus
A. subclavia

A. subclavia
Arcus
aortae Coarctation of the aorta
A. subscapularis
A. circumflexa scapulae Aa. intercostales
posteriores
A. thoracodorsalis
Pars
ascendens Lig. arteriosum
aortae
Truncus
pulmonalis
Rr. intercostales
anteriores

Fig. 6.11 Coarctation of the

Pars thoracica
aortae aorta. Stenosis causes the for-
mation of bypass circulations
between the branches of the A.
subclavia and the Aorta descen-
A. thoracica dens. The convoluted course of
interna dilated intercostal vessels is
characteristic (rib erosion in the
x-ray image). [L266]

262
 6.1 Heart

N. vagus [X]

(Nodi lymphoidei
mediastinales N. laryngeus
anteriores) recurrens

V. cava superior Lig. arteriosum

Pars ascendens
aortae V. pulmonalis
sinistra superior
A. pulmonalis
A. pulmonalis
dextra
sinistra
V. pulmonalis
V. pulmonalis
sinistra inferior
dextra

Truncus Ventriculus
pulmonalis sinister

Atrium Ventriculus dexter

dextrum

Apex cordis Fig. 6.12 Situs cordis; location

of the heart in the thorax. Ven-
Nodi lymphoidei
phrenici superiores tral view, after the opening of
the pericardium.

Fig. 6.13 Cardiac massage. By

Compression of the heart
in the event of a heart massage applying pressure to the chest,
the ventricles are also com-
pressed so that blood is ejected
into the great vessels and blood
circulation can be maintained.
For cardiac massage, both
hands are initially placed loose-
ly on the chest (a), then the
heart is alternately compressed
by pressure on the chest (b) and
then released again (a) in order
a b to maintain blood circulation.
[L266]

The right border of the heart is located approximately 2 cm beside • Right border of the heart (from top to bottom):
the right sternal border, starting from the 3rd–6th costal cartilage. – V. cava superior
The left coronary border projects onto a connecting line between – Right atrium (Atrium dextrum)
the lower border of the 3rd rib (2–3 cm parasternal, left) to the 5th • Left border of the heart (from top to bottom):
ICS in the medioclavicular line (MCL). The apex beat can be tested – Aortic arch (Arcus aortae)
in the 5th midclavicular ICS. From the centre of the base of the – Truncus pulmonalis
heart to the apex a 12 cm long longitudinal axis (anatomical car- – Left auricle (Auricula sinistra)
diac axis) can be described. It passes along the thorax diagonally – Left ventricle (Ventriculus sinister)
from dorsal right top to ventral left bottom and normally creates an
angle of approximately 45° to all 3 main planes of the space. The NOTE
anatomical cardiac axis may differ depending on the type of consti- In an x-ray image with sagittal projection (posterior–anterior) the
tution. Knowledge of the marginal structures is of major clinical right ventricle does not form a margin. In a lateral x-ray image the
importance in the interpretation of x-ray images (› Fig. 6.14). In right atrium does not form a margin.
the sagittal (posterior–anterior) projection, the following struc-
tures are marginal:

263
6 Chest viscera

Trachea
Clavicula
Scapula

Arcus aortae

V. cava M
Truncus pulmonalis
superior
Auricula sinistra

Arcus aortae
Atrium V. cava
dextrum superior Truncus pulmonalis
Ventriculus Auricula sinistra
sinister Atrium
dextrum Ventriculus sinister
Diaphragma
V. cava Apex cordis
inferior
Diaphragma
Recessus costo-
diaphragmaticus

a b M

Fig. 6.14 Cardiac contours in the chest x-ray.

Clinical remarks • Apex cordis (apex of the heart): is mainly formed by the left
ventricle and is directed to the bottom left
An x-ray overview of the thorax provides information on the
At the ventral Facies sternocostalis, the location of the interventric-
size of the heart. The transverse heart diameter is interindi-
vidually different; however, if it is larger than half of the diam- ular septum (Septum interventriculare) at the Sulcus interven-
eter of the thorax, an enlargement of the heart is present tricularis anterior can be observed through which the R. interven-
which may be caused by hypertrophy of the cardiac muscle or tricularis anterior of the A. coronaria sinistra runs. On the bottom
by dilation of the cardiac wall. In most cases an enlargement side (Facies diaphragmatica) this limit corresponds to the Sulcus
to the left side is present, which points to damage to the left interventricularis posterior with the R. interventricularis posteri-
ventricle. Possible causes are high blood pressure (hyperten- or. The distinction between atria and ventricles is formed by the
sion) in the systemic circulation or a stenosis or insufficiency
Sulcus coronarius, through which, among others, the A. coronaria
of the aortic or mitral valve. Enlargement of the right ventri-
cle, e.g. in pulmonary hypertension due to chronic obstructive dextra and the Sinus coronarius run.
pulmonary disease (asthma) or due to occlusion of the pulmo-
nary arteries (pulmonary embolism), are not visible on an x-ray
in a sagittal beam path, because the right ventricle does not 6.1.6 Atria and ventricles
form a margin. In this case, lateral radiographic projections or
tomographic methods, such as computed tomography (CT) or The heart is a hollow muscle with 4 separate spaces that can be di-
magnetic resonance imaging (MRI) are required.
vided into a right heart with right atrium and right ventricle and a
left heart with left atrium and left ventricle:

Based on the relative positions various surfaces of the heart can be Right atrium (Atrium dextrum)
distinguished: The V. cava inferior and the V. cava superior as well as the Sinus
• Facies sternocostalis: ventral location and mostly formed by the coronarius enter into the right atrium (› Fig. 6.15) and drain
right ventricle ­venous blood from the systemic circulatory system as well as from
• Facies diaphragmatica: (under)side lying on the diaphragm, the heart's own supply (Vasa privata). Small cardiac veins from the
consisting of parts of the right and left ventricle; the Facies dia- Vasa privata discharge directly into the right atrium (Foramina
phragmatica corresponds to the clinical ‘posterior wall’ ­venarum minimarum). The right atrium is separated laterally from
• Facies pulmonales dextra and sinistra: adjacent to the pleural the left atrium by the Septum interatriale, where the sealed Fora-
cavities on each side; on the right it is formed by the right atri- men ovale is located in the form of the Fossa ovalis, the edge of
um, on the left by the left atrium and ventricle which is raised to form the limbus fossae ovalis. In the right atrium
The heart has the form of a reversed cone: is the atrial sinus (Sinus venarum cavarum), which developmen-
• Basis cordis (base of the heart): cranial, corresponds to the valve tally originated from the sinus horn and has a smooth surface anat-
level. This is where the great vessels (aorta, Truncus pulmonalis) omy. It is located between the V. cava inferior and V. cava superior.
originate. The Truncus pulmonalis issuing from the right ventri- In contrast, in the rest of the atrium, especially in the auricle (Au-
cle is enlarged directly at the outlet to the Conus arteriosus. The ricula dextra), the inner surface is lined with Mm. pectinati. From
aorta issues from the left ventricle and has a spiral course, so that the outside this transition can be recognised at the Sulcus terminalis
its origin behind the Truncus pulmonalis is not visible from the cordis and on the inside this corresponds to the Crista terminalis.
outside. The base of the heart is elastically fixed by the great ves- Subepicardially at the sulcus terminalis lies the pacemaker of the
sels and pulmonary veins and Membrana bronchopericardiaca. conduction system, the sinus node. At the confluence of the V. cava

264
 6.1 Heart

inferior the rudimentary formed Valvula venae cavae inferioris (Auricula sinistra). In the Septum interatriale the valve of the
protrudes. A second ‘valve’ is located on the opening of the Sinus Valvula foraminis ovalis can be recognised, the edge of the original
coronarius, the Valvula sinus coronarii. The extension of the Val- Septum primum, which is fused with the Septum secundum.
vula venae cavae inferioris leads to TODARO's TENDON. Together
with the Ostidum of the Sinus coronarius and the edge of the septal Left ventricle (Ventriculus sinister)
cusp of the tricuspid valve they form the boundaries of KOCH's tri- The Ostium atrioventriculare sinistrum contains the left atrioven-
angle, in which the atrioventricular node (AV node, Nodus atrio- tricular valve (mitral valve/Valva mitralis) with 2 cusps and rep-
ventricularis) of the cardiac conduction system is found (› Chap. resents the connection from the atrium to the left ventricle. The
6.1.9). The Ostium atrioventriculare dextrum, where the tricuspid mitral valve is connected to 2 papillary muscles (M. papillaris an-
right atrioventricular valve (Valvula tricuspidalis) lies, separates terior, M. papillaris posterior) via tendinous cords (Chordae tend-
the right atrium from the right ventricle. ineae). Because of the higher pressure the wall of the left ventricle
is three times as strong as the right ventricle and is thus 8–12 mm
Right ventricle (Ventriculus dexter) thick (› Fig. 6.16). The musculature of the left ventricle has three
The musculature of the right ventricle consists of two layers and layers (› Fig. 6.16) and is elevated by trabeculae (Trabeculae carne-
raised by trabeculae (Trabeculae carneae). The wall thickness is ae). The Septum interventriculare functionally belongs to the left
3–5 mm (› Fig. 6.15). There are 3 papillary muscles in the ven­ ventricle. The predominantly smooth outflow part leads the blood
tricle (M. papillaris anterior, M. papillaris posterior, M. papillaris into the Vestibulum aortae.
septalis) at which the tendinous cords (Chordae tendineae) of the
tricuspid valve are fixed. They are part of the active cuspid attach- NOTE
ment apparatus and prevent retrogression of the cuspids during The muscles of the left ventricle are three times as strong as the
systole. The ventricle can be divided into inflow and outflow right ventricle (› Fig. 6.16).
streams, which are divided by a myocardial crest, the Crista supra-
ventricularis. The inflow stream also includes the Trabecula sep-
tomarginalis (moderator band described by Leonardo da Vinci) Clinical remarks
extending from the intermuscular septum (Septum intermuscu- The wall thickness of the right ventricle should not be more
lare) to the anterior papilllary muscle. In this regularly occurring than 5 mm, and of the left ventricle not more than 15 mm. If
trabecula there are fibres of the conducting system. The outflow there is an enlargement of the myocardium, this is called car-
stream crosses the Conus arteriosus to the Truncus pulmonalis. diac hypertrophy. A right ventricular hypertrophy can, for ex-
ample, be caused by stenosis of the pulmonary valve or chron-
Left atrium (Atrium sinistrum) ic obstructive pulmonary disease (pulmonary hypertension). A
left ventricular hypertrophy may be caused by underlying arte-
In the left atrium the 4 pulmonary veins issue; 2 right and 2 left Vv.
rial hypertension or aortic valve stenosis. In this case the left
pulmonales. They transport oxygenated blood from the lungs to heart has to generate higher pressure during the ejection
the heart. The opening of the Vv. pulmonales has a smooth wall, phase and becomes hypertrophic.
otherwise Mm. pectinati can be found, especially in the left auricle

Ostium atrioventriculare dextrum

Pars ascendens aortae
Septum interatriale
Fossa ovalis Mm. pectinati
V. cava superior
Auricula dextra

Foramina venarum A. coronaria dextra

minimarum
Atrium dextrum
Limbus fossae ovalis
KOCH's triangle
Crista terminalis
Valva atrioventricularis
TODARO tendon dextra, cuspis anterior

Chordae tendineae

M. papillaris septalis
V. cava inferior
M. papillaris anterior
Valvula venae
cavae inferioris Valva atrioventri-
cularis dextra,
Ostium sinus coronarii cuspis septalis
Valvula sinus coronarii
Valva atrioventricularis dextra,
Cuspis posterior Septum interventriculare,
Mm. papillares posteriores pars muscularis

Ventriculus dexter
Myocardium Apex cordis
Fig. 6.15 Right atrium and right
ventricle.

265
6 Chest viscera

6.1.7 Heart wall and pericardium stability. In the pericardial cavity (Cavitas pericardiva) there are
10–20 ml of serous fluid. The heart sac consists of:
Heart wall • Pericardium fibrosum (outside), close-fitting connective tissue
The heart wall consists of three layers (› Fig. 6.16): • Pericardium serosum (inside), a serous membrane (Tunica se-
• Endocardium: rosa)
– Inner surface, which is made up of endothelial cells and con- – The section of the pericardium directly inside the Pericardium
nective tissue fibrosum, is referred to as the parietal sheet (Lamina parieta-
– Cuspid and semilunar valves are duplicates of the endocardi- lis). This folds over the large blood vessels (Aorta, Truncus
um pulmonalis, V. cava superior) on the front side to form the vis-
• Myocardium: ceral sheet (Lamina visceralis).
– Cardiac muscle consists of individual cardiomyocytes; the fi- – The visceral sheet corresponds to the Epicardium of the heart
bre bundles run in diagonal, circular and longitudinal lines, wall (see above). At the weak points of the heart muscle, espe-
which enables concentric contraction and longitudinal short- cially the atria, the Lamina parietalis is very strong.
ening of the longitudinal axis The enveloping folds of the epicardium and pericardium create a
– In the atria and the right ventricle there is a dual layered vertical fold on the back of the atrium between the V. cava inferior
structure; in the left ventricle the myocardium is made up of and the V. cava superior and a transverse fold between the 4 pul-
three layers. monary veins. This T-shaped arrangement creates 2 dorsal exten-
– In the area of the apex of the heart the muscles form a vortex sions to the pericardial cavity:
(Vortex cordis). • Sinus transversus pericardii: above the horizontal fold between
• Epicardium (Lamina visceralis pericardii): the V. cava superior and Aorta or Truncus pulmonalis, respectively
– The epicardium consists of a single layer of epithelium as well • Sinus obliquus pericardii: below the horizontal and to the left
as connective and adipose tissue. The adipose tissue contains of the vertical fold, and therefore between the 4 openings of the
the blood vessels and nerves of the heart. pulmonary veins
– The epicardium corresponds to the Lamina visceralis of the
Pericardium serosum (see below) and is therefore a part of the NOTE
heart sac. The epicardium forms the visceral sheet (Pericardium serosum) of
the pericardial cavity, and its parietal sheet lies adjacent to the
Pericardium (heart sac) Pericardium fibrosum of the heart sac (pericardium).
For the development of the pericardial cavity › Chap. 6.5.5
The pericardium, with a volume of 700–1100 ml including the The pericardium is fixed at 3 points:
heart serves to aid low-friction contraction of the heart and gives it • Centrum tendineum of the diaphragm, where it broadly adheres

Endocardium

Myocardium

Ventriculus
sinister

Epicardium

a
Lamina
propria

Mesothelium b Ventriculus
(epicardiale) dexter Fig. 6.16 Muscles of the cardiac
wall. [S010-2-16]

266
 6.1 Heart

Aortic ring
Pulmonary ring

Trigonum fibrosum sinistrum

Trigonum fibrosum dextrum

Valva atrioventricularis dextra

Valva atrioventricularis sinistra [Valva tricuspidalis]
[Valva mitralis]

Anulus fibrosus sinister

Anulus fibrosus dexter
Bundle of HIS TODARO tendon
Fig. 6.17 Cardiac skeleton.

• Posterior side of the sternum via the Ligg. sternopericardiaca • Atrioventricular valves (Valvae atrioventriculares) between
• Bifurcatio tracheae via the Membrana bronchopericardiaca atria and ventricles:
– Tricuspid valve (Valva tricuspidalis, Valva atrioventricularis
dextra) between right atrium and right ventricle
Clinical remarks – Bicuspid mitral valve (Valva mitralis, Valva atrioventricularis
In cases of heart failure or inflammation of the pericardium sinistra) between the left atrium and left ventricle
(pericarditis) fluid can accumulate in the pericardium (pericar- • Semilunar valves (Valvae semilunares) between ventricles and
dial effusion) and affect cardiac activity. large vessels
In the case of rupture of the heart wall, e.g. after a heart attack – Pulmonary valve (Valva trunci pulmonalis) at the junction of
or due to injury (knife stab), the pericardium fills with blood
the right ventricle to the Truncus pulmonalis
(cardiac tamponade). The cardiac activity is inhibited by the
blood. Progression is usually fatal. – Aortic valve (Valva aortae) at the transition from the left ven-
tricle into the aorta
The atrioventricular valves (› Table 6.1) are closed during systo-
le, when the myocardium of the ventricle contracts and prevent re-
turn flow of blood to the atrium (passive valve-supporting sys-
6.1.8 Cardiac skeleton and heart valves tem). The bases of the cusps (Cuspes) are adhered to the fibrous
ring of the cardiac skeleton. The cusps are connected to the papil-
Cardiac skeleton lary muscles via tendinous cords (Chordae tendineae). By contrac-
The atria and ventricles are separated by close-fitting, colla- tion of the muscles during systole, inversion of the cusps into the
gen-based connective tissue, known as the cardiac skeleton (› Fig. atrium is prevented (active valve-supporting system). During di-
6.17). This forms the fibrous rings around the 4 heart valves. Be- astole (filling phase) the atrioventricular valves open.
cause they are all on the same plane, which corresponds to the Sul- The semilunar valves (› Table 6.1) are located at the transition
cus coronarius on the outside, this level is also referred to as the from the ventricles to the major vessels (Truncus pulmonalis, aor-
valve level (› Fig. 6.18): ta). The pulmonary and aortic valves each consist of 3 semilunar
• The tricuspid valve lies in the Anulus fibrosus dexter. valves (Valvae semilunares). On their free edges (Lunulae) a small,
• The mitral valve lies in the Anulus fibrosus sinister. central thickened areas (Noduli) seals the valve completely when
• Aortic and pulmonary valves are surrounded by the aortic and closed. The valves open in response to the pumping action of the
pulmonary ring, respectively. The aortic ring is connected via ventricles and close again when the blood flows black when the
the Tendo infundibuli with the fibrous ring of the Truncus pul- pressure in the circulation rises above the pressure in the ventricle.
monalis.
At 2 triangular points the cardiac skeleton is slightly wider (Trigo- Table 6.1 Heart valves.
num fibrosum dextrum and sinistrum).
Type Valve Components
In addition to stabilisation of the valves, the cardiac skeleton proba-
bly enables the electrical insulation of the atrial and ventricular Cuspid valves Valva atrioventricularis • Cuspis anterior, Cuspis posteri-
musculature. Conduction from the atria to the ventricles therefore dextra, Valva tricuspidalis or, Cuspis septalis
• M. papillaris anterior, M. papil-
only takes place via a portion of the cardiac conduction system, the
laris posterior, M. papillaris
HIS bundle, which passes through the cardiac skeleton at the Trigo- septalis with Chordae
num fibrosum dextrum. This ensures the insulated contraction of tendineae
atria and ventricles, to ensure regular filling of the ventricles. Valva atrioventricularis • Cuspis anterior, Cuspis
sinistra, Valva mitralis posterior
NOTE • M. papillaris anterior, M. papil-
The function of the cardiac skeleton is to isolate the atrial and ven- laris posterior with Chordae
tricular muscles and to stabilise the heart valves. tendineae
Semilunar Valva trunci pulmonalis • Valvula semilunaris dextra
valves • Valvula semilunaris sinistra
Heart valves • Valvula semilunaris anterior

The heart valves are essential for the directional blood flow. In the Valva aortae • Valvula semilunaris dextra
heart, a distinction is made between 2 types of valves (› Fig. 6.18): • Valvula semilunaris sinistra
• Valvula semilunaris posterior

267
6 Chest viscera

Valvula semilunaris dextra

Valvula semilunaris Valvula semilunaris sinistra
Valva trunci
anterior Valvula semilunaris dextra
pulmonalis
Valvula semilunaris Valva aortae
Valvula semilunaris
sinistra posterior
Trigonum fibrosum sinistrum

Anulus fibrosus sinister

Anulus fibrosus dexter
Cuspis commis-
suralis sinistra
Valva atrioven- Cuspis anterior Valva atrioven-
Cuspis anterior
tricularis sinistra Cuspis posterior tricularis dextra
[Valva mitralis] Cuspis posterior Cuspis septalis [Valva tricuspidalis]
Cuspis commis-
suralis dextra Trigonum
fibrosum dextrum
Fig. 6.18 Heart valves.

Clinical remarks The heart sounds and heart murmurs are carried along by the
bloodstream. This means that the auscultation sites of the heart
After a heart attack that also includes the papillary muscles, valves do not correspond to their anatomical location (› Table 6.2,
the Chordae tendinae may become detached. The leaflets re- › Fig. 6.19).
coil into the atrium during systole (active valve insufficiency)
and blood flows back into the atrium.
Clinical remarks
Congenital or acquired disorders (such as bacterial colonisa-
NOTE tion of the heart valves with endocarditis or rheumatic diseas-
During systole the semilunar valves open; during diastole the atrio- es) can damage the valves. Possible consequences are valve
ventricular valves open. stenosis or valve insufficiency (› Fig. 6.20). Failures are usu-
ally acquired and can also be caused by heart attacks, if the
papillary muscles, which anchor the cuspidal valves are dam-
On auscultation of the heart, heart sounds (physiological) and aged.
heart murmurs (pathological) need to be distinguished: These damages are heard as heart murmurs on auscultation.
• The first heart sound is created at the beginning of the systole These are most noticeable at the auscultation sites of the re-
by ventricular contraction and the cuspidal valves snapping shut. spective valves (› Fig. 6.19). If over more than one atrioven-
• The second heart sound is generated at the beginning of the di- tricular valve
astole by the closure of the semilunar valves. • a noise occurs during systole (between the 1st and 2nd
heart sounds), this suggests insufficiency, because the
• Heart murmurs are only created when the valves are damaged.
valve should be closed during this phase
• a noise occurs during diastole, this suggests stenosis, as
Table 6.2 Anatomical projection and auscultation of the heart the valve should be open in the filling phase.
valves. With the semilunar valves it is exactly the opposite.

Heart valve Anatomical projection Auscultation site

Pulmonary valve 3. ICS left sternal border 2nd ICS left parasternal
Aortic valve 3. ICS left sternal border 2nd ICS right parasternal
Tricuspid valve 5th rib cartilage on the dor- 5th ICS right parasternal
sal side of the sternum
Mitral valve with
Mitral valve 4th–5th costal cartilage left 5th ICS midclavicula insufficiency

Mitral valve
with stenosis

Aorta
V. cava
superior Valva trunci
pulmonalis
Valva aortae
Valva atrio-
ventricularis
Valva atrio- sinistra
ventricularis
Apex cordis
dextra

a b

Fig. 6.20 Valve insufficiency and stenosis using the example of the
mitral valve, e g. due to inflammatory changes underlying bacterial or
Fig. 6.19 Projection of the heart contours and the heart valves with rheumatic endocarditis. a Mitral insufficiency. b Mitral stenosis.
auscultation sites onto the ventral thoracic wall [L266]

268
 6.1 Heart

6.1.9 Conduction system and innervation of the

heart
Nodus
sinuatrialis
Electrical stimulation and conduction system of the heart
Crus
The heart has an autonomous electrical stimulation and conduc- sinistrum
tion system that is independent of the nervous system (› Fig. Nodus
6.21). It is formed by specialised heart muscle cells. The stimulus atrioventricularis
follows the following pathway:
• Sinus node as a pacemaker (Nodus sinuatrialis, Fasciculus
atrioventricularis
KEITH–FLACK node)
• AV node (Nodus atrioventricularis, Crus dextrum
ASCHOFF-TAWARA node)
• Atrioventricular bundle (Fasciculus atrioventricularis, Fig. 6.21 Electrical stimulation and conduction system of the heart.
bundle of HIS)
• Bundle branches (Crus dextrum and sinistrum, bundles of
TAWARA ) sinistrum) passes through the Pars membranacea of the Septum
The electrical stimulation is created in the pacemaker, the sinus interventriculare into the left ventricle, where it divides into 3 fas-
node (3 × 10 mm) by spontaneous depolarisation. It lies subepicar- cicles:
dially in the right atrium at the mouth of the V. cava superior at the • The front fascicle leads to the M. papillaris anterior and the api-
height of the Crista terminalis. Starting from the sinus node, the cal ventricular septum.
stimulus is transferred via the atrial myocardium to the AV node. • The middle fascicle leads towards the apex of the heart.
Here, excitation transfer to the ventricle is delayed by 60–120 ms. • The rear fascicle leads to the M. papillaris posterior and the ven-
This delay ensures separate contraction of atria and ventricles. If tricular myocardium.
the sinus node fails, there is a possibility of the AV node taking The specialised heart muscle cells of the individual fascicles pass
over the pacemaker function as a secondary pacemaker with a low- under the endocardium (Rr. subendocardiales) and occasionally
er frequency. The AV node (3 × 5 × 1 mm) is located in the triangle between the trabeculae of the heart wall through the ventricular
of KOCH in the right atrium (› Fig. 6.15), which is bordered by lumen.
the following: The spread of the stimulus through the heart can be revealed by the
• Tendon of TODARO ECG (electrocardiogram) (› Fig. 6.22):
• Edge of the septal leaflet of the tricuspid valve • P-wave: spread of stimulation in the atria.
• Ostium of the Sinus coronarius • PQ interval: spread of the stimulus from the AV node to the
Starting from the AV node, the stimulus can be transferred to the ventricle; during this interval there is no change in the excitation
ventricular myocardium at one point only: the atrioventricular level (isoelectric), because the atrium is already completely
bundle passes through the Trigonum fibrosum dextrum of the car- ­depolarised and the ventricles have not yet been depolarised.
diac skeleton. (HIS bundle; 4 × 20 mm) to the ventricular muscles. • QRS complex: spread of stimulation in the ventricles at the
In the Pars membranacea of the Septum interventriculare the bun- same time, invisible repolarisation of the atria.
dle of HIS divides into the bundle branches (TAWARA). The right • ST segment: full depolarisation of the ventricles.
bundle branch (Crus dextrum) stimulates the right ventricle and • T wave: repolarisation in the ventricles (spreads from the apex
has individual fibres that lead to the Trabecula septomarginalis on to the base of the heart).
to the right M. papillaris anterior. The left bundle branch (Crus

S 1 Sinus node depolarisation

(no ECG signal)
Projection of the R-vector on 1
the level of 1st derivation 2 Excitation delay
In the AV nodes
(PQ route)

P Atrial excitation
1st extremity Q Stimulation of
derivation ventricular septum

R Excitation of the tip third

(vector in heart longitudina)
1 P 2 R Q R
S Stimulation of
mV
0,5 other ventricle sections
T
P ST Full depolarisation of the
0
Positive rash, ST ventricle (no potential
due to R-vector projection Q S difference)
shows the positive pole –0,5
0 0,1 0,2 0,3 0,4 0,5 0,6 Second T Excitation recovery
ECG

Fig. 6.22 Formation of the typical ECG.

269
6 Chest viscera

Clinical remarks Table 6.3 Innervation of the heart.

The ECG allows arrhythmia of various etiologies to be verified, Autonomic innervation (Plexus cardiacus) Afferent innervation
where the heart beats too quickly (tachycardia >100/min.), too
• N. vagus (parasympathetic) • N. phrenicus
slowly (bradycardia <60/min.) or simply irregularly (arrhyth- – Rr. cardiaci cervicales superiores and inferiores – R. pericardiacus
mia). A possible cause of cardiac arrhythmia are atrial fibres – Rr. cardiaci thoracici
that bypass the AV node and connect directly to the HIS bun- • Sympathetic (from the ganglia cervicalia superius,
dle or the ventricular muscles. If the resulting arrhythmias media and cervicothoracicum; T1–T4)
(WOLFF-PARKINSON-WHITE syndrome, WPW syndrome) be- – Nn. cardiaci cervicales superior, medius and inferior
come unpleasantly symptomatic and cannot be treated with – Nn. cardiaci thoracici
medicinal products, cardiac catheterisation is required in
which the accessory conduction bundles are interrupted.
In addition, in the case of coronary heart diseases (e.g. heart The parasympathetic nervous system leads to a reduction of car-
attack) circulation disorders and other diseases such as in- diac output and has a negative chronotropic, dromotropic and
flammation of the myocardium affect stimulus propagation. bathmotropic effect on the heart and a negative inotropic effect on
The ECG is of particular importance for the identification of the atria. The sympathetic nervous system leads to an increase in
myocardial infarction. cardiac output and therefore has a positive chronotropic, dromo-
tropic, inotropic, lusitropic and adhesiotropic effect. The phrenic
nerve only sensitively innervates the pericardium and therefore is
not counted as part of the cardiac plexus.
Innervation
Cardiac output can adapt to the current individual performance of
the body. The autonomic nerves of the heart (Plexus cardiacus,
Clinical remarks
› Fig. 6.23, › Table 6.3) can impact frequency (chronotropic), An increased sympathetic tonus, as in stress situations, is ac-
force development (inotrope), conduction (dromotropic), excit- companied by increased heart rate (tachycardia) and elevated
ability (bathmotropic), the laxity (lusitropy) as well as cardiomyo- arterial blood pressure (hypertension). Damage of the para-
cyte cohesion (adhesiotropy). The cardiac plexus contains para- sympathetic nerve fibres can also lead to tachycardia. The es-
calation of cardiac output increases the oxygen requirements
sympathetic (N. vagus) and sympathetic fibres (postganglionic
of the cardiomyocytes and with narrowing of the coronary ves-
nerve fibres of the cervical and upper chest ganglia of the sympa- sels (coronary heart disease) can lead to angina pectoris and
thetic trunk). Near the base of the heart are up to 550 usually only myocardial infarction.
microscopically visible ganglia (Ganglia cardiaca) with the cell
bodies of postganglionic parasympathetic neurons.

N. vagus [X]
Ganglion cervicale superius

N. cardiacus cervicalis superior

Ganglion cervicale medium

N. laryngeus recurrens
N. laryngeus recurrens

R. cardiacus cervicalis inferior Ganglion cervicothoracicum

[Ganglion stellatum]

N. cardiacus cervicalis medius

R. cardiacus thoracicus
N. cardiacus cervicalis inferior

Ganglion cardiacum

Plexus cardiacus

Fig. 6.23 Autonomic innerva-

tion.

270
 6.1 Heart

6.1.10 Coronary blood vessel Table 6.4 Branches of the coronary arteries.

Branches of the Branches of the

The coronary blood vessels (› Fig. 6.24) are the Vasa privata of A. coronaria dextra A. coronaria sinistra
the heart and ensure the heart's own supply. There are 2 coronary
• R. coni arteriosi: runs to the Conus • R. interventricularis anterior:
arteries:
arteriosus – R. coni arteriosi to the Conus
• A. coronaria sinistra • R. nodi sinuatrialis (two thirds of all arteriosus
• A. coronaria dextra cases): approx. 1 mm thick artery, that – R. lateralis for the front and side
The coronary arteries are functional terminal arteries. Both coro- stretches to the sinus node (in some wall of the left ventricle
nary arteries originate from the ascending aorta above the aortic cases also 2 arteries) – Rr. interventriculares septales
valve. • Rr. atriales and Rr. atrioventricularis: for the anterior two thirds of the
The A. coronaria dextra ( › Table 6.4) originates from the right small branches for the atrium and ven- Septum interventriculare (in
tricle some cases also involved in sup-
Sinus aortae, runs through the Sulcus coronarius along the right
• R. marginalis dexter: stretches along ply of the AV node)
atrium to the lower edge of the heart (Margo dexter) and extends the Margo dexter of the right ventricle • R. circumflexus
across the underside (Facies diaphragmatica), where it usually ends • R. polsterolateralis dexter: inconsistant – R. nodi sinuatrialis (one third of
in the R. interventricularis posterior as a terminal branch. • R. nodi atrioventricularis: to the AV all cases): to the sinoatrial node
The A. coronaria sinistra (› Table 6.4) issues from the left aortic node (usually) – R. marginalis sinister
valve sinus. After only 1 cm it divides into the R. interventricula- • R. interventricularis posterior (usually) – R. posterior ventriculi sinistri to
with Rr. interventriculares septales the Facies diaphragmatica of the
ris anterior and the R. circumflexus. The R. interventricularis an-
(supplies the HIS bundle) left ventricle
terior runs forwards through the Sulcus interventricularis anterior
above the Septum interventriculare on the Facies sternocostalis
and issues another major branch, the R. lateralis, along its trajec­ Clinical remarks
tory. The R. circumflexus runs through the Sulcus coronarius In clinical practice the description of the coronary arteries is
around the left margin of the heart to the back and normally issues different from the Nomina Anatomica. The following names are
the R. posterior ventriculi sinistri. common:
• A. coronaria sinistra corresponds to the LCA (left coronary
NOTE artery)
Normally the A coronaria sinistra supplies the left atrium, the left – R. interventricularis anterior corresponds to the RIVA or
ventricle, the anterior two thirds of the ventricular septum and por- LAD (left anterior descending coronary artery)
tions of the right front ventricular wall. The A. coronaria dextra sup- – R. circumflexus corresponds to the RCX
plies parts of the underside of the left ventricle, the right atrium • A. coronaria dextra corresponds to the RCA (right coronary
and right ventricle as well as most of the conduction system. artery)
– R. interventricularis posterior corresponds to the RPD
(right posterior descending coronary artery)

A. coronaria dextra A. coronaria sinistra

R. circumflexus
R. nodi sinuatrialis
R. interventricularis anterior
R. coni arteriosi Rr. atriales
A. coronaria sinistra,
R. lateralis
Rr. atrioventriculares R. circumflexus
R. coni arteriosi
R. atrialis R. marginalis sinister A. coronaria sinistra,
R. lateralis R. posterior ventriculi sinistri
R. marginalis dexter Rr. interventriculares
septales A. coronaria dextra,
R. nodi atrioventricularis R. interventricularis posterior A. coronaria
R. posterior dextra
R. interventricularis posterior ventriculi sinistri
Rr. interventri-
a (R. posterolateralis dexter) culares septales b

A. coronaria sinistra,
R. circumflexus A. coronaria sinistra,
R. circumflexus
A. coronaria sinistra,
R. posterior ventriculi sinistri A. coronaria sinistra,
R. posterior ventriculi sinistri

A. coronaria dextra A. coronaria dextra

A. coronaria sinistra, A. coronaria dextra,

c R. interventricularis posterior d R. interventricularis posterior

Fig. 6.24 Coronary arteries, Aa. coronariae. a Cranial view. b Normal supply type. c Left supply type. d Right supply type.

271
6 Chest viscera

The previously described normal case only occurs in about two

thirds to three quarters of the population. Therefore, in addition to Characteristic referred pain
the normal supply types additional supply types are distinguished in event of coronary heart disease
(“Angina pectoris”)
(› Fig. 6.24):
• Normal supply type: (approx. 55–75 %) the R. interventricularis
posterior from the A. coronaria dextra supplies the right ventri-
cle whereas the back of the left ventricle is supplied by the R.
posterior ventriculi sinistri of the A. coronaria sinistra.
• Left supply type: (approx. 11–20 %) the R. interventricularis
posterior (and also the R. nodi atrioventricularis) derive from
the A. coronaria sinistra. Both issue from the R. circumflexus. In
this case, the entire septum is supplied by the A. coronaria sinis-
tra.
• Right supply type: (approx. 14–25 %) the A. coronaria dextra
issues the R. interventricularis posterior (and also the R. nodi
atrioventricularis) and, via an additional branch called the R. a
posterior ventriculi sinistri, supplies parts of the back of the left
ventricle as well as most of the Septum interventriculare.
Especially in clinical practice, the term ‘dominance’ is used in ad-
dition to supply types. The dominant artery is the vessel that issues
the R. interventricularis posterior, i.e., for the normal supply type
and the right supply type this is the A. coronaria dextra.
b
Atherosclerotic plaque
Clinical remarks In the tunica intima

Coronary heart disease (CHD) is one of the most common

causes of death in the Western world. Coronary artery disease
(CAD) is caused by stenosis of the coronary arteries resulting
from arteriosclerosis (› Fig. 6.25). Due to the lack of blood
circulation this may lead to pain in the chest (Angina pectoris)
that radiates into the arm (mostly on the left) or into the neck. c
In the case of a complete occlusion muscle tissue dies (heart
Plaque with internal bleeding
attack). As the coronary arteries are functional terminal arter-
ies, an occlusion of individual branches leads to certain in-
farction patterns (› Fig. 6.26). These can often already be de-
termined in the various leads in an ECG. The most certain con-
firmation method is achieved by cardiac catheter examination
using x-ray contrast media. In posterior wall myocardial infarc-
tion the perfusion of the AV node is typically also impaired be-
cause the perfusing artery usually originates at the outlet of d
the R. interventricularis posterior. This can result additionally Plaque rupture with
in bradycardiac arrhythmias. Mostly (in the case of balanced thrombus formation
and right supply type) the R. interventricularis posterior is the
terminal branch of the A. coronaria dextra. Since the muscle Fig. 6.25 Coronary heart disease (CHD). a Tightness in the chest with
wall of the right ventricle has a lower oxygen demand than characteristic radiating pain. b–d, The cause is usually atherosclero-
that of the left ventricle due to pressure conditions, a proximal sis of the coronary arteries, which starts with plaque formation due to
occlusion of the A. coronaria dextra often results in an isolat- lipid deposits (b) that are enlarged by bleeding (c) and in the case of
ed posterior myocardial infarction. In this case, the bradycar- rupture can completely close the lumen due to formation of a blood
dia can be very pronounced due to insufficient perfusion of clot (thrombus, d). [L266]
the SA node.
If the narrowing of the coronary artery cannot be resolved by NOTE
balloon dilatation or implantation of a stent, a bypass circula- Infarction patterns and their most affected arteries are (› Fig.
tion must be created. The A. thoracica interna or epifascial leg 6.26):
veins are often used for this purpose (› Fig. 6.27). Since the • Anterior wall myocardial infarction: R. interventricularis anterior
supply areas of the coronary arteries can vary in size depend- • Lateral myocardial infarction: R. lateralis or proximal branches of
ing on supply type, the extent of the damage and the clinical the R. circumflexus
picture can also vary enormously between patients. • Front wall myocardial infarction: A. coronaria sinistra
• Posterior wall myocardial infarction (Facies diaphragmatica):
A. coronaria dextra (conduction defects) or distal branches of the
R. circumflexus

272
 6.1 Heart

A. coronaria A. coronaria sinistra

dextra
R. interventricularis anterior
R. lateralis R. interventricularis
anterior

Fig. 6.26 Areas of infarction.

Infarction area a Anterior wall myocardial
a b infarction in the case of occlu-
sion of the R. interventricularis
anterior. b Apical infarction in
the case of distal occlusion of
the R. interventricularis anterior.
R. lateralis
c Small lateral myocardial infarc-
tion in the case of closure of the
R. interventricularis R. lateralis (from the R. interven-
posterior tricularis anterior). d Posterior
wall myocardial infarction in the
c d case of occlusion of the R. inter-
ventricularis posterior.

A. subclavia
Pars ascendens
aortae [Aorta
ascendens]
A. thoracica
interna
Venous bypass
on R. circum-
flexus
Venous bypass
on coronary artery Venous bypass
dextra on R. interven-
tricularis anterior
Fig. 6.27 Bypasses. a For arteri-
al bypasses the A. thoracica
interna is attached distal to the
stenosis. b In venous bypasses
Arterial bypass
epifascial leg veins (V. saphena
on R. interventri- magna or parva) are attached
cularis anterior from the ascending aorta to the
respective narrowed branches of
the coronary arteries. Several
a b bypasses can be attached to
this site. [L266]

6.1.11 Veins and lymphatic vessels of the heart Table 6.5 Cardiac veins (vv. cordis).

Venous system Veins

Veins of the heart
The venous drainage (› Fig. 6.28) of the heart occurs via 3 venous Sinus coronarius system • V. cardiaca magna: corresponds to the supply
systems (› Table 6.5): area of the A. coronaria sinistra
– V. interventricularis anterior
• Coronary sinus system – V. marginalis sinistra
• Transmural system – Vv. ventriculi sinistri posteriores
• Endomural system • V. cardiaca media: in the Sulcus interventricularis
Two thirds of the venous blood are taken up by the Sinus coronar- posterior
ius and drained through the Ostium sinus coronariis into the right • V. cardiaca parva: in the right coronary groove,
atrium. 3 main veins lead to the Sinus coronarius: present in 50% of cases
• V. obliqua atrii sinistri (vein of MARSHALL)
• The V. cardiaca magna corresponds to the supply area of the
A. coronaria sinistra. Transmural system • Vv. ventriculi dextri anteriores
• Vv. atriales
• The V. cardiaca media runs around the R. interventricularis
posterior. Endomural system • Vv. cardiacae minimae (Vasa THEBESII)
• The V. cardiaca parva is a small vessel which drains the rest of
the supply area of the A. coronaria dextra but it is only present in
50% of cases.

273
6 Chest viscera

V. cava superior Truncus pulmonalis

A. coronaria sinistra
Pars ascendens aortae
A. coronaria sinistra,
R. circumflexus

V. cardiaca [cordis] magna

A. coronaria dextra
A. coronaria sinistra,
Sulcus coronarius R. interventricularis anterior

Vv. ventriculi V. interventricularis

dextri anteriores anterior

Sinus coronarius
V. cardiaca [cordis]
parva
V. marginalis dextra Fig. 6.28 Cardiac veins, Vv.
cordis Ventral view. [E402]

The final third of the venous blood reaches the atria and ventricles parts of the respiratory system and serves to transport the inhaled
directly via the transmural and endomural systems. air, humidify and warm it. The trachea is like the upper respiratory
tract, the bronchi and most of the bronchioles of the lungs part of
Lymph vessels the anatomical dead space (150–170 ml). This means that these
The lymph of the heart flows endocardially, myocardially and epi- portions of the respiratory system are not involved in gas exchange.
cardially over larger collectors along the coronary arteries in small, Gas exchange itself (uptake of oxygen from the inhaled air, elimi-
usually only microscopically visible lymph nodes that are located nation of carbon dioxide) during breathing takes place in the lungs.
ventral to the aorta and Truncus pulmonalis. From there it is trans- Therefore the lungs are one of the absolutely vital organs. The anat-
ferred via the Nodi lymphoidei tracheobronchiales and other me- omy of the respiratory tract is therefore also of medical importance
diastinal lymph nodes. because respiratory diseases in Germany are among the most com-
For the pericardium the Nodi lymphoidei prepericardiaci and mon diseases. Acute upper respiratory tract infections with bacte-
Nodi lymphoidei pericardiaci laterales drain in Nodi lymphoidei ria or viruses are the most common cause of treatment in paediat-
parasternales and other mediastinal lymph nodes. ric medical practices (paediatrics). If this no longer involves the
presence of a minor infection, which can be treated by general
practitioners, a pulmonologist must be consulted. Disorders re-
6.2 Trachea and lungs quiring surgery are treated by a thoracic surgeon.

Skills Table 6.6 Respiratory system.

After working through this chapter, you should be able to: Upper respiratory tract Lower respiratory tract
• explain the structuring of the lower airway with development
from the foregut • Nasal cavity (cavitas nasi) • Larynx
• explain the sections from the trachea to the tracheal bifurca- • Throat (pharynx) • Trachea
tion with wall construction on a specimen • Lungs (Pulmones): the right lung (Pulmo dexter)
• indicate on a specimen the projection of the lungs and their has 3 lobes, the left lung (Pulmo sinister) has 2
division into lobes and segments lobes
• explain the systematics of the bronchial tree and structures
of the lung hilum on a specimen
• describe Vasa publica and privata of the lungs including ori-
gin, course and function
• describe the lymph vessel systems and the autonomic in-
nervation of the lungs

Clinical remarks
The volume of the anatomical dead space has an important
6.2.1 Overview and function practical relevance for resuscitation. During ventilation the
volume of oxygenated air needs to exceed 170 ml to effective-
The trachea and the two lungs (Pulmones) as well as the larynx ly reach the alveoli and avoid just moving the air column with-
belong to the lower respiratory tract (› Fig. 6.29, › Table 6.6). in the conducting part. Therefore, it is preferable to ventilate
The trachea connects the larynx with the main bronchi (Bronchus slowly with more volume than quickly with too little volume.
principalis dexter and sinister). It is one of the air conducting

274
 6.2 Trachea and lungs

Sinus paranasales

Cavitas nasi

Vestibulum nasi Pars nasalis pharyngis

Pars oralis pharyngis Pharynx
Larynx Pars laryngea pharyngis

Trachea

Bronchi principales

Lobus superior Lobus superior

Pulmo dexter Lobus medius Pulmo sinister
Lobus inferior
Lobus inferior

Fig. 6.29 Upper and lower

respiratory tract. Ventral view.

6.2.2 Development of trachea and lungs • Canalicular phase (16th–26th week): early development of gas
exchanging bronchial tree with formation of first primitive alve-
The epithelial tissues of the larynx, trachea and lungs develop oli
from the 4th week from the entoderm of the foregut. Connective • Saccular phase (26th week until birth): proliferation of capillary
tissue, smooth muscles, and blood vessels are derived from the network with formation of the blood–air barrier. Increase in sur-
surrounding mesoderm. First, a laryngotracheal groove forms factant production
on the inside of the foregut, that bulges outwards to form the • Alveolar phase (32nd week–8th year): formation of the alveoli
lung bud (› Fig. 6.30). By extension, a laryngotracheal tube is
formed, from the lowest sections of which form bronchial buds, Septum oesophagotracheale
the predecessors of the main bronchi. The bronchial buds fold
medially into the coelomic ducts (Ductus pericardiacoperitone-
ales), which later expand to form the pleural cavities (› Fig.
6.53). The medial septum of the coelomic ducts forms the visceral
pleura (Pleura visceralis), the lateral septum the parietal pleura Primitive larynx entrance
(Pleura parietalis).
During the 4th–5th week mesenchymal folds form on both sides, Laryngotracheal composition

which join to form the tracheoesophageal septum and thus sepa-

rate the lower respiratory tract system from the oesophagus
(› Fig. 6.31).
In due course the bronchial buds start to branch and create the
bronchial tree of the lungs. In lung development a distinction is
made between 4 phases, which partially overlap (› Fig. 6.32): Bronchial buds
• Pseudoglandular phase (6th-16th week): formation of the
air-conducting bronchial tree Fig. 6.31 Development of the Septum tracheoesophageale. [E581]

25th day 32nd day

Foregut

Lung bud
Trachea

Stomach
Pericardial cavity
Oesophagus

Midgut
Lung bud

Hindgut
Fig. 6.30 Development of the
lower respiratory tract. a 4th
week of development (25th
a b day). b 5th week of development
(32nd day).

275
6 Chest viscera

Right Left main

28th day 56th day
main bronchus bronchus
Trachea

Bronchial 42nd day

buds
A
D
a A
D

35th day B B

E
C E
c
C
Left main bronchus
d
Right main bronchus
A Right upper lobe D Left upper lobe
b
B Right middle lobe E Left middle lobe
C Right lower lobe Fig. 6.32 Stages of lung devel-
opment. [E581]

Clinical remarks The lumen of the trachea is kept open by the 16–20 horse-
shoe-shaped cartilage rings (tracheal cartilage) (› Fig. 6.33).
A disorder in the separation of the oesophagus and trachea The cartilage rings consist of hyaline cartilage, but are elastically
can lead to the formation of a shunt (tracheaoesophageal fis-
deformable. They are connected by the Ligg. anularia made of col-
tulas), often with a blind ending oesophagus (oesophageal
atresia). lagen fibres and elastic fibres, which gives them flexibility and en-
From the 20th week onwards surfactant is produced in the al- ables changes in length. On the rear wall of the trachea, the ends of
veoli, which reduces the surface tension of the alveoli. From the cartilage rings are connected to elastic fibres (Paries membra-
the 35th week onwards, surfactant production is usually suffi- naceus) via a connective tissue plate, in which smooth muscles
cient to enable spontaneous breathing. Insufficient surfactant (M. trachealis) are embedded. This membranous portion of the
production results in respiratory distress syndrome (Respira- trachea allows an enlargement of the tracheal diameter. The M. tra-
tory Distress Syndrome, RDS), which is the most common
chealis is always minimally contracted at rest and ensures that the
cause of death in newborn infants. In the case of birth before
the 30th week up to 60% of premature babies develop RDS. Paries membranaceus is taught, making the diameter of the trachea
Since the lungs are filled with air at birth, the coroner can use approx. 16–18 mm. For inspiration, the muscle tone is reduced and
the lung floatation test to determine if the child was born the lumen increases slightly. At the fork of the trachea dividing it
dead (lungs submerge) or died after birth (lungs float). into the two main bronchi, at the level of the 4th thoracic vertebra,
corresponding to the sternal attachment of the 3rd rib, is a ridge
projecting into the lumen from the last tracheal cartilage (Carina
tracheae). Here, the air is divided into the left (Bronchus principa-
lis sinister) and right main bronchi (Bronchus principalis dexter).
6.2.3 Topography and structure of the trachea and At this point, turbulence may occur that are heard as breathing
main bronchi sounds during auscultation.
The angle between the main bronchi is 55°–65°. The distribution
The trachea is 10–13 cm long; however, due to its flexibility can ex- of the trachea is asymmetrical: the right main bronchus is stronger,
tend up to 5 cm during deep inspiration. It joins to the cricoid car- 1–2.5 cm long and almost vertical, whereas the left main bronchus
tilage of the larynx and projects onto the 7th cervical vertebrae, is almost twice as long and the diameter is narrower and angled
and higher when lying down. It ends at the Bifurcatio tracheae at (› Fig. 6.33). The further division of the bronchial tree (Arbor
the level of the 4th-5th thoracic vertebra in the two main bronchi bronchialis) is dichotomous (› Chap. 6.2.6).
(Bronchi principales). A distinction is made between 2 parts:
• Cervical section (Pars cervicalis)
• Thoracic section (Pars thoracica)
Clinical remarks
The Pars cervicalis lies ventral and lateral on both sides to the thy- An enlarged thyroid gland (struma or goitre), that extends
roid. In the chest cavity, the thymus lies ventral to the Pars thorac- through the upper thoracic aperture (retrosternal goitre), can
ica. The trachea here runs in the superior mediastinum. Directly lead to pressure-induced softening of the tracheal cartilage
ventral to the bifurcation is the aortic arch with its ascending ves- (tracheomalacia) to full compression of the trachea, resulting
in shortness of breath.
sels. The left V. brachiocephalica crosses the trachea and receives
Because of the asymmetrical division of the trachea, during
the V. thyroidea inferior lying in front of it. In the channel between inspiration (aspiration) of foreign bodies they more frequently
the trachea and the oesophagus the recurrent laryngeal nerve aris- enter the right lung. In the event of imminent suffocation this
es on both sides in the direction of the larynx. Throughout its tra- knowledge can bring a crucial time advantage!
jectory the dorsal trachea is accompanied by the oesophagus.

276
 6.2 Trachea and lungs

Bronchus principalis dexter Bronchus principalis sinister

Bronchus lobaris superior dexter Bronchus lobaris superior sinister

1 = Bronchus segmentalis apicalis [B I] 1, 2 = Bronchus segmentalis apicoposterior [B I+II]
2 = Bronchus segmentalis posterior [B II] Cartilago 3 = Bronchus segmentalis anterior [B III]
3 = Bronchus segmentalis anterior [B III] thyroidea 4 = Bronchus lingularis superior [B IV]
5 = Bronchus lingularis inferior [B V]
Bronchus lobaris medius dexter
4 = Bronchus segmentalis lateralis [B IV] Bronchus lobaris inferior sinister
5 = Bronchus segmentalis medialis [B V] Cartilago 6 = Bronchus segmentalis superior [B VI]
cricoidea 8 = Bronchus segmentalis basalis anterior [B VIII]
Bronchus lobaris inferior dexter 9 = Bronchus segmentalis basalis lateralis [B IX]
6 = Bronchus segmentalis superior [B VI] 10 = Bronchus segmentalis basalis posterior [B X]
7 = Bronchus segmentalis basalis medialis [B VII]
8 = Bronchus segmentalis basalis anterior [B VIII] Cartilagines
9 = Bronchus segmentalis basalis lateralis [B IX] tracheales
10 = Bronchus segmentalis basalis posterior [B X]

Ligg. anularia

Bifurcatio tracheae
Bronchus principalis dexter
1 2
Bronchus
Bronchus lobaris 1 principalis
superior dexter sinister 3
2 Bronchus lobaris
superior sinister
3 4

Bronchus lobaris Cartilagines 5

medius dexter bronchiales Bronchus lobaris
6 6 inferior sinister
4
Bronchus lobaris 8
5 inferior dexter
8 10 9
7

9
10

Fig. 6.33 Lower respiratory tract. Ventral view.

6.2.4 Vessels and nerves of the trachea and main • Innervation

bronchi – Parasympathetic innervation: Rr. tracheales from the N. la-
ryngeus recurrens (N. vagus).
Vessels and nerves of the trachea and main bronchi are: – Sympathetic innervation: sympathetic trunk.
• Arterial blood supply
– Pars cervicalis of the trachea: Rr. tracheales of the A. thy-
roidea inferior. 6.2.5 Projection of the lungs
– Pars thoracica of the trachea and Bronchi principales: Rr.
tracheales and Rr. bronchiales of the A. thoracica interna and The right and left lungs (Pulmo dexter and sinister) lie in the tho-
the Aorta thoracica, 3rd–4th A. intercostalis. rax and are separated by the mediastinum in the two pleural cavi-
• Venous drainage ties (Cavitates pleurales, › Chap 6.5.3). The lungs have the shape
– Pars cervicalis of the trachea: the venous blood of the trachea of a rounded off cone (› Fig. 6.34). The upper convex portion of
collects in the Plexus thyroideus impar and flows from there the lungs (Apex pulmonis) reach above the upper thoracic aper-
into the V. thyroidea inferior. ture by approx. 5 cm, while the concave base of the lungs broadly
– Pars thoracica of the trachea and Bronchi principales: covers the diaphragmatic dome (Facies diaphragmatica). The Fa-
drainage occurs in the veins of the oesophagus or via the Vv. cies costalis lying laterally on the ribs is the largest area of the
bronchiales into the V. azygos/hemiazygos. lungs. In the medially lying Facies mediastinalis, that separates
• Lymphatic drainage the lungs towards the mediastinum, is the lung hilum (Hilum pul-
– Pars cervicalis of the trachea: the Nodi lymphoidei paratra- monis) (› Fig. 6.35).
cheales drain via the Nodi lymphoidei cervicales profundi Between the 3 areas of the lungs, lie the lung margins (› Fig.
into the Truncus jugularis. 6.34), which, however, just like the depressions created by the vari-
– Pars thoracica of the trachea and Bronchi principales: the ous surrounding structures, are only visible in lungs fixed in situ
Nodi lymphoidei tracheobronchiales and paratracheales drain and therefore regarded as artefacts:
into the Truncus bronchomediastinalis.

277
6 Chest viscera

Apex pulmonis
Lobus superior

Fissura obliqua Lobus superior,

Facies costalis

Margo anterior

Margo posterior
Fissura horizontalis

Lobus medius,
Lobus inferior,
Facies costalis
Facies costalis

Lobus inferior Fissura obliqua

Margo inferior

Basis pulmonis Fig. 6.34 Right lung, lateral

view.

• Margo anterior: lying ventrally between Facies costalis and Fa- Table 6.7 Projection of the lung boundaries in resting expiratory
cies mediastinalis. The blunt dorsal transition between these two position; the pleural boundaries each lie one rib lower.
areas is often referred to as ‘Margo posterior’. Body line Right lung boundaries Left lung boundaries
• Margo inferior: lying caudally between Facies costalis and Fa-
cies diaphragmatica Sternal line 6th rib 4th rib

The main bronchi and the vessels and nerves of the lungs (Aa. pul- Midclavicular line (MCL) 6th rib parallel 6th rib
monales, Vv. pulmonales, Rr. bronchiales, Vv. bronchiales, lymph Midaxillary line 8th rib 8th rib
vessels and nodes, autonomic nerve fibres) run in and out of the Scapula line 10th rib 10th rib
Hilum pulmonis and form the ‘root of the lungs’. In the fixed
Paravertebral line 11th rib 11th rib
lung, the topographic relationships to adjacent organs can be un-
derstood based on the impressions generated. On the right lung
there are impressions of the V. azygos, the oesophagus and the
heart (Impressio cardiaca); the cardiac impression is bigger on the

Apex pulmonis

(Sulcus arteriae
Fissura obliqua subclaviae)

A. pulmonalis sinistra (Sulcus venae

brachiocephalicae)
V. pulmonalis
sinistra superior Pleura parietalis,
Pars mediastinalis
Bronchus
principalis sinister
Margo anterior
Nodi lymphoidei
tracheobronchiales Hilum pulmonis
Facies costalis

V. pulmonalis Impressio cardiaca

sinistra inferior

Lobus inferior Facies mediastinalis

Lig. pulmonale Incisura cardiaca

(Sulcus aorticus)
Lingula pulmonis

Margo inferior (Impressio Fissura obliqua

Facies diaphragmatica; oesophagea)

Basis pulmonis Fig. 6.35 Left lung, medial
view.

278
 6.2 Trachea and lungs

left due to the shape of the heart. On the left lung there are impres- Table 6.8 Segments of the lungs.
sions of the aortic arch and Aorta thoracica.
Pulmo dexter Pulmo sinister
Lobus superior (3 segments) Lobus superior (5 segments)
NOTE
• Segmentum apicale [S I] • Segmentum apicoposterius [S I + II]
Directly on the hilum of the lung a distinction is made between the
• Segmentum posterius [S II] • Segmentum anterius [S III]
following location of in-going and out-going structures:
• Segmentum anterius [S III] • Segmentum lingulare superius [S IV]
• On the right lung the right main bronchus (or upper lobe bron-
Lobus medius (2 segments) • Segmentum lingulare inferius [S V]
chus) lies cranial to the A. pulmonalis.
• Segmentum laterale [S IV] Lobus inferior (4 segments)
• In the hilum of the left lung, the left main bronchus enters caudal
• Segmentum mediale [S V] • Segmentum superius [S VI]
to the A. pulmonalis.
Lobus inferior (5 segments) • Segmentum basale anterius [S VIII]
The Vv. pulmonales are always facing forward, below the previously
• Segmentum superius [S VI] • Segmentum basale laterale [S IX]
mentioned structures (› Fig. 6.35).
• Segmentum basale mediale (cardi- • Segmentum basale posterius [S X]
acum) [S VII]
• Segmentum basale anterius [S VIII]
During the clinical examination, the projection of the lung • Segmentum basale laterale [S IX]
boundaries is assessed (› Table 6.7) to obtain a first impression of • Segmentum basale posterius [S X]
the lung volume and volume changes during breathing. It has to be
noted that the projection of the lung boundaries depends on dia-
phragmatic excursion. This means the lungs are lower during in- the 7th segment (mediobasal segment) is not formed at all or only
spiration and higher during expiration. in rudimentary fashion due to the predominant expansion of the
heart, so that there are only 9 segments. The segments form a func-
tional unit and are only separated from each other by connective
Clinical remarks tissue. Macroscopically this distinction is not visible.
The movement of the lung boundaries during breathing is de-
termined in clinical investigations by percussion (tapping).
Usually there should be a two finger-width distance between
Clinical remarks
deep inspiration and expiration. The classification of the lungs into individual segments is clin-
ically important as this means that during, for example, bron-
choscopy, tissue samples can be assigned to individual seg-
ments.
Since a lung segment is supplied by a corresponding segmen-
6.2.6 Structure of the lungs tal bronchus with associated segmental artery and segmental
vein, the segment forms a functional unit. Surgically, this cre-
The lungs weigh approximately 800 g (without blood 550 g). The ates the option of segment resection. This means that in the
total volume of the lungs is 2–3 L and during inspiration 5–8 L. case of lung metastases, for example, multiple segments from
Through the left shift of the mediastinum, the left lung has about a all lobes can be excised, without endangering the function of
10-20% lower volume. the lungs. In the case of lung tumours (lung carcinoma), at
The tissue of the lungs is formed by the dichotomously branching least the whole affected lobe of a lung is resected.
bronchial tree and its accompanying blood vessels. The main
bronchi each divide into the lobar bronchi (Bronchi lobares), of
which the right lung has 3 and the left lung 2 (› Fig. 6.34, › Fig.
6.35). Accordingly, the right lung has 3 lung lobes (Lobi), an up-
per lobe (Lobus superior), a middle lobe (Lobus medius) and a
lower lobe (Lobus inferior). Table 6.9 Distribution of the bronchi.
In contrast, due to the mediastinum dilating predominantly to the Bronchial tree Lung Function Comment
left, the left lung only has 2 lobes, an upper lung lobe (Lobus supe- unit
rior) and a lower lobe (Lobus inferior). The lingula of the left lung
Bronchi principales Lung Conductive
(Lingula pulmonis sinistri), that runs below the Incisura cardiaca, (main bronchi)
corresponds to the middle lobe of the right lung.
Bronchi lobares Lung Conductive
The lobes of the lungs are separated from each other by fissures, lobes
which allow the lobes to expand against each other. Both lungs are
Bronchi segmentales Lung seg- Conductive
transversed by the sloping Fissura obliqua. It starts dorsal above at
ments
the level of the 4th rib and follows this to the midaxillary line. Then
Bronchi Conductive
it rises steeply to the 6th rib, which it reaches in the midclavicular
line. On the right lung the Fissura obliqua separates the upper Bronchioli Lung lob- Conductive No cartilage and no glands
from the middle lobe dorsally and the lower lobe from the middle ules in the wall

lobe ventrally. On the left lung it runs between the upper and lower Bronchioli terminales Acinus Conductive Only microscopically visi-
lobe. ble

On the right lung is additionally there is the Fissura horizontalis, Bronchioli respiratorii Alveoli Respiratory Only microscopically visi-
which extends the trajectory along the 4th rib and separates the (gas ble
upper lobe from the middle lobe. exchanging)

The lobe bronchi are split into the segmental bronchi (Bronchi Ductus alveolares, Alveoli Respiratory Only microscopically visi-
segmentales), that correspond to one lung segment each (› Fig. Sacculi alveolares (gas ble
exchanging)
6.36, › Table 6.8). The right lung has 10 segments. In the left lung

279
6 Chest viscera

I
I
II

II
III VI
III

VI IV

IV VIII
IX
V V X
VIII
IX
X

a b

I I
II
II

III
III VI
VI

IV

VII V
V
X
X

VIII
VIII IX
IX

c d

Pulmo dexter Pulmo sinister

Lobus superior Lobus superior
Segmentum apicale [S I]
Segmentum apicoposterius [S I + II]
Segmentum posterius [S II]
Segmentum anterius [S III] Segmentum anterius [S III]
Segmentum lingulare superius [S IV]
Lobus medius
Segmentum lingulare inferius [S V]
Segmentum laterale [S IV]
Segmentum mediale [S V] Lobus inferior
Segmentum superius [S VI]
Lobus inferior
Segmentum basale anterius [S VIII]
Segmentum superius [S VI]
Segmentum basale laterale [S IX]
Segmentum basale mediale [cardiacum] [S VII]
Segmentum basale posterius [S X] Fig. 6.36 Lung segments
Segmentum basale anterius [S VIII]
a Pulmo dexter. Lateral view.
Segmentum basale laterale [S IX] b Pulmo sinister. Lateral view.
Segmentum basale posterius [S X] c Pulmo dexter. Medial view.
d Pulmo sinister. Medial view.

The segmental bronchi divide 6–12 times into bronchi, which in minales. This ends the air-conducting portion of the bronchial
turn divide into the already cartilage-free bronchioles, the primary tree. From the Bronchioli terminales, the Bronchioli respiratorii
division of which form the pulmonary lobules (Lobuli pulmonis) issue, which branch into Ductus and Sacculi alveolares, where gas
(› Table 6.9). The lobules are separated incompletely from connec- exchange takes place.
tive tissue. Macroscopically, these polygonal fields are made visible The air conduction section comprises a volume of 150–170 ml.
by retention of carbon dust particles from the air in the subpleural This volume (anatomical dead space) does not take part in the gas
connective tissue along the lymph vessels. In the lung lobules the exchange and must therefore first be filled before the alveoli can be
bronchioles divide another 3–4 times to form the Bronchioli ter- ventilated.

280
 6.2 Trachea and lungs

Clinical remarks The bronchial vessels also supply the Pleura visceralis around the
Hilum pulmonale.
A pathological hyperextension of the lung (pulmonary emphy-
sema) originates in the lobules of the lungs.
Anastomoses between Vasa publica and Vasa privata
Direct shunts exist between the A. pulmonalis and the Rr. bronchi-
ales. Normally, these arteries are closed (contractile arteries), but
may open in the case of reduced blood pressure in the pulmonary
6.2.7 Vessels and nerves of the lungs artery.

Vessels
The lungs serve the total organism. Therefore, in vessel supply, a dis-
Clinical remarks
tinction is made between the Vasa publica, that correspond to the In cases of pulmonary embolism (obstruction of the vessel by
smaller circulation (pulmonary circulation) the purpose of which is a blood clot [thrombus]), the Vasa privata have a limited abili-
oxygenation of the blood and therefore the oxygen supply of the ty to maintain the tissue by continuing minimal supply until
whole body, and the Vasa privata, which are responsible for the recanalisation is possible. When the supply is not enough, the
doubled blood supply causes the formation of a haemorrhag-
lung's own supply. Both vessel networks are connected by shunts.
ic infarct, which can macroscopically be recognised as a hae-
morrhage (› Fig. 5.68).
Vasa publica
The Aa. pulmonales transfer blood low in oxygen (deoxygenated
blood) from the heart to the lungs. They run along the bronchi in
the pulmonary tissue and follow the division of the bronchi down Lymphatic drainage
to the small blood vessels of the terminal vascular bed (microcircu- Lymphatic drainage is ensured by 2 lymphatic drainage systems:
lation) (› Fig. 6.37). the subpleural and septal as well as the periarterial or peribronchial
The Vv. pulmonales do not follow the bronchi, but lie interseg- lymphatic systems. Both lymph vessel systems run together at the
mentally in the connective tissue, i.e. between the individual lung hilum (› Fig. 6.38).
segments. They transfer the oxygen-rich (oxygenated) blood from In the peribronchial lymphatic system 3 lymph node stations are
the lungs back to the heart (› Fig. 6.37). arranged in series in the lung tissue:
• Nodi lymphoidei intrapulmonales (at the branching of lobar and
Vasa privata segmental bronchi)
The Vasa privata course with the bronchi. • Nodi lymphoidei bronchopulmonales (located in the hilum)
• Arterial blood supply: Rr. bronchiales originate on the left di- • Nodi lymphoidei tracheobronchiales superiores and inferiores
rectly from the aorta but on the right mostly from the 3rd inter- (lymph node clusters at the tracheal bifurcation)
costal artery The subpleural lymph vessel system is only joined with the
• Venous outflow: Vv. bronchiales carry the blood into the V. peribronchial system at the hilum and therefore has the Nodi lym-
azygos, V. hemiazygos. The further peripherally located Vv. phoidei trachebronchiales as the first lymph node station. The fur-
bronchiales drain directly into the Vv. pulmonales. ther outflow of the lymph from the lungs is carried out by the Nodi
lymphoidei paratracheales or directly into the Trunci bronchome-

Bronchiolus terminalis
Pulmonary
V. pulmonalis alveoli
A. pulmonalis

R. bronchialis

Bronchioli respiratorii

Intersegmental connective
tissue (Septum)

Capillary network of the

pulmonary alveoli

Pleura with subpleural

vessel plexus
Fig. 6.37 Blood supply to the
lungs.

281
6 Chest viscera

V. jugularis interna dextra

V. jugularis interna sinistra
Mouth of the ductus
lymphaticus dexter Mouth of the ductus
thoracicus
V. subclavia dextra
V. subclavia sinistra
Truncus broncho-
mediastinalis dexter

Nodi lymphoidei Ductus thoracicus

paratracheales

Nodi lymphoidei
tracheobronchiales
Nodi lymphoidei
superiores
tracheobronchiales
inferiores
Nodi lymphoidei
intrapulmonales Nodus lymphoideus
bronchopulmonalis
Subpleural
lymph vessels

Peribronchial
Septal lymph vessels
lymph vessels

Fig. 6.38 Lymphatic drainage

from the lungs.

diastinales or below the main bronchi also directly into the Ductus The parasympathetic nervous system feeds the pulmonary plexus
thoracicus. The connection to the paratracheal lymph nodes and via branches of the N. laryngeus recurrens and the N. vagus (Rr.
the Trunci bronchiomediastinales is crossed, so that lymph from bronchiales). The parasympathetic nervous system leads to nar-
one lung is transferred into the Truncus bronchomediostinalis of rowing of the bronchi (bronchoconstriction).
the opposite side. Afferent, sensory fibres run through the N. vagus. The perikarya
originate from the sensitive ganglia of the nerve (Ganglion superi-
us [jugulare] and Ganglion inferius [nodosum]) and are used for
Clinical remarks the transmission of pain and stretch stimuli.
Clinicians usually collectively call all lymph nodes of the lungs
hilar lymph nodes. This is deceptive as the Nodi lymphoidei
(intra)pulmonales are spread relatively widely into the lung 6.3 Oesophagus
parenchyma. This linguistic inexactitude can lead to mass le-
sions in the parenchyma being prematurely considered as in-
dependent disease processes and not as enlargements of the Skills
lymph nodes, so that unnecessary diagnostic steps for their
clarification are initiated. After working through this chapter, you should be able to:
The crossed over lymphatic drainage from the Nodi lymphoidei • indicate on a specimen the sections of the oesophagus with
paratracheales has the consequence that lymph node metas- their positional relationships
tases from lung carcinoma in the diagnostics are not limited • localise narrowing of the oesophagus
to the respective pleural cavity, but have already spread to • describe the closure mechanisms of the proximal and distal
both sides of the mediastinum. This means that healing by oesophagus and their clinical significance
surgical removal of a lung is usually no longer possible. • explain the vessels and nerves of the different sections of
the oesophagus including the relationship of the veins to
the portal venous system

Innervation
The autonomic innervation of the lungs, whether afferent or effer-
ent, takes place via the Plexus pulmonalis, that lies ventral and
dorsal to the main bronchi. 6.3.1 Overview, function and development
The sympathetic nervous system runs fibres (Rr. pulmonales)
from the Ganglion cervicale inferius and from the 1st–4th thoracic The oesophagus is a 25–30 cm long, elastically deformable muscle
ganglion to the Plexus pulmonalis. Activation of the sympathetic tube. It is used to transport food from the throat (pharynx) into the
nervous system leads to expansion of the bronchi (bronchodila- stomach (Gaster) (› Fig. 6.39).
tion).

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 6.3 Oesophagus

6.3.2 Structure and projection

Cavitas oris propria The oesophagus begins at the bottom of the cricoid cartilage (Car-
Os Vestibulum oris tilago cricoidea) 15 cm from the front row of teeth, at the level of
Rima oris Pars oralis the 6th cervical vertebra. It runs behind the trachea, between the
pharyngis
Pharynx sheets of the middle and deep cervical fascia from the superior me-
Pars laryngea
Oesophagus pharyngis diastinum into the rear mediastinum and passes through the dia-
phragm at the Hiatus oesophageus. It ends at the entrance to the
stomach (Cardia) at the level of the 10th thoracic vertebra.

Clinical remarks
Hepar Gaster
The projection of the oesophagus makes is easy to under-
stand why inflammation caused by gastric juice (gastroesoph-
Pancreas ageal reflux disease) causes pain and retrosternal burning in
Vesica biliaris
a similar location as during a heart attack. From the two or-
Intestinum gans the afferent nerve fibres go into the same spinal cord
[fellea]
tenue segments as neurons of the anterior thoracic wall, so that the
Intestinum brain cannot properly differentiate whether the pain stems
crassum from the body surface or from one of the internal organs. Such
organ-related areas of skin are referred to as a HEAD's zones.
The distance from the front row of teeth to the stomach en-
trance is approximately 40 cm. This is extremely important for
the placement of a gastric tube or for carrying out a gastrosco-
py (oesophagogastroduodenoscopy) because it is possible to
estimate the location of pathological abnormalities based on
Fig. 6.39 Overview of the digestive tract. the length of the tube.

Diseases of the oesophagus fall into the field of gastroenterology. If

surgery is required, a visceral surgeon is consulted.
The epithelium and glands of the oesophagus are formed as of the 6.3.3 Classification
4th week from the entoderm of the foregut, connective tissue and
muscle from the surrounding mesoderm (› Fig. 6.30). Since only The oesophagus is macroscopically divided into 3 parts:
the distal part of the foregut has its own artery in the Truncus coe- • Pars cervicalis
liacus, the oesophagus is supplied by various blood vessels in its • Pars thoracica
various sections. • Pars abdominalis
As of the 4th–5th week, the oesophagus is separated by a tracheo- The Pars cervicalis is 5–8 cm long, joins to the pharynx and reach-
esophageal septum from the lower respiratory tract, which also es to the upper thoracic aperture. Here, the oesophagus lies behind
originates from the from the foregut (› Fig. 6.31). Only the dis- the trachea and directly in front of the cervical spine.
tal part of the oesophagus (Pars abdominalis) is surrounded by The Pars thoracica is the longest section of the oesophagus mea-
the expanding peritoneal cavity and has a coating of visceral peri- suring 16 cm. On its trajectory to the diaphragm it increases its
toneum just like the stomach and adjacent segments of the intes- distance to the spine and runs to the right of the aorta, whereby the
tine. The proximal parts in the area of the neck (Pars cervicalis) aortic arch crosses over the oesophagus and constricts it. In the
and in the mediastinum of the thoracic cavity (Pars thoracica) chest part the oesophagus lies next to the left atrium of the heart,
have no contact with the sections of the abdominal cavity and separated only by the pericardium. In the thoracic part the lumen
therefore only have a connective tissue coating (Tunica adventi- of the oesophagus is usually open because of prevailing negative
tia) (› Fig. 6.52). pressure.
The Pars abdominalis is 1–4 cm long and extends from the pas-
sage through the oesophageal hiatus up to the stomach entrance
Clinical remarks (Cardia). The abdominal part is covered by visceral peritoneum
A disorder in the separation of the oesophagus and trachea (Tunica serosa) and therefore lies in an intraperitoneal position. At
can lead to the formation of a shunt (tracheoesophageal fistu- rest the Pars abdominalis is closed and opens only during swallow-
las), often with a blind ending oesophagus (oesophageal ing. The transition of mucosa from the oesophagus to the stomach
atresia). Breast milk is spat out after intake and can lead to is macroscopically visible, e.g. during gastroscopy, as a jagged line
breathing difficulties due to aspiration in the lungs.
(Z-line) (› Fig. 6.41). This lies in an area 0.75 cm proximal to 1.3
cm distal of the externally assumed border between the oesopha-
gus and stomach. In 70% of cases, it is present only in the area of
the oesophagus and in 20% it extends to the Cardia.

NOTE
The oesophagus is separated from the left atrium only by the peri-
cardium.

283
6 Chest viscera

Clinical remarks vertebrae. It is located at the entrance of the oesophagus in the area
of the upper oesophageal sphincter. It is the narrowest point with a
Due to the proximity of the oesophagus to the heart, enlarge-
diameter of 1.5 cm. At rest the upper constriction is closed. The
ment of the left atrium or pericardial effusion can lead to diffi-
culty swallowing or changes the position of the oesophagus. closure is ensured by a true sphincter (› Chap. 6.3.5).
This topographic relationship is used during diagnostics by The aortic constriction is located approximately 10 cm caudal to
investigating the heart with an ultrasound probe inserted into the uppermost constriction at the height of the 4th thoracic verte-
the oesophagus (transoesophageal echocardiography). bra. Here, the oesophagus is constricted by the left main bronchus
The position of the Z-line is of clinical significance. In reflux and the aortic arch, which are located dorsal and left, respectively.
disease (see below), there is often a conversion of the oe- The Pleura parietalis and the main bronchus are connected here to
sophageal mucosa into mucosa containing glands
the oesophagus via smooth muscle fibres, but do not contribute to
(BARRETT’s oesophagus), which can lead to the formation of
adenocarcinomas in the oesophagus (oesophageal cancer). In its constriction.
this case, the regular Z-line is no longer present during endos- The diaphragmatic constriction lies at the passage through the
copy. Hiatus oesophageus of the diaphragm at the level of the 10th thoracic
Oesophageal carcinomas that are located above the tracheal vertebra. Here, the oesophagus is fixed by elastic fibres (Lig. phren-
bifurcation, often infiltrate the trachea due to their close prox- oesophageale) and the musculature of the diaphragm (› Fig.
imity, which makes operability and therefore prognosis con- 6.41). There is no true sphincter here only an angiomuscular exten-
siderably poorer.
sion closure which functionally results in closure (› Chap. 6.3.5).

Clinical remarks
6.3.4 Constrictions of the oesophagus At the constrictions swallowed foreign matter (e.g. fish bones)
can become stuck. Chemical burns also create the most dam-
The oesophagus is constricted by neighbouring structures in 3 age at the constrictions.
places (› Fig. 6.40):
• Cricoid cartilage constriction
• Aorta constriction
• Diaphragm constriction 6.3.5 Closing mechanisms
The first, uppermost constriction at the level of the cricoid cartilage
(cricoid cartilage constriction) is projected on the 6th cervical Upper oesophageal sphincter
At the cricoid cartilage constriction circular muscle fibres of the
lower pharyngeal constrictor muscle (M. constrictor pharyngis in-
Mm. pharyngis ferior) and circular muscle fibres of the oesophagus, together with
the submuscular venous plexus form a true sphincter (upper oe-
sophageal sphincter). The venous plexus ensures the airtight seal-
Cricoid cartilage constriction
ing of the oesophagus, which is opened with an audible sound
during burping, for example.

Trachea Lower sphincter

Caudally, at the transition of the oesophagus to the stomach, there
is no true sphincter. Closure is achieved functionally via several
mechanisms:
• Angiomusuclar extension closure (› Fig. 6.42):
Truncus
brachiocephalicus
– Under physiological conditions, the oesophagus is under
strong longitudinal elastic tension. This means that at rest it
Aortic constriction is closed in the area of the neck and abdomen and only slight-
Pars ascendens aortae Pars descendens aortae ly opened in the chest area. The spirally arranged muscles fi-
[Aorta ascendens] [Aorta descendens] bres of the muscular layer (Tunica muscularis) are subject to
Bronchus
contraction and longitudinal tension (due to gastric torsion
principalis dexter during development) and provide a ‘screw cap closure’ in a
physiological position. Food is transported by the peristaltic
waves: the longitudinal tension is reduced locally by an arriv-
Pars thoracica aortae ing peristaltic wave, which means that the longitudinal mus-
[Aorta thoracica] culature contracts and the lumen is widened so that the food
can pass through.
– The oesophageal venous plexus under the mucosa acts as a
cavernous body and, amongst other things, ensures the clo-
Hiatus oesophageus
Diaphragmatic constriction sure is airtight.
• Mucosal fold in the angle of HIS (› Fig. 6.41, › Fig. 6.42): at
the gastro-oesophageal junction a steep angle (65°) is formed
Gaster, Cardia between the gastric orifice (Cardia) and gastric fundus in the In-
cisura cardialis (angle of HIS). Apparently a mucosal fold creat-
Fig. 6.40 Narrowing of the oesophagus. Ventral view. ed by the notch prevents reflux of the stomach contents.

284
 6.3 Oesophagus

Angio-muscular expansion closure

Oesophageal Spiral running

venous plexus smooth muscle fibres in
Oesophagus the muscular coat

Lig. phrenicooesophageale

Diaphragma
Oesophagus
Incisura cardialis
Lig. phrenico-
Mucus Fundus oesophageale
skin limit gastricus Incisura cardialis
(Z line) Diaphragma
Peritoneum
Gaster, pars viscerale Angle of HIS
cardiaca
Peritoneum
parietale

Gaster, Mucosal fold

Corpus

Peritoneum
viscerale
Fig. 6.41 Anchoring of the oesophagus in the Hiatus oesophageus.
[L238] Gaster

• Lig. phrenicoesophageale (› Fig. 6.41): anchoring of the oe-

sophagus in the diaphragm (Lig. phrenicoesophageale) and the Fig. 6.42 Angiomuscular oesophageal sphincter and HIS angle at
tone of the diaphragm musculature also ensure a fixation of the the terminal oesophagus. [L126]
oesophagus in the slit in the diaphragm and a narrowing of the
lumen.
• Different pressure gradients in the abdomen and thorax: in the 6.3.6 Vessels and nerves of the oesophagus
abdomen there is a higher pressure than in the chest cavity. This
pressure gradient is especially high during inspiration resulting Arteries
in a stronger closure. The oesophagus does not have its own arteries, but is supplied from
the surrounding vessels (› Fig. 6.43, › Table 6.10):
• Pars cervicalis: Rr. oesophageales of the A. thyroidea inferior
Clinical remarks • Pars thoracica: Rr. oesophageales of the Aorta thoracica and
If the closing mechanisms at the lower oesophagus fail, the from right intercostal arteries
result is reflux of gastric acid into the oesophagus, which
causes an inflammation of the mucosa (oesophageal reflux
disease). The consequences can be a BARRETT’s oesophagus A. thyroidea inferior,
and malignant degeneration (oesophageal cancer). A possible Rr. oesophageales
cause is the lack of stabilisation in the diaphragmatic slit with
A. vertebralis
loosening of the oesophagus. This means that the Pars ab-
dominalis and even parts of the stomach may gain access to A. subclavia
the chest area via the oesophageal hiatus (hiatal hernia). This A. carotis A. carotis
supports the development of reflux where gastric acid can at- communis dextra communis sinistra
tack the mucosa of the oesophagus. Surgically this can be cor-
Trachea
rected by restoring the angle of HIS. For this purpose, the fun-
dus of the stomach is placed around the oesophagus and
sewed into the front wall of the stomach (fundoplication).
The formation of pouches (diverticula) of the entire oesopha-
geal wall can occur at different points: Oesophagus
• ZENKER’s diverticulum is the most common (70%). These Pars thoracica aortae,
diverticula penetrate through KILLIAN's dehiscence of the hy- Rr. oesophageales
popharynx and are erroneously attributed to the oesopha-
geal diverticula. The cause is a defective weakening of the A. gastrica sinistra,
lower pharyngeal constrictor muscle and therefore the upper Diaphragma Rr. oesophageales
oesophageal sphincter.
• Traction diverticula (22%) are phylogenetically caused by a
defective separation of oesophagus and trachea.
• Epiphrenic diverticula (8%) are believed to be evoked by a
Truncus coeliacus
disturbed function of the lower angiomuscular oesophageal
sphincter.

Fig. 6.43 Arterial blood supply of the oesophagus.

285
6 Chest viscera

Table 6.10 Vessels and nerves of the oesophagus. Drainage via the jugular trunks

Oesophagus Vessels and nerves

section
Oesophagus,
Pars cervicalis • A. thyroidea inferior Drainage via the Pars cervicalis
Trunci broncho-
• V. thyroidea inferior
mediastinales
• Nodi lymphoidei cervicales profundi
Lymph drainage
Pars thoracica • Rr. oesophageales of the aorta thoracica and right inter- from the cranial
costal arteries
• V. azygos/hemiazygos Lymph drainage
to the caudal Oesophagus,
• Nodi lymphoidei paratracheales, Nodi lymphoidei tracheo- Pars thoracica
bronchiales, Nodi lymphoidei mediastinales posteriores
Pars abdomina- • A. gastrica sinistra, A. phrenica inferior
lis • V. gastrica dextra and sinistra in V. portae
• Nodi lymphoidei gastrici and Nodi lymphoidei phrenici
inferiores Oesophagus,
Pars abdominalis

• Pars abdominalis: Rr. oesophageales of the A. gastrica sinistra

and A. phrenica inferior
Fig. 6.45 Lymphatic drainage of the oesophagus.
Clinical remarks
Because, in contrast to other organs of the gastrointestinal Similar to the lymphatic drainage, the tracheal bifurcation appears
tract, the oesophagus has no dedicated arteries but is sup- to be a landmark for venous drainage: above, the blood is drained
plied by blood vessels from the surrounding organs, it is not in a cranial direction and below the bifurcation caudally (› Fig.
easy to operate on, which is why oesophageal surgery is con- 6.45).
sidered as challenging.

Clinical remarks
Veins When the pressure in the portal vein system increases (portal
The venous blood flows through a very strong venous plexus under hypertension), e.g. because the flow resistance in the liver is
the mucosa and the Tunica adventitia. These venous plexuses are increased by scarred reorganisation (liver cirrhosis), blood is
also part of the angiomuscular extension closure in the lower oe- fed in via short circulatory connections of the superior and in-
ferior venae cavae (portocaval anastomoses). The most clini-
sophagus (› Fig. 6.44). Drainage takes place via the Vv. oesopha-
cally important portocaval anastomoses are the connections
geales (› Table 6.10): via the gastric veins to the oesophagus since these can cause
• Pars cervicalis: to the V. thyroidea inferior expansion of the submucous veins (oesophageal varices).
• Pars thoracica: into the V. azygos/V. hemiazygos Rupture of these varices is associated with a mortality of ap-
• Pars abdominalis: via the Vv. gastrica dextra and sinistra, which proximately 50 % and is, therefore, the most frequent cause of
are connected to the portal vein system (V. portae hepatis) and death in patients with liver cirrhosis. In the case of rupture in-
can therefore act as portocaval anastomoses (› Chap. 7.3.11 ). wards, the stomach is usually filled with black blood; in rarer
ruptures the blood flows outside into the abdominal cavity.
Therefore, oesophageal varices are prophylactically ligated
(rubber band ligation) or injected with vascular cauterising
substances.
V. cava superior

V. azygos
V. hemiazygos

Lymph
The lymph is drained into the local lymph nodes of the oesophagus
Vv. oesophageales
(Nodi lymphoidei juxtaoesophageales), which transfers the
lymph accordingly (› Table 6.10):
Oesophageal venous plexus
• Pars cervicalis: via Nodi lymphoidei cervicales profundi to the
Vv. gastricae breves Truncus jugularis
V. gastrica sinistra • Pars thoracica: Nodi lymphoidei paratracheales, Nodi lym-
phoidei tracheobronchiales and Nodi lymphoidei mediastina-
V. gastrica dextra les posteriores into the Truncus bronchomediastinalis
V. portae
• Pars abdominalis: via Nodi lymphoidei gastrici and Nodi lym-
hepatis phoidei phrenici inferiores into the Trunci intestinales and
lumbales
Drainage occurs above the tracheal bifurcation mainly in a cranial
V. splenica direction, below the bifurcation in a caudal direction (› Fig.
[lienalis] 6.45).

Fig. 6.44 Veins of the oesophagus with portocaval anastomoses.

[L126]

286
 6.4 Thymus

Clinical remarks 6.4 Thymus

The venous blood and the lymph are transported in a cranial
direction above the Bifurcatio tracheae and in a caudal direc-
tion below the bifurcation. This means that oesophageal can- 6.4.1 Overview, function and development
cer above the bifurcation metastasises via the blood especial-
ly through the azygos system into the lungs and lymph node The thymus is located in the Trigonum thymicum in the superior
metastases are found mainly in the mediastinum and neck. mediastinum (› Fig. 6.46). It is located behind the sternum and
Carcinomas below the bifurcation spread via the gastric veins extends from the upper sternal border up to the pericardium
especially into the liver and can cause lymph node metasta- (height of 4th rib cartilage). On the side it is covered by the medi-
ses in the abdominal cavity.
astinal part of the Pleura parietalis. The large vessels and nerves
run behind the thymus: aortic arch and Vv. brachiocephalicae with
their unification into the V. cava superior.
Innervation The thymus, together with bone marrow, is one of the primary
The oesophagus has an independently functioning enteral nervous lymphatic organs, because the thymus is the location of matura-
system, which is modulated by the parasympathetic and sympa- tion of T-lymphocytes. From the bone marrow the lymphocytes
thetic nervous systems: the parasympathetic nervous system pro- wander via the blood vessels to the thymus. This is where matura-
motes peristalsis and gland secretion, the sympathetic nervous sys- tion (imprinting) and proliferation as well as selection of the
tem inhibits both processes. T-lymphocytes takes place. Then, the T-lymphocytes reach the sec-
• The parasympathetic innervation occurs cranially via the N. ondary lymphatic organs (spleen, lymph nodes, tonsils and muco-
laryngeus recurrens and in the thoracic and abdominal sections sa-associated lymphatic tissue) via the blood, where the actual spe-
via the N. vagus. Below the Bifurcatio tracheae both N. vagus cific immune response takes place.
trunks lie alongside the oesophagus and form the Plexus oe- The entoderm of the 3rd pharyngeal pouch forms a ventral bud
sophageus in the adventitia, which in the distal part issues the on both sides, which from the 6th week both move medially and
Trunci vagales anterior and posterior. Both trunks pass through together form the two lobes of the thymus.
the oesophageal hiatus of the diaphragm together with the oe-
sophagus. Due to the extension of the stomach, the left N. vagus
lies on the front and the right N. vagus on the back of the stom-
Clinical remarks
ach. An enlarged thymus that projects through the upper thoracic
• The sympathetic innervation results from post-ganglionic sym- aperture, can lead to compression of the trachea and there-
pathetic fibres from the cranial cervical and upper thoracic sym- fore to breathing difficulties in neonates.
pathetic ganglia (2nd–5th).
Sensitive afferent information, such as stretch and pain stimuli in
particular are also centrally transferred via the N. vagus.

V. thyroidea inferior Glandula thyroidea

Truncus brachiocephalicus Trachea
V. subclavia N. laryngeus recurrens
A. subclavia A. carotis communis
V. brachiocephalica
Plexus brachialis
sinistra
V. thoracica interna
N. vagus [X]
Vv. pericardiaco-
phrenicae A. subclavia

V. brachio- Pleura parietalis,

cephalica dextra Pars mediastinalis

N. phrenicus N. phrenicus
Lobus
V. cava superior
sinister
Thymus
Pulmo dexter, Lobus
Lobus superior dexter

Pulmo sinister

Pericardium fibrosum

(Nodi lymphoidei
phrenici superiores)

Sternum Fig. 6.46 Overview of the thy-

mus.

287
6 Chest viscera

The DiGEORGE syndrome describes a thymus aplasia. The thy- 6.5.1 Overview

mus is formed but does not develop. The reason for this is a
malformation of the 3rd pharyngeal pouch. This leads to a loss The chest cavity (Cavitas thoracis) is surrounded by the rib cage
of cellular immunity. The patients are affected by recurrent in- (Cavea thoracis). It is divided into 2 pleural cavities (Cavitates
fections and require a sterile environment.
pleurales), that each contain one lung. Between them lies the me-
diastinum, which represents a connective tissue space between the
sternum and thoracic spine (› Fig. 6.48).
NOTE
Thymus and bone marrow are part of the primary lymphatic or-
gans. Their purpose is the production and maturation (DiGEORGE 6.5.2 Mediastinum
syndrome imprinting) of immune cells. Here, the mature cells gain
the ability to distinguish between own body cells and foreign bod-
ies. The actual immune reaction takes place in the secondary lym- The mediastinum (Lat.: what stands in the middle) is a connective
phatic organs. tissue space between the sternum and spine, that is filled with an
individually very different amount of fat. The mediastinum is di-
vided into different sections relative to the location of the heart
(› Fig. 6.47):
6.4.2 Structure Mediastinum superius, above the heart
Mediastinum inferius, where the heart is. The lower mediastinum
The thymus consists of 2 asymmetric lobes (lobi), each of which is is divided into:
surrounded by a dedicated connective tissue capsule. Septa made • Mediastinum anterius (in front of the heart)
up of connective tissue divide the lobes into microscopically visible • Mediastinum medium (with the pericardium)
lobules (Lobuli thymici), which in turn can be divided into a cor- • Mediastinum posterius (between heart and spine)
tex and medulla. After puberty the thymus experiences involution. The upper mediastinum contains the thymus, the trachea up to its
The cortex is significantly reduced and replaced by fat tissue (ret- bifurcation, the oesophagus, as well as the major arterial and ve-
rosternal fat body). In older people only microscopically detect- nous blood vessels of the heart (aortic arch, Truncus pulmonalis,
able remnants of the thymus tissue are left, which however can be V. cava superior with tributaries), the mediastinal lymph nodes and
used in an immune response if necessary. Here thymus tissue with lymphatic trunks as well as various nerves that run from the neck
a high percentage of fatty tissue and higher blood vessel density is through the chest cavity (N. phrenicus, N. vagus, Truncus sympa­
characteristic. Macroscopically, these remnants can only be identi- thicus with branches) (› Table 6.11).
fied by the small arterial branches of the A. thoracica interna and
venous connections to the Vv. brachiocephalicae. Table 6.11 Content of the mediastinum.
At the neck accessory thymus lobules may occur.
Content of the superior mediastinum Content of the inferior medias-
tinum

6.4.3 Vessels and nerves of the thymus • Thymus • Mediastinum anterius: retroster-

• Trachea nal lymphatic drainage of the
• Oesophagus mammary glands
• Arterial blood supply: Rr. thymici of the A. thoracica interna • Aortic arch and Truncus pulmonalis • Mediastinum medium: pericardi-
• Venous drainage: Vv. thymicae to the V. brachiocephalica • Vv. brachiocephalicae and V. cava um with vessels around the
• Lymph vessels: only efferent lymph vessels to the mediastinal ­superior heart, N. phrenicus with Vasa
lymph nodes • Lymphatic pathways: lymphatic trunks pericardiacophrenica
• Innervation: predominantly sympathetic via the neck ganglia of (Ductus thoracicus, Trunci bronchiome- • Mediastinum posterius: Aorta
diastinales) and mediastinal lymph descendens, oesophagus with
the sympathetic trunk; parasympathetic: N. vagus
nodes Plexus oesophageus of the N.
• Autonomic nervous system (Truncus vagus, Ductus thoracicus, Trun­
sympathicus, N. vagus [X] with N. laryn- cus sympathicus with Nn.
6.5 Thoracic cavity geus recurrens) splanchnici, V. azygos and V.
• N. phrenicus hemiazygos as well as intercostal
vessels and nerves
Skills
After working through this chapter you should be able to:
• describe the structure of the thoracic cavity and the con-
tents of the mediastinum on a specimen
• show the sections of the pleural cavity with its recesses and
explain the vessels and nerves of the pleura Mediastinum
• explain the processes during respiration and demonstrate superius
the function of the respiratory muscles Mediastinum
• understand the principles of development of the abdominal posterius
cavities and the diaphragm Mediastinum
Mediastinum
medium
inferius

Mediastinum
anterius

Fig. 6.47 Structure of the mediastinum.

288
 6.5 Thoracic cavity

The front lower mediastinum contains only the retrosternal Both pleural membranes form a capillary cleft space that contains a
lymph outflows of the mammary gland (the A./V. thoracica interna total of 5 ml of serous fluid, which mediates the adhesion of the
are, however, included in the abdominal wall). The middle lower lungs to the wall of the torso, so that during breathing the lungs
mediastinum is filled completely by the pericardium, on which the can mirror the volume change of the rib cage.
N. phrenicus and A./V. pericardiacophrenica run. In the pericardi-
um are the heart and the Aorta ascendens. The rear lower medias-
tinum in contrast has a complex structure and is crossed by the oe-
Clinical remarks
sophagus, the Aorta descendens, the azygos venous system, the N. When inserting a central venous catheter (CVC) into the V.
vagus and the sympathetic trunk with branches, the Ductus thorac­ subclavia, the distension of the pleural dome must be consid-
icus as well as the intercostal vessels and nerves (› Table 6.11). ered. In doing so the catheter is inserted in bottom edge of the
front convexity of the clavicle in the direction of the sternocla-
vicular joint. If the cannula is positioned too steeply, the Cavi-
tas pleuralis may be injured which can result in collapse of the
6.5.3 Pleural cavities lungs (pneumothorax) by an inflow of air into the Cavitas pleu-
ralis.
The pleural cavities (Cavitas pleuralis) are lined by the parietal
pleura (Pleura parietalis) that is divided according to its 3 areas:
• Pars costalis (inside on the ribs) The pleural cavities have 4 paired reserve spaces (Recessus pleura-
• Pars mediastinalis (on the mediastinum) les) into which the lungs expand during deep inspiration:
• Pars diaphragmatica (on the diaphragm) • Recessus costodiaphragmaticus: lateral, in the mid-axillary line
The enveloping folds push medially between the Pleura costalis up to 5 cm deep; it stretches in a caudal direction to the right be-
and Pleura mediastinalis on both sides so far between the medias- hind the right lobe of the liver and to the left behind the stomach
tinum and sternum that they touch. Only in 2 small areas do they and spleen and can also extend on both sides behind the upper
stay apart, so that the mediastinum directly comes into contact renal pole (› Fig. 6.48)
with the sternum (› Fig. 6.48): • Recessus costomediastinalis: bilateral, ventral between medias-
• Trigonum thymicum (cranial), contains the thymus tinum and chest wall; corresponds to the area of ‘relative cardiac
• Trigonum pericardiacum (caudal), in which the pericardium dullness’, because here the air-filled lung is located between peri-
lies adjacent to the sternum with varied levels of expansion and cardium and chest wall and thus does not reduce the percussion
corresponds to the field of ‘absolute cardiac dullness’ sound as much as in the area of ‘absolute cardiac dullness’
At the top the pleural cavities extend over the thoracic aperture (› Fig. 6.48)
with the pleural dome (Cupula pleurae) by up to 5 cm (!). • Recessus phrenicomediastinalis: caudal, between diaphragm
At the hilum of the lungs, the Pleura parietalis continues into the and mediastinum
visceral pleura (Pleura visceralis), which covers the external sur- • Recessus vertebromediastinalis: dorsal, adjacent to the verte-
face of the lungs. The enveloping fold may extend caudally to vary- bral column
ing degrees as the pulmonary ligament. While the Pleura visceralis is also supplied by the vessels and
nerves of the lungs and is not sensitive to pain, the 3 sections of the

Clavicula Vv. brachiocephalicae

V. thoracica interna

Apex pulmonis

Thymus (Trigonum thymicum)

Pleura parietalis,
Pars costalis Pulmo sinister,
Pulmo dexter, Lobus superior
Margo anterior Margo anterior

Lobus
(Trigonum
superior
pericardiacum)
Pulmo Lobus
dexter medius Incisura cardiaca
Lobus
Lingula pulmonis
inferior
Pleura parietalis, Pulmo sinister,
Pars diaphragmatica Lobus inferior
Recessus costo- Margo inferior
diaphragmaticus Fig. 6.48 Pleural cavities and
mediastinum of an adolescent.
Ventral view after removal of the
Recessus costomediastinalis Pericardium chest wall and fat tissue of the
mediastinum.

289
6 Chest viscera

Since only the parietal pleura is pain-sensitive, lung diseases

are only painful once the Pleura parietalis is affected. In the
case of irritation of the Pleura costalis, the pain is felt in the
respective ICS of the abdominal wall; in the case of involve-
ment of the diaphragmatic pleura, however, pain is felt via the
Thorax drainage according to MONALDI N. phrenicus in the area of the shoulder (referred pain). Lung
(2nd ICR in the MCL) cancer only becomes noticeable through pain when the dis-
ease is advanced and has invaded the costal pleura; before
the symptoms are unspecific.

6.5.4 Breathing

The human body meets its energy needs predominantly through

oxidative breakdown of nutrients. All cells therefore require suffi-
cient oxygen and emit carbon dioxide as a waste product. These
gases are conveyed by the blood in the pulmonary circulation to
the lungs, where they are exhaled to the outside air. The lungs
Thorax drainage according to BÜLAU thereby passively follow the volume changes of the pleural cavities
(5th ICR in the middle axillary line)
in the chest cavity.
Fig. 6.49 Chest drainage according to MONALDI in the 2nd ICS in the During inspiration the volume of the pleural cavity can be in-
midclavicular line (MCL) or according to BÜLAU in the 5th ICS in the creased by 2 mechanisms (› Fig. 6.50):
middle axillary line. The trapped air or liquid is removed from the • In diaphragmatic breathing (‘abdominal breathing’) the pleu­ral
pleural cavity using the drainage system. [L126] cavity is enlarged in a caudal direction by contraction of the dia-
phragm (the most important respiratory muscle), on which the
Pleura parietalis are supplied by the surrounding vessels and diaphragmatic part of the pleura rests.
nerves. It therefore also has somatic innervation and is sensitive to • In rib cage breathing (‘chest breathing’) the pleural cavity is
pain: ­enlarged in a ventral, dorsal and lateral direction by lifting of the
• Pars costalis: ribs via the Mm. intercostales externi and Mm. scaleni ventrally,
– Aa./Vv. intercostales posteriores (back)/Rr. intercostales ante- dorsal and laterally.
riores (front) Inhalation requires the use of the muscles of the thorax and there-
– Nodi lymphoidei intercostales (back) and parasternales fore active. Accessory respiratory muscles support inspiration
(front) during forced breathing (› Table 6.12).
– Nn. intercostales Expiration on the other hand, is mostly passive, as the diaphragm
• Pars mediastinalis and diaphragmatica: relaxes and the cartilaginous parts of the ribs that were deformed
– A./V. pericardiacophrenica, A./V. musculophrenica, A./V. during inspiration, the ligaments of the rib cage and the elastic tis-
phrenica superior sue of the lung tissue return to their original position. In addition,
– Nodi lymphoidei mediastinales and Nodi lymphoidei phrenici exhalation is supported by various muscles, that all lead to sinking
superiores of the ribs (› Fig. 6.50, › Table 6.12).
– N. phrenicus The antagonistic function of the Mm. intercostales externi and the
lateral portions of the Mm. intercostales interni, can be explained
by the torque the muscles create on the ribs. Since the Mm. inter-
Clinical remarks costales externi run from an upper lateral position to a lower medi-
Increased fluid in the pleural cavity (pleural effusion) may oc- al position, the virtual lever of caudal muscles to the axis of rota-
cur during pneumonia (pleuritis), by tailback due to heart fail-
ure or tumours of the lungs or the pleura. In addition, there is
chylous pleural effusion, in which lymph bursts out of the Duc-
tus thoracicus into the pleural cavity. Pleural effusions cause a
dull knocking sound. They are punctured in the Recessus
costodiaphragmaticus to clarify the cause and to improve res-
piration.
Ribs during
For thorax drainage the pleural cavity is punctured, either to expiration
allow the lungs to expand by removing the air that has en-
tered, as in the case of a pneumothorax or to remove blood in Ribs during
Inspiration
the case of haemothorax (› Fig. 6.49). The access routes cho-
sen in emergency medicine are:
• for MONALDI drainage the 2nd ICS in the midclavicular line
Diaphragm
or in the case
• for the BÜLAU drainage the 5th ICS in the middle axillary of expiration
line. Diaphragm
For the BÜLAU drainage puncture of the liver on the right side in the case
of inspiration
must be avoided, as it can extend underneath the diaphrag-
matic dome to the 4th ICS. Fig. 6.50 Ribs and diaphragm during inspiration (red) and expiration
(blue). [L126]

290
 6.5 Thoracic cavity

Table 6.12 Muscles for breathing and accessory breathing muscles. with life. Since the Nn. phrenici issue from the Plexus cervica-
lis are predominantly supplied by the C4 spinal cord segment,
Inspiration Expiration injuries of these segments in paraplegia can lead to suffoca-
Effective during inspiration: Rffective during expiration: tion. Lesions caudal to C4 that still can lead to a complete pa-
• The diaphragm (most important respira- • Mm. intercostales interni and ralysis of the extremities, do not endanger breathing.
tory muscle!) intimi
• Mm. intercostales externi • Mm. subcostales
• Parasternal portions of the Mm. intercos- • M. transversus thoracis
tales interni (‘Mm. intercartilaginei’) Expiratory accessory respiratory
• Mm. scaleni muscles: 6.5.5 Development of the visceral cavities
Inspiratory accessory respiratory muscles: • M. transversus abdominis
• M. sternocleidomastoideus (when head • Mm. obliqui externus and inter- The chest cavity (Cavitas thoracis), together with the abdominal
is fixed by neck musculature) nus abdominis
cavity (Cavitas abdominalis, › Chap. 7.7.1) and the pelvic cavity
• Mm. serrati posteriores superior and • Mm. latissimus dorsi (‘cough
inferior (by fixing the ribs) muscle’) (Cavitas pelvis, › Chap. 8.7.1) form the 3 large visceral cavities of
• M. pectoralis major (with supported arm) • M. iliocostalis (lateral tract of the trunk. In these visceral cavities 3 abdominal cavities develop,
• M. pectoralis minor (with supported arm) autochthonous back muscles) lined with a serous membrane (Tunica serosa):
• M. serratus anterior (with supported arm) • In the thoracic cavity the pericardial cavity (Cavitas pericardi-
aca) and pleural cavity (Cavitates pleurales), develop
tion is enlarged by the neck of the ribs, as well as the torsional • In the abdominal and pelvic cavities, the peritoneal cavity
movement, so that the muscles lift the caudal ribs in particular. The (Cavitas peritonealis) develops.
Mm. intercostales interni (and intimi), on the other hand, have an The serous skin derives from the mesoderm whereas the parietal
opposite trend and therefore more strongly depress the cranial ribs. sheet (parietal sheet of the Pericardium serosum, Pleura parietalis,
Peritoneum parietale) is derived from the abdominal wall (so-
called somatopleural mesenchyme) and covers it. The visceral
Clinical remarks sheet (epicardium, Pleura visceralis, Peritoneum viscerale), on the
Since the diaphragm is the most important respiratory mus- other hand, is derived from the mesoderm of the gut wall (so-
cle, bilateral diaphragmatic insufficiency, e.g. due to traumat- called splanchopleural mesenchyme) and covers the surface of the
ic or surgical wounding of the Nn. phrenici is not compatible organs.

Heart bulge
Amnion Amnion Midgut
Amnion
Aorta
ld
Head fo

Ta
il fold

Heart Late
Intraembryonic
ral fold
Coelom

Pericardial cavity Body stalk

Section plane of c Yolk
sac
Yolk
sac
a b Extra-embryonic coelom c

Section plane Vitelline duct/

of f Ductus omphaloentericus Midgut Neural tube
Peritoneal
Hindgut cavity
Foregut
Dorsal
Mesenterium

Septum Parietal
transversum peritoneum Anterior
body
Umbilical cord Visceral wall
peritoneum

d e f Septum
transversum

Fig. 6.51 Embryonic cleavage in the 4th week of development. a Side view of an embryo in the 4th week (26th day). b Sagittal section of the
embryo at the same time. c Transverse section through the section plane specified in a. d Side view of the embryo at the end of the 4th week
(28th day). e Sagittal section of the embryo at the same time. f Transverse section through the section plane specified in d. [E347-09]

291
6 Chest viscera

The abdominal cavity (Coelom) is formed by the merging of the coperitoneales) a continuous intra-embryonic abdominal cavity is
gaps in the mesoderm. The coelom consists of an extra-embryonic first formed (› Fig. 6.52), which is separated later into sections.
portion (extra-embryonic coelom, chorionic cavity), that devel- In the 4th developmental week embryonic folding begins in both a
ops between the intermediate trophoblast and yolk sac, and an in- craniocaudal as well as lateral direction (› Fig. 6.51c, e), so that the
tra-embryonic coelom in the mesoderm between the endoderm navel is formed and the widely spaced connection between the in-
and ectoderm of the germ disc. While these two sections first com- tra-embryonic intestinal system and the extra-embryonic yolk sac
municate with each other, the extra-embryonic coelom later de- to the vitelline duct (Ductus omphaloentericus/Ductus vitellinus) is
generates, while the intra-embryonic coelom is divided into peri- narrowed (› Fig. 6.51e). As a result, the intestinal attachment is di-
cardial, pleural and peritoneal cavities. vided into 3 sections that are cranial, caudal and at the level of the
Initially at the end of the 3rd developmental week the horse- Ductus omphaloentericus, representing the foregut, hindgut and
shoe-shaped pleuropericardial cavity, is formed, the cranial por- midgut. The lateral folding results in an enlargement of the perito-
tion of which later becomes the pericardial cavity in the region of neal cavity on both sides of the intestinal tube, so that it is connect-
the heart, whereby the two caudal legs are the attachments for the ed to the dorsal wall of the trunk only by a small line of connective
pleural cavities (› Fig. 6.51). Caudal the division of the coelom, tissue (dorsal mesentery) (› Fig. 6.51f › Fig. 6.52d). The mesen-
starts to form which communicates laterally with the extra-embry- terium is therefore covered by peritoneum on both sides (peritone-
onic coelom, creating the attachment for the peritoneal cavity. The al duplication), which as the Peritoneum viscerale covers the sur-
pleuropericardial cavity is now connected to the division in the face of the intestinal system and in the form of the Peritoneum pa-
coelom, so that through these coelom ducts (Ductus pericardia- rietale lines the peritoneal cavity (› Fig. 6.52e).

Neural tube
Chorda dorsalis,
Aorta dorsalis
Ductus pericardioperitonealis Oesophagus section of the
oesophageal-tracheal
Tracheal section of the oesophageal- tube
tracheal tube
Dorsal mesocard
Heart
b
Pericardial cavity

Foregut artery (branch of

the Truncus coeliacus)
Section plane
of b Stomach

Ventral
Liver Mesenterium

Peritoneal cavity
Structure of the
diaphragm c Anterior abdominal wall
Prosence-
phalon
Heart Section plane
of c

Liver
Dorsal
Peritoneal cavity
Mesenterium
Dorsal mesentery

Allantois Midgut artery

Midgut
(A. mesenterica superior)
Section plane of d
Yolk sac
d
Section plane of e
Metanephros
a
(kidney)
Neural tube

Aorta dorsalis
Peritoneal cavity
Visceral
Dorsal mesentery
peritoneum
Hindgut
Parietal
peritoneum
e

Fig. 6.52 Body cavities and mesentery in the 5th week of development. a Overview. b–e Planes as indicated in a. [E347-09]

292
 6.5 Thoracic cavity

A ventral mesentery only forms in the area above the navel, i.e. at By division into the pleural and peritoneal cavities the diaphragm
the foregut, because the developing liver here has a connection to is also formed, the Centrum tendineum of which is derived from
the ventral trunk wall by being embedded in the Septum transver- the Septum transversum (› Fig. 6.51e). Since this occurs first at the
sum (› Fig. 6.52c). The Septum transversum is a mesenchymal height of the cervical somites and is only displaced to the height of
plate between pericardial cavity and Ductus omphaloentericus and the thoracic somites (descensus) due to the fast growth of the back
therefore the initial separation between pericardial and peritoneal of the embryo, it becomes obvious why the muscle precursor cells
cavities (› Fig. 6.51e, f). The peritoneal cavity communicates with entering the Septum transversum are innervated by the cranial spi-
the extra-embryonic coelom in the umbilicus even up to the 10th nal cord segments, the nerve fibres of which later form the N. phre-
week, until this degenerates during regression of the gut. nicus (plexus cervicalis, C3–5). The largest parts of the diaphragm
The cranial parts of the coelomic ducts extend to the pleural cavity that surround the central tendon (Partes sternalis, costalis and
and extend ventrally on both sides of the pericardial cavity, from lumbalis) are largely derived from the adjacent parts of the body
which they are separated in the 7th week by the pleuropericardial wall. Only the diaphragmatic leg of the Pars lumbalis are a relic
membranes (› Fig. 6.53b). The pericardial cavity is incorporated of the dorsal mesentery of the oesophagus. The pleuroperitoneal
in the mesenchyme in the vicinity of the foregut, which later be- membranes degenerate to a large extent and only form a small area
comes the mediastinum (› Fig. 6.53c, d). The folds in the serosa at of the diaphragm near the Trigonum lumbocostale (BOCH-
the caudal aspect of the pleura separate these at the end of the 2nd DALEK's triangle).
month as pleuroperitoneal membranes from the pericadial cavity,
by combining ventrally with the Septum transversum and dorsally NOTE
with the mesentery of the oesophagus. This happens earlier on the The diaphragm is made up of 4 parts:
right than on the left, perhaps because the liver has already been • Centrum tendineum: from the Septum transversum
formed here. • Partes sternalis, costalis and lumbalis (largest part): from the
­adjacent abdominal wall
• Diaphragmatic leg: from the dorsal mesentery of the oesophagus
NOTE • Small section at the Trigonum lumbocostale: from the pleuroperi-
The coelom arises from gaps in the mesoderm and is later divided toneal membranes
into the pericardial, pleural and peritoneal cavities. These are lined The muscle cells and their innervation (N. phrenicus) originate
by serous skins, also originating from the mesoderm. from the cervical somites.

Chorda dorsalis

Aorta
Bronchial bud

Pleural cavity Lung

Ductus pericardio-
peritonealis
Side
Left V. cardinalis communis thoracic wall
N. phrenicus

Pleuropericardial
Heart Plica pleuropericardiaca membrane

a Pericardial cavity b

Aorta

Aorta
Meso-oesophagus
Pleural cavity
Thoracic wall
Oesophagus in the
embryonic mediastinum
V. cava
inferior

N. phrenicus Pericardium

c d Pericardial cavity
Pericardial cavity

Fig. 6.53 Division of the body cavity between 5th and 8th developmental week. a At the end of the 5th week, the arrows show the connec-
tions between pleural and pericardial cavities. b 6th week: formation of pleuropericardial membrane. c 7th week: expansion of the pleural cav-
ity ventrally. d 8th week. [E347-09]

293
6 Chest viscera

Clinical remarks 6.6.2 Arteries of the thoracic cavity

The complicated development of the diaphragm explains why
In the superior mediastinum the ascending aorta (Aorta ascen-
congenital malformations can occur. The most common is the
posterolateral diaphragmatic hernia, in which closure of the dens) flows into the aortic arch (Arcus aortae) and then continues
pleuroperitoneal membrane is usually missing. This defect is as the descending leg (Aorta descendens) of the thoracic aorta
also known as congenital BOCHDALEK's hernia, although there (Aorta thoracica) (› Fig. 6.54).
is no hernial sac. Due to the relocation of the stomach, spleen The coronary arteries (A. coronaria dextra and sinistra) issue
and small intestine sections in the thoracic cavity, a frequent from the Aorta ascendens still in the pericardium.
result is underdevelopment of the lungs (pulmonary hypoplasia) The aortic arch traverses the Bifurcatio tracheae and arrives at the
leading to shortness of breath, blue discolouration of the skin
left side of the trachea, oesophagus and spine. It issues the follow-
(cyanosis) and increase in heart rate (tachycardia) after birth.
ing branches (› Fig. 6.55, › Fig. 6.56):
• Truncus brachiocephalicus, which branches into the A. subcla-
via dextra and the A. carotis communis
• A. carotis communis sinistra
6.6 Vessels and nerves of the thoracic cavity • A. subclavia sinistra
• (A. thyroidea ima): an unpaired lowest thyroid artery is present
in up to 10% of all cases, but typically branches off from the
Skills
After working through this chapter, you should be able to:
• understand the basic structure of the vessels and nerves of
the thoracic cavity, so that you can see the origin of the ves-
sels and nerves in the individual organs A. carotis
• show the sections of the aorta in the chest with its branches – interna
in a specimen – externa
– communis
• name the V. cava superior with tributaries, the azygos vein
system and cavocaval anastomoses and understand their
clinical relevance A. subclavia
• explain lymph node groups and systematics of lymphatic
Truncus brachio-
trunks in the thoracic cavity and describe the course of the cephalicus
Ductus thoracicus in detail on a specimen
• show the trajectory and supply area of the N. phrenicus Arcus
• explain the organisation of the autonomic nervous system aortae
Aa. intercostales
in the thoracic cavity as well as demonstrate the construc- Pars ascendens posteriores
tion of the sympathetic trunk and trajectory and branches of aortae [Aorta
ascendens]
the Nn. vagi on a specimen
Rr. oeso-
Pars thoracica
phageales
aortae [Aorta
thoracica]

6.6.1 Overview Pars abdominalis

aortae [Aorta
A. phrenica
abdominalis]
inferior
The major arterial, venous and lymphatic vascular trunks of the
body are positioned in the upper and rear lower mediastinum of Truncus
coeliacus
the thoracic cavity. In a cranial direction the vessels and nerves
A. mesenterica
protrude through the upper thoracic aperture into the connective superior
tissue area of the neck. In a caudal direction they protrude through
A. renalis
the diaphragm and continue into the retroperitoneal space of the
A. testicularis
abdominal cavity (› Chap. 8.7). (ovarica)
The aorta is divided into Aorta ascendens, aortic arch (Arcus aor-
A. iliaca A. mesenterica
tae) and the thoracic section of the Aorta descendens (Pars thorac- – communis inferior
ica aortae), which each issue various branches. – interna
Aa. lumbales
The superior vena cava (V. cava superior) transports the blood of – externa

the upper half of the body to the heart. It receives the veins of the
azygos vein system, the inflows of which correspond to the supply
area of the aorta.
The main lymphatic trunk of the body, the thoracic duct (Ductus
thoracicus), ascends in front of the spine, crosses the left pleural
dome and exits in the left venous angle. In addition, the mediasti-
num contains a variety of lymph nodes.
As parts of the somatic nervous system the intercostal nerves,
A. sacralis
which innervate the abdominal wall (› Chap. 3.2.3), and the mediana
N. phrenicus are in the mediastinum. The autonomic nervous sys-
tem consists of the thoracic section of the sympathetic trunk
(Truncus sympathicus) and the N. vagus.
Fig. 6.54 Sections of the aorta with outlets of the great arteries from
the aortic arch. [S010-2-16]

294
 6.6 Vessels and nerves of the thoracic cavity

A. carotis externa A. carotis externa Table 6.13 Branches of the Pars thoracica aortae.
dextra sinistra
Parietal branches to the thoracic Visceral branches to the thoracic
A. carotis interna A. carotis interna
sinistra
wall viscera
dextra
A. vertebralis dextra A. vertebralis • Aa. intercostales posteriores: 9 pairs • Rr. bronchiales: Vasa privata of the
sinistra (the first two are branches of the lungs (on the right side mostly from
A. subclavia A. subclavia Truncus costocervicales from the A. the A. intercostalis posterior dextra
dextra sinistra subclavia) III)
A. carotis A. subclavia • A. subcostalis: the last pair under • Rr. oesophageales: 3–6 branches to
communis dextra sinistra the 12th rib the oesophagus
Truncus brachio- A. carotis communis • A. phrenica superior: to the upper • Rr. mediastinales: small branches to
cephalicus sinistra
side of the diaphragm the mediastinum and pericardium
Pars ascendens aortae Arcus aortae

Pars descendens aortae, 6.6.3 Veins of the thoracic cavity

Pars thoracica aortae

Fig. 6.55 Aortic arch with branches.

The superior vena cava (V. cava superior) is 5–6 cm long and
forms to the right of the spine behind the 1st sternocostal joint
through unification of the V. brachiocephalica dextra and sinistra
Truncus brachiocephalicus or an A. carotis communis and (› Fig. 6.57). On entering the pericardium on the right side the
therefore not directly from the aorta. azygos vein flows into it at the height of the 4th–5th thoracic verte-
bra. The V. cava superior and Vv. brachiocephalicae have no valves.
The Vv. brachiocephalicae originate in the V. jugularis interna and
Clinical remarks the V. subclavia in the venous angle, which is placed directly be-
In rare cases (< 1%), the A. subclavia dextra can issue from the hind the sternoclavicular joint and have very different trajectories
aortic arch as the last independent branch and then extend on either side (› Fig. 6.57). On the right the vein is short and
behind the oesophagus to the right arm. As the oesophagus is merges almost vertically into the superior vena cava. Clinicians
constricted in this case between the A. subclavia dextra (also also refer to this as ‘V. anonyma’ and use it for the introduction of a
known as A. lusoria) and the aortic arch, swallowing disorders
central venous catheter (CVC). On the left, on the other hand, the
may occur (Dysphagia lusoria).
vein traverses the branches of the aortic arch and trachea practical-
ly horizontally and includes 2 unpaired vessels:
• V. thyroidea inferior
The Aorta descendens lies left ventral of the spine in the posterior • V. hemiazygos accessoria
mediastinum (Aorta thoracica) and issues various parietal Bilaterally the following are conjoined:
branches to the abdominal wall and the diaphragm as well as vis- • V. vertebralis
ceral branches for the lungs, oesophagus and mediastinum (› Ta- • V. thoracica interna
ble 6.13, › Fig. 6.54). • V. intercostalis suprema

A. submentalis

A. facialis
A. lingualis
A. occipitalis
A. carotis externa
A. carotis externa
A. thyroidea superior A. carotis interna
A. carotis communis A. carotis communis
A. cervicalis ascendens A. thyroidea inferior

Plexus brachialis A. vertebralis

Truncus thyrocervicalis
A. transversa colli,
R. superficialis A. thoracica interna

A. suprascapularis
A. subclavia
Truncus brachio-
cephalicus

Fig. 6.56 Aorta with branches.

[S010-2-16]

295
6 Chest viscera

Vv. brachiocephalicae V. jugularis interna

dextra and sinistra
V. jugularis externa

V. subclavia

V. cava superior
V. thoracica interna

V. azygos

V. hemiazygos
accessoria
V. intercostalis

V. hemiazygos
V. azygos

V. lumbalis
ascendens Vv. lumbales

V. cava V. lumbalis
inferior ascendens

V. iliaca V. iliaca
communis communis
(Variety)

V. iliaca
interna V. sacralis
mediana

V. iliaca
externa Plexus sacralis

Fig. 6.57 Vv. cavae superior and

inferior with tributaries and
azygos system. [S010-2-16]

The azygos venous system is located on both sides of the spine and that indirectly connects the upper and lower vena cava (Cavocaval
its tributaries are equivalent to the branches of the thoracic aorta. anastomoses) and makes it possible to divert the blood if one or
The V. azygos ascends on the right side of the spine, crosses the both of the vessels are occluded or compressed. The 4 most import-
main bronchi and pulmonary vessels and exits at the level of the ant cavocaval anastomoses are:
IVth/Vth thoracic vertebra dorsally into the V. cava superior. On the • V. epigastrica superior with V. epigastrica inferior (at the ven-
left it corresponds to the hemi-azygos vein, which, for its part, ex- tral wall posterior to the M. rectus abdominis)
its between the Xth and VIIth thoracic vertebrae into the V. azygos. • V. epigastrica superficialis with V. thoracoepigastrica (at the
From the upper intercostal veins, the blood is received by a V. ventral trunk wall in the subcutaneous fat)
hemiazygos accessoria, which in addition to the V. hemiazygos • Vv. lumbales with V. azygos/hemiazygos (on the inside of the
has a cranial connection to the V. brachiocephalica sinistra. Since posterior abdominal wall in the retroperitoneum and the rear
the V. azygos is the strongest vessel and in the lower half of the pos- mediastinum)
terior mediastinum often runs ventral to or even to the left of the • Plexus venosus vertebralis with azygos vein and V. iliaca inter-
spine, the venous system is usually not symmetrical. The azygos na (outside of the vertebrae and in the vertebral canal with an
veins have the following inflows: expansion from the pelvis to the skull)
• Visceral inflows: Vv. mediastinales: of the organs of the medias-
tinum (Vv. oesophageales, Vv. bronchiales, Vv. pericardiacae)
• Parietal inflows: 6.6.4 Lymph vessels of the thoracic cavity
– Vv. intercostales posteriores and V. subcostalis: from the pos-
terior abdominal wall The different groups of lymph nodes in the mediastinum are cate-
– Vv. phrenicae superiores: from the diaphragm gorised into parietal lymph nodes (drainage of the thoracic walls)
Below the diaphragm a V. lumbalis ascendens continues the course and visceral lymph nodes (drainage of the chest viscera) (› Fig.
of the azygos veins left and right and connects into the V. cava infe- 6.58). From these lymph node groups the lymph flows into the ma-
rior. The azygos system therefore forms part of the bypass circuit jor lymphatic trunks.

296
 6.6 Vessels and nerves of the thoracic cavity

Nodi lymphoidei supraclaviculares

Nodi lymphoidei paratracheales

(Nodi lymphoidei mediastinales

anteriores)

Nodi lymphoidei Nodi lymphoidei

intercostales tracheobronchiales

Nodi lymphoidei
Ductus thoracicus parasternales

Nodi lymphoidei
Nodi lymphoidei
pericardiaci
juxtaoesophageales

Nodus lymphoideus Fig. 6.58 Lymph vessels and

phrenicus superior
lymph nodes of the mediasti-
num. View from the right ventro-
Nodus lymphoideus Nodus lymphoideus lateral side after removal of the
phrenicus inferior lumbalis lateral chest wall. (according to
[S010-2-16])

Parietal lymph nodes are: tinum, and also the Truncus subclavius sinister (from the arm) and
• Nodi lymphoidei parasternales: They lie adjacent to the sternum the Truncus jugularis sinister (from the neck).
on both sides and receive lymph from the anterior thoracic wall, On the right side, a short (1 cm) Ductus lymphaticus dexter con-
the mammary glands, and the diaphragm. From them, the lymph nects the respective lymphatic trunks and enters the right venous
passes into the Truncus subclavius. angle. The lymphatic trunks can also enter the venous angle sepa-
• Nodi lymphoidei intercostales: They lie between the ribs and rately on both sides. At the mouth of the lymphatic trunks are flaps
filter lymph from the posterior chest wall. The efferent lymph that reduce reflux of blood; however, after death the blood that has
vessels drain directly into the Ductus thoracicus. been introduced may result in them being confused with veins.
Visceral lymph nodes with connection to the Trunci broncho-
mediastinales are:
• Nodi lymphoidei mediastinales anteriores: They are located on
Clinical remarks
both sides of the great vessels, receive inflows from lungs and Injuries of the Ductus thoracicus can be caused by malignant
pleura, diaphragm (Nodi lymphoidei phrenici superiores), the tumours in the mediastinum, such as malignant lymphomas
heart and the pericardium (Nodi lymphoidei pericardiaci) and (cancer of the lymph nodes) or during surgery of the oesopha-
thymus. gus. This may result in an extension of the mediastinum or the
formation of fatty pleural effusion (chylothorax) as well as a
• Nodi lymphoidei mediastinales posteriores: They lie on the
nutrient deficiency, because most lipids from food are trans-
bronchi and trachea (Nodi lymphoidei tracheobronchiales and ported via the lymph. Conservative therapy therefore aims to
paratracheales) and oesophagus (Nodi lymphoidei juxta-oeso­ reduce the lymph flow through a low fat diet, and enable
phageales). spontaneous closure. If this therapy is unsuccessful, the Duc-
The Trunci bronchiomediastinales also receive inflow from lymph tus thoracicus can be disabled by surgery or, recently, embol-
vessels of the other half of the body. The lymph vessels of the indi- ysed by radiological intervention after puncture.
vidual organs and their regional lymph nodes are dealt with in the The systematics of the major lymphatic trunks also explain
why malignant tumours of abdominal organs (e.g. gastric can-
individual organs of the thoracic cavity.
cer) or pelvic viscera (e.g. ovarian cancer) can lead to lymph
The Ductus thoracicus (thoracic duct) is the main lymphatic node metastasis in the area of the left venous angle. These
trunk of the body. It has a total length of 38–45 cm and is 5 mm lymph node swellings in the left supraclavicular fossa are
thick up to its usually enlarged outlet. It is formed underneath the named after their initial descriptors VIRCHOW's node and
diaphragm through the merging of the two lumbar trunks with the means the doctor always has to check for tumours in the ab-
intestinal trunks and therefore carries the lymph of all of the lower dominal and pelvic cavities.
body from there (› Chap. 8.8.4). At the level of the XIIth thoracic
vertebra, the Ductus thoracicus protrudes dorsal and to the right
of the aorta through the Hiatus aorticus of the diaphragm and as-
cends in the posterior mediastinum between aorta (left), V. azygos 6.6.5 Nerves of the thoracic cavity
(right) and oesophagus (front) on the spine to the VIIth cervical ver-
tebra. It crosses the pleural dome behind the left A. subclavia and The thoracic cavity is innervated by parts of the somatic and auto-
issues dorsally into the left venous angle (between V. subclavia and nomic nervous systems.
V. jugularis interna). As it does so, it crosses over the first outflows
of the V. subclavia, as well as the sympathetic trunk and the N. phrenicus
N. phrenicus, but remains dorsal to the N. vagus and V. jugularis The N. phrenicus (C3–5) is a nerve of the Plexus cervicalis, which
interna. Shortly before draining, it receives the Truncus broncho- due to the developmental connection of the diaphragm in the cer-
mediastinalis sinister, which courses independently in the medias- vical area was transferred with the diaphragm into the thoracic

297
6 Chest viscera

cavity. It innervates the diaphragm in terms of motor function and In the sympathetic trunk neurons can also rise or descend several
throughout its trajectory the pericardium, Pleura (costalis and di- segments. The nerve fibres of T2–7, for example rise to the stellate
aphragmatica) in terms of sensitive function and with its terminal ganglion and extend sudomotor neurons to the sweat glands of the
branches (Rr. phrenicoabdominales) the peritoneum on the un- head, neck and arm.
derside of the diaphragm as well as on the liver and gallbladder. Some preganglionic neurons are not switched in the sympathetic
The N. phrenicus first descends on the neck on the M. scalenus an- trunk, but instead run with the Nn. splanchnici through the dia-
terior and then runs behind the venous angle over the pleural phragm to the ganglia in the nerve plexuses on the Aorta abdomi-
dome into the upper mediastinum. It extends right onto the V. bra- nalis (prevertebral) where the switch happens. These neurons are
chiocephalica dextra and to the left over the aortic arch to the peri- used for the innervation of the abdominal organs. The N. splanch-
cardium in the lower middle mediastinum, where, accompanied by nicus major is formed from the preganglionic neurons of the spi-
the A./V. pericardiacophrenica, it extends to the diaphragm. Its ter- nal cord segments T5–9, the N. splanchnicus minor from T10–11.
minal branches extend through the foramen V. cava on the right, Sometimes a N. splanchnicus imus (T12) is present.
and left on their own through an opening at the apex of the heart. The N. vagus runs right across the A. subclavia and left between A.
subclavia and the A. carotis communis behind the V. brachioce-
Autonomic nervous system phalica in the upper mediastinum. On the left, it crosses the aortic
The autonomic nervous system of the thoracic cavity is formed arch. It issues an N. laryngeus recurrens, which winds right around
from the sympathetic trunk (of the sympathetic nervous system the A. subclavia and left around the aortic arch and then rises be-
[Truncus sympathicus]) and from the N. vagus (of the parasympa- tween the oesophagus and trachea.
thetic nervous system) (for the organisation of the autonomic The preganglionic parasympathetic neurons approach the heart
nerve plexuses of the abdominal organs › Chap. 7.8.5). and lungs (Rr. cardiaci thoracici and Rr. bronchiales) as well as the
The sympathetic trunk in the posterior mediastinum is made up oesophagus behind the root of the lungs via the vagus nerves and
of 12 thoracic ganglia, which are located in the respective ICS on form the Plexus oesophageus. 2 trunks form from this (Trunci va-
both sides of the spinal cord (paravertebral) and are connected to gales anterior and posterior), which traverse the diaphragm with
each other by Rr. interganglionares (› Fig. 7.52). It continues on the oesophagus to the autonomic nerve plexuses of the abdominal
directly behind the pleural dome through the upper aperture of the aorta. Here, however, there is no interconnection, as the postgan-
thorax into the connective tissue area of the neck and through the glionic neurons are usually found in the vicinity of the respective
diaphragm into the retroperitoneal space. The first ganglion is usu- organs.
ally fused with the lower cervical ganglion forming the Ganglion
cervicothoracicum (stellatum), through which the nerve fibres of
the C8–T3 segments reach the head via the cervical sympathetic
Clinical remarks
trunk and the arm via the Plexus brachialis. The preganglionic The trajectory of the sympathetic neurons can be clinically rel-
neurons of the sympathetic nervous system are located in the later- evant:
al horns (C8 – L3) of the spinal cord and exit the spinal canal with • Sympathetic nerve fibres for the head run from the spinal
the spinal nerves and reach the ganglia of the Truncus sympathi- cord segments C8–T3 via the stellate ganglion, which is lo-
cated directly behind the pleural dome, to the neck. Lung
cus via their Rr. communicantes albi. This is the location of the
cancer from the upper sections of the lungs (so-called PAN-
perikarya of the postganglionic neurons, with which they are con- COAST tumours) can damage these nerve fibres and lead to
nected via synapses. Their axons return to the spinal nerves and HORNER's syndrome, which with symptoms of the eyes,
their branches via the Rr. communicantes grisei and therefore such as pupil constriction (myosis), drooping eyelids (pto-
reach the abdominal walls in the thoracic region or run from the sis) and backward placement of the eyeball (enophthal-
2nd-5th thoracic ganglion to the heart and lungs (Rr. cardiaci tho- mus), damage to the cervical sympathetic nervous system
racici/Rr. pulmonales thoracici), to innervate them sympathetical- must always be considered.
• In the case of a tendency to increased sweating in the face
ly. On the abdominal wall and arm (via the Ganglion stellatum) the
and hands, there is the possibility of severing the sympa-
sympathetic nervous system causes narrowing of the blood vessels thetic trunk below the 1st ICS (endoscopic thoracic sympa-
(vasoconstriction/vasomotor), activates the sweat glands (sudomo- thectomy).
tor activation) and induces ‘goose bumps’ (pilomotor reflex) by
making hair stand on end.

298
7 Abdominal viscera
Jens Waschke

7.1 Stomach . . . . . . . . . . . . . . . . . 302 7.3.3 Development of

7.1.1 Overview . . . . . . . . . . . . . . . . . 302 the liver and gall bladder . . . . 323
7.1.2 Functions of the stomach . . . 302 7.3.4 Projection of the liver . . . . . . . 323
7.1.3 Development of stomach, 7.3.5 Structure . . . . . . . . . . . . . . . . . 324
Bursa omentalis, Omentum 7.3.6 Parts and segments
minus and Omentum majus . 303 of the liver . . . . . . . . . . . . . . . . 325
7.1.4 Projection of the stomach . . . 305 7.3.7 Fine structure of the liver . . . . 326
7.1.5 Structure and sections 7.3.8 Topography . . . . . . . . . . . . . . . 327
of the stomach . . . . . . . . . . . . 305 7.3.9 Arteries of the liver . . . . . . . . . 327
7.1.6 Surface enlargement 7.3.10 Veins of the liver . . . . . . . . . . . 328
of the stomach lining . . . . . . . 306
7.3.11 Portocaval anastomoses . . . . 328
7.1.7 Topography . . . . . . . . . . . . . . . 306
7.3.12 Lymph vessels of the liver . . . 329
7.1.8 Arteries of the stomach . . . . . 307
7.3.13 Innervation of the liver . . . . . . 330
7.1.9 Veins of the stomach . . . . . . . 307
7.1.10 Lymph vessels 7.4 Gall bladder and bile ducts . . 331
of the stomach . . . . . . . . . . . . 308 7.4.1 Overview and function . . . . . . 331
7.1.11 Innervation of the stomach . . 309 7.4.2 Projection and topography
of the gall bladder . . . . . . . . . 331
7.2 Intestines . . . . . . . . . . . . . . . . . 309
7.4.3 Construction of gall bladder
7.2.1 Overview . . . . . . . . . . . . . . . . . 310 and extrahepatic bile ducts . . 331
7.2.2 Functions of the intestine . . . 310 7.4.4 Pathways of the gall bladder
7.2.3 Development . . . . . . . . . . . . . . 310 and bile ducts . . . . . . . . . . . . . 332
7.2.4 Structure and projection 7.4.5 CALOT’s triangle . . . . . . . . . . . 333
of the small ­intestine . . . . . . . 312
7.2.5 Structure and projection 7.5 Pancreas . . . . . . . . . . . . . . . . . 333
of the large intestine . . . . . . . 313 7.5.1 Overview . . . . . . . . . . . . . . . . . 333
7.2.6 Structural features of the 7.5.2 Functions of the pancreas . . . 334
small and large ­intestines . . . 315 7.5.3 Development . . . . . . . . . . . . . . 334
7.2.7 Topography of small 7.5.4 Projection and structure
and large intestines . . . . . . . . 316 of the pancreas . . . . . . . . . . . . 334
7.2.8 Intestinal arteries . . . . . . . . . . 318 7.5.5 Excretory duct system
7.2.9 Veins of the intestine . . . . . . . 320 of the pancreas . . . . . . . . . . . . 335
7.2.10 Lymph vessels 7.5.6 Topography . . . . . . . . . . . . . . . 335
of the intestine . . . . . . . . . . . . 320 7.5.7 Vessels and nerves
7.2.11 Innervation of the intestine . . 320 of the pancreas . . . . . . . . . . . . 337

7.3 Liver . . . . . . . . . . . . . . . . . . . . . 322 7.6 Spleen . . . . . . . . . . . . . . . . . . . 338

7.3.1 Overview . . . . . . . . . . . . . . . . . 322 7.6.1 Overview . . . . . . . . . . . . . . . . . 338
7.3.2 Functions of the liver . . . . . . . 322 7.6.2 Functions of the spleen . . . . . 338
7.6.3 Development . . . . . . . . . . . . . . 338 7.8 Vessels and nerves
7.6.4 Projection, construction and of the peritoneal cavity . . . . . 343
topography of the spleen . . . . 339 7.8.1 Overview . . . . . . . . . . . . . . . . . 343
7.6.5 Vessels and nerves 7.8.2 Arteries of the
of the spleen . . . . . . . . . . . . . . 339 peritoneal cavity . . . . . . . . . . . 343
7.8.3 Veins of the
7.7 Peritoneal cavity . . . . . . . . . . . 340 peritoneal cavity . . . . . . . . . . . 345
7.7.1 Overview . . . . . . . . . . . . . . . . . 340 7.8.4 Lymph vessels
7.7.2 Omentum majus of the peritoneal cavity . . . . . 345
and Omentum minus . . . . . . . 341 7.8.5 Nerves of the
7.7.3 Recessus of the peritoneal cavity . . . . . . . . . . . 346
peritoneal cavity . . . . . . . . . . . 342
 CLINICAL CASE

Acute appendicitis
Case study What is the preliminary diagnosis?
A 24-year-old female student presents at the outpatient department The clinical evidence most likely suggests an acute inflammation of
of the surgical clinic. She reports that she has had severe stomach the appendix (appendicitis). Typical for this, in addition to the
pain for 2 days, first of all spread through the upper abdomen and spread of pain, is pain on application of pressure, especially above
since yesterday stronger pain in the right lower abdomen. Since McBURNEY's point and a little less pain over LANZ's point as well as
yesterday she has vomited twice due to nausea and was not able to the crossed BLUMBERG's release sign. Pain dependent on the
leave her bed because of the abdominal pain; there have, however, movement and position of the right leg indicates a positive psoas
been no instances of diarrhoea. It was noted that the pain subsided sign, by which irritation of the muscular fascia is painful when
if the right leg was bent slightly when lying down. She measured her straining and tensioning the M. iliopsoas. Differential diagnoses
temperature as being 38°C. include an acute gastrointestinal infection and for women, inflam-
Menstruation is regular and most recently ended 1 week ago. There mation of the ovaries or pregnancy where there has been an
is no history of pre-existing conditions and no previous surgery in incorrect implantation of the embryo (ectopic pregnancy). Also an
the abdominal cavity has taken place. inflammation of MECKEL's diverticulum and a kidney stone in the
ureter might be possible.

Examination results
Treatment
The patient has severe pain. Heart-rate (70/min), respiratory rate
­(20/min) and blood pressure (120/80 mmHg) are regular, rectal Removal of the appendix by means of a laparoscopy (laparoscopic
temperature 38°C, axillary temperature 37°C; weight approx. 56 kg appendectomy). Here, the appendix is very red and swollen in a
and 165 cm in height; bowel sounds in all 4 quadrants sparse. The retrocaecal position, which is sent to the pathology department to
pain in the right lower abdomen is greatest when pressure is confirm the diagnosis.
applied, but also occurs when the pressure is reduced again in the
left lower abdomen (cross release pain). Raising the right leg against
resistance also increases the pain. The rectal examination is normal. Subsequent progression
The patient shows rapid improvement in the evening after the
Diagnosis procedure and she is discharged the following day.

Except for leukocytosis (> 11,000 white blood cells/µl), all laboratory
results are normal. A medical sonography of the abdomen is not
clear due to excessive flatulence.
A pregnancy test is negative.

You're doing a rotational placement in the emergency admission. It is Friday afternoon and there is a
lot going on. Your senior consultant sends you to the examination room because he himself has other
patients he is looking at. You have already carried out a medical history and physical examination and
consider what you should report to the senior consultant later.

The most stressful day in the outpatient clinic ever… Mc Burney, Lanz,
Blumberg
Hx.: 24-year-old patient, student, for 2 days
severe abdominal pain, first diffuse, now right bowel,
also nausea and 2x vomiting, diarrhoea, Temp. 38 °C
less pain when lying down and with right leg bent
Menstr. regular, last 1 week ago, pre-existing conditions and procedures.
CE: strong pressure pain in the right bowel, cross release-
pain, pain when lifting the right leg against resistance.
Bowel sounds across all four quadrants sparse, rectal examination normal
Proc.: blood taken, pregnancy test negative.
→ abdominal scan
in particular acute appendicitis!!
7 Abdominal viscera

7.1 Stomach Table 7.1 Structure of the digestive system.

Section Components
Skills Digestive tract

After working through this chapter, you should be able to: Head bowel • Oral cavity (Cavitas oris) (› Chap. 9.7.1)
• show the positional relationships of the stomach to the rest • Throat (Pharynx) (› Chap. 10.7)
of the upper abdominal organs and describe its develop- Torso bowel • Gullet (Oesophagus) (› Chap. 6.3)
ment • Stomach (Gaster)
• explain the sections of the stomach and their closure mech- • Small intestine (Intestinum tenue) (› Chap. 7.2)
anisms with the oesophagus and small intestine • Large intestine (Intestinum crassum) (› Chap. 7.2)
• identify the arteries of the stomach with their origins and
Digestive glands
understand their development in the various peritoneal du-
plicatures. Salivary glands • Oral salivary glands (Glandulae salivariae majores)
• recognise the connections of the gastric veins to the portal (› Chap. 9.7.9)
vein system and the veins of the oesophagus and their im- • Pancreas (› Chap. 7.5)
portance Liver (Hepar) • › Chap. 7.3
• explain the clinical significance of the lymphatic pathways
of the stomach Bile ducts • Gall bladder (Vesica biliaris) (› Chap. 7.4)
• Bile ducts (Ductus hepaticus communis, Ductus cysti-
• outline the autonomic innervation of the stomach on a spec-
cus, Ductus choledochus) (› Chap. 7.4)
imen

beer’). Like the rest of the digestive system, the stomach is of great
importance for various medical fields, such as gastroenterologists
7.1.1 Overview and visceral surgeons, as well as general medical practitioners and
family physicians. While the construction and location are import-
The stomach (Gaster) together with the intestines (often referred to ant for radiologists and internists, particularly for the diagnosis of
as the gastrointestinal tract), the anterior sections of the oral cavity, various diseases, a visceral surgeon needs additional detailed
pharynx, and oesophagus as well as the digestive glands (salivary knowledge about the vessels and nerves and precise topographical
glands, pancreas, liver and bile ducts) forms the digestive system conditions.
(› Fig. 7.1, › Table 7.1). In the digestive tract, a distinction is
made between the head and torso bowels which differ in terms of
histological wall construction. 7.1.2 Functions of the stomach
As a hollow organ, the stomach serves to temporarily store food
and to initiate digestion. It is located intraperitoneally in the left The stomach has various functions that are largely fulfilled by the
epigastrium between the left lobe of the liver and spleen and takes cells of the gastric glands. Like most hollow organs, the stomach is
up differing amounts of space depending on the extent to which it not, however, absolutely essential and can therefore be removed in
is filled (‘between liver and spleen there should still be room for a whole or in part.

Oesophagus

Pulmo

Cor
Diaphragma
Hepar
Gaster
Spleen [Lien]
Pancreas
Ren
Duodenum
Jejunum
Colon
Ileum

Appendix
vermiformis

Rectum

Fig. 7.1 Projection of the stom-

ach and the rest of the internal
a b organs onto the body surface.
a Ventral view. b Dorsal view.

302
 7.1 Stomach

The functions of the stomach include: part of the yolk sac is included in the body and, together with the
• Intermediate storage and breaking down of food endoderm, forms the intestinal system. The link to the yolk sac
• Denaturation and digestion of proteins around the navel is thus narrowed to form the vitelline duct (Duc-
• Killing of micro-organisms tus omphaloentericus /Ductus vitellinus). As a result, the intestinal
• Formation of the ‘intrinsic factor’ for the absorption of vitamin system is divided into 3 sections (foregut, midgut and hindgut),
B12 each served by their own unpaired artery, departing from the ab-
• Secretion of messenger substances (e. g. histamine) and hor- dominal section of the aorta.
mones (e. g. gastrin) to regulate the formation of gastric acid. Since the stomach emerges from the foregut, it is supplied with
Once the food has passed through the oesophagus, it is stored in blood from the branches of the Truncus coeliacus (› Fig. 7.2).
the stomach and broken down through its peristaltic movements. During development only the epithelium of the stomach is derived
Through the hydrochloric acid formed in the glands in the stom- from the entoterm of the foregut, while connective tissue and
ach body, proteins are also denatured and the chyme is acidified so smooth muscles are formed from the surrounding mesoderm. In
that the enzyme precursors produced by the glands are activated to contrast to the lower sections of the intestine, the stomach and du-
form pepsin. Pepsin initiates the digestion of protein by splitting odenum, as derivatives of the foregut, are not only connected over
the proteins. Gastric acid also serves to kill most of the micro-­ a wide surface with the posterior wall of the peritoneal cavity
organisms ingested with the food. The glands of the stomach body through the dorsal mesentery (Mesogastrium dorsale), but also
therefore also form the ‘intrinsic factor’, a protein that binds in through the ventral mesentery (Mesogastrium ventrale) with the
the stomach with vitamin B12 and which is necessary for its reab- anterior abdominal wall. The ventral connection is as a result of the
sorption at a later stage in the small intestine (terminal Ileum). Septum transversum being sited here as an appendage to the dia-
phragm, in which the liver and gall bladder systems are embedded
(› Fig. 7.3a). Through the liver, the Mesogastrium ventrale is
7.1.3 Development of stomach, Bursa omentalis, ­divided into the Mesohepaticum ventrale (between the ventral wall
Omentum minus and Omentum majus and liver) and the Mesohepaticum dorsale (between the liver and
stomach). Through this suspension via mesenteries on the front
The stomach develops from the lower section of the foregut. At the and back of the peritoneal cavity, the stomach is completely intra-
time at which embryonic cleavage takes place in the 4th week, a peritoneal and is covered on all sides with Peritoneum viscerale.

Truncus coeliacus Dorsal

Pharynx mesogastrium
Septum transversum Posterior
(upper part of the foregut) abdominal wall
Stomach
A. mesenterica superior
A. gastrica A. gastrica
Spinal cord sinistra
sinistra
Pharyngeal A. mesenterica
arch arteries Liver position Truncus
inferior coeliacus
Hindgut
A. splenica
Cloaca A. hepatica (lienalis)
Heart propria
Brain Tail gut
Ductus Aorta dorsalis
Midgut choledochus
Vitelline duct Allantoic duct
a b

Arrowhead in
Truncus
Recessus superior
Aorta coeliacus A. gastrica sinistra
Oesophagus
V. cava V. cava Arrowhead in Isthmus
inferior inferior bursae omentalis
Recessus superior Posterior
bursae omentalis abdominal wall
Pancreas
Liver Omentum Liver
minus A. splenica

Large curvature Lig. falciforme Spleen

Isthmus of the stomach
bursae
omentalis Foramen
Lig. hepato- omentale
duodenale
Duodenum

Bursa A. gastroduodenalis A. gastroomentalis

Duodenum omentalis sinistra
A. gastroomen-
talis dextra A. gastrica Omentum Stomach
Omentum majus dextra minus Omentum
majus
c d

Fig. 7.2 Development of the epigastric region with the stomach, Bursa omentalis, as well as Omentum minus and Omentum majus in the 4th
and 5th weeks of development. a Sagittal section through an embryo at the end of the 4th week (28th day). b–d Representation of rotation of
the stomach on the 26th day (b), 32nd day (c) and 52nd day (d). [E347-09]

303
7 Abdominal viscera

The further development of the stomach and the entire upper ab- From the Mesogastrium ventrale dorsal to the liver (Mesohepati-
dominal region in the 5th week is determined by stomach rotation. cum dorsale), the lesser omentum (Omentum minus) develops
First of all, the rear of the stomach system grows faster than the with its two parts:
front and appears increasingly more saggy. This creates the large • Lig. hepatogastricum (between the liver and stomach)
and the small stomach curvatures. Then the stomach revolves clock- • Lig. hepatoduodenale (between the liver and duodenum)
wise around a longitudinal axis at 90° (view from cranial); since the As a result of the stomach rotation, the lesser omentum extends as
left stomach wall grows faster than the right, the large stomach cur- a frontal peritoneal duplicature. The Lig. hepatoduodenale is the
vature is now directed to the left and the small curvature to the right free lower edge of the former ventral mesentery, which was only
(› Fig. 7.3). This also twists the Trunci vagales, which accompany formed in the area of the foregut. Under this ligament the Fora-
the oesophagus through the diaphragm as terminal branches of the men omentale remains the only access to the Bursa omentalis.
N. vagus. Therefore the right N. vagus predominantly innervates the Through the Bursa omentalis, the dorsal mesogastrium sags and
back surface of the stomach via the Truncus vagalis posterior, and forms the greater omentum (Omentum majus) (› Fig. 7.3d) with
the left N. vagus innervates the front surface of the stomach as the its large apron-shaped section. Since the spleen is also formed in the
Truncus vagalis anterior. In addition, the stomach rotates around dorsal mesogastrium, this part of the Omentum majus is also de-
the sagittal axis, so that the stomach entrance (Cardia) is shifted to scribed as the Lig. gastrosplenicum (› Fig. 7.3c), while the parts
the left and the stomach exit (Pylorus) is shifted to the right. running further to the dorsal torso wall are the Lig. gastrophreni-
Parallel to the stomach rotation the Bursa omentalis also develops cum. Because the greater omentum thus originates from the stomach
in the 4th and 5th week in the dorsal mesogastrium as a recess (Re- curvature, it is also supplied by the vessels and nerves of the greater
cessus) of the peritoneal cavity (› Chap. 7.7.3). First, an invagina- curvature of the stomach (› Chap. 7.7.2).
tion of the right surface anatomy of the Mesogastrium dorsale
forms and extends cranially as a narrow tube into the site of the NOTE
lungs. Therefore, this enlargement is initially called the pneuma- The development of the stomach with stomach rotation is decisive
toenteric recess. During the stomach rotation, the gap spreads for the entire formation of the epigastric region:
along the posterior side of the stomach and thus forms the Bursa • The Omentum minus develops from the Mesogastrium ventrale.
• The Omentum major arises from the Mesogastrium dorsale.
omentalis as a serosa-lined adjoining space of the peritoneal cavity
• The liver and gall bladder systems are found in the Mesogastrium
between the stomach and the developing pancreas (› Fig. 7.3c, d). ventrale.
Through the stomach rotation and the formation of the Bursa omen­ • The Bursa omentalis, pancreas and spleen arise in the Mesogas-
talis, the Mesogastrium ventrale and the Mesogastrium dorsale are trium dorsale.
ex­truded as thin layers and thus form the Omentum majus and minus.

Aorta

Mesogastrium Peritoneal cavity

Bursa omentalis
dorsale
Gaster
Peritoneal cavity
Recessus Hepar
pneumatoentericus Gaster
Septum
Pericardial cavity transversum

a b Hepar

V. cava inferior

Adhesion surface of the Hepar

pancreas with the abdominal wall
Lig. splenorenale
Spleen [lien] Bursa omentalis
Pancreas
Omentum minus
Bursa omentalis
Gaster
Lig. gastrosplenicum Pancreas
Peritoneal cavity
Gaster Colon Duodenum
Omentum minus transversum

Hepar Omentum
majus Intestinum tenue
Lig. coronarium
c d

Fig. 7.3 Development of the epigastric region; Peritoneum (green); peritoneum of the pneumatoenteric recess and the Bursa omentalis (dark
red) (according to [S010-1-16]). a End of the 4th week, transverse section. b Beginning of the 5th week, transverse section. c Beginning of the
7th week, transverse section. d Paramedian section.

304
 7.1 Stomach

7.1.4 Projection of the stomach The Cardia starts at the lower end of the oesophagus. The limit can
be seen on the greater curvature as a notch (Incisura cardialis).
The projection of the stomach is relevant in the event of clinical ex- This creates an angle between the stomach and oesophagus (HIS
aminations undertaken to assign discomfort or examination find- angle), which is normally less than 80°. Through this angle, a fold
ings to the stomach. While the body of the stomach (Corpus) is of mucous skin is formed inside that prevents the reflux of stomach
highly variable depending on the size and the extent to which it is acid into the oesophagus and thus functionally contributes to the
filled and extends caudally to the level of the II–III. lumbar verte- closure mechanisms of the oesophagus (› Chap. 6.3.5). On the
brae, the stomach entrance (Cardia) and stomach exit (Pylorus) are inside, the mucosal transition is located between the oesophagus
relatively constant as a result of the fixing of the oesophagus and and stomach in an area 0.75 cm proximal and 1.5 cm distal of the
duodenum. The stomach entrance (Cardia) is projected caudally borders defined by the Incisura cardialis and forms a jagged line
in the lower constriction of the oesophagus during its passage (Z-line). Thereby the mucosal transition is predominantly (approx.
through the diaphragm at approximately the height of the XI. tho- 70%) exclusively in the Pars abdominalis of the oesophagus,
racic vertebra and therefore lies directly below the Proc. xiphoideus whereas it is rare (10%) to be completely below the HIS angle. The
of the breastbone. The easiest way is to understand the position of Cardia itself forms a thin mucous membrane strip that is only
the pylorus in the patient. The pylorus is relatively constant 1–2 1–3 cm wide and can only be separated histologically from the
cm to the right of the midpoint of a line between the pubic sym- main part of the stomach.
physis (Symphysis pubica) and the jugular fossa (Fossa jugularis)
and thus projects approximately over the I. lumbar vertebra.
Clinical remarks
NOTE If the HIS angle is lost, e.g. as a result of erroneous fixing in
Projection of the sections of the stomach on the skeleton and the the diaphragm (axial hiatal hernia), it can result in reflux of
anterior abdominal wall: gastric juice with inflammation of the oesophagus (gastro-
• Cardia: XI. thoracic vertebra, below the Proc. xiphoideus esophageal reflux disease). If drug therapy for reducing acid
• Body of the stomach: II.–III. lumbar vertebrae production with proton pump blockers fails, an operation
• Pylorus: I. lumbar vertebra, to the right of the midpoint of the line leads to improved closure whereby the fundus of the stomach
between the pubic symphysis and the jugular fossa is looped around the oesophagus (NISSEN fundoplication).
A tumour in the transition from the oesophagus to the stom-
ach must be categorised either as oesophageal or gastric can-
cer and then either the oesophagus or the stomach is re-
7.1.5 Structure and sections of the stomach moved. Therefore, various classifications have been devel-
oped for tumours in this transition area, whereby currently the
first gastric mucosal fold is considered to be the border. This
The stomach has a volume capacity of 1,000–1,500 ml (one to
subdivision is necessary because stomach acid reflux may
­one-and-a-half Bavarian glasses of beer!) and is divided into 3 sec- lead to an expansion of gastric mucosa in the oesophagus, in
tions (› Fig. 7.4): which adenocarcinoma frequently form that are treated clini-
• Stomach entrance: Pars cardiaca (Cardia) cally as oesophageal cancer. In this case, the visible mucosal
• Main part: Corpus gastricum with Fundus gastricus limit (Z-line) is shifted in an oral direction.
• Stomach exit: Pars pylorica
The stomach is almost positioned head-on due to the stomach ro-
tation that takes place during development. Therefore, its large ar- The main part of the stomach contains the typical gastric glands
eas form a front (Paries anterior) and a rear wall (Paries posteri- that are, e.g. responsible for the formation of gastric acid. It begins
or). The two edges between these areas are curved and are called with a Fundus gastricus, the upper pole of which is known as the
curvatures. The lesser curvature (Curvatura minor) is to the right, Fornix gastricus.
the greater curvature (Curvatura major) is to the left.

Incisura cardialis

Oesophagus

Cardia
[Pars cardiaca] Fundus
gastricus

Curvatura minor
Duodenum Corpus
gastricum

Curvatura
major

Incisura
Canalis pyloricus angularis Fig. 7.4 Structure of the stom-
Pars
pylorica Antrum pyloricum ach. Schematic drawing.
(according to [S010-1-16])

305
7 Abdominal viscera

The transition to the Pars pylorica is visible at the lesser curvature as

an angular notch (Incisura angularis) and, in turn, differs histologi-
cally from the main part. The following section is known as the An-
trum pyloricum and continues into the Canalis pyloricus, which is
surrounded by the sphincter of the stomach (M. sphincter pyloricus).

7.1.6 Surface enlargement of the stomach lining

The gastric mucosa has a characteristic relief that serves to enlarge

the surface anatomy; however, macroscopically, only the gastric
folds (Plicae gastricae) are seen, which are longitudinally oriented
(gastric folds) (› Fig. 7.5). With a magnifying glass, plot-like
fields (Areae gastricae) are visible on these folds. Depressions ema-
nate from the surface anatomy, at the bottom of which the gastric
glands open.
Fig. 7.6 Stomach ulcer (Ulcus ventriculi); Asterisks mark the pyloric
ring, arrows mark the borders of the ulcer. [R236]
Clinical remarks
Gastric ulcers are substance defects that affect the entire therefore mostly covered by the left costal arch but a small area is
stomach lining (› Fig. 7.6). Therefore, it is understandable directly adjacent to the ventral abdominal wall.
why this can lead to perforations into the abdominal cavity. Contact surfaces of the stomach with adjacent organs are:
More than 80% of all gastric and duodenal ulcers are caused • ventral: liver, diaphragm, abdominal wall
by the bacterium Helicobacter pylori. In addition, there can be
• dorsal: spleen, kidneys, adrenal glands, pancreas, Mesocolon
increased gastric acid production or reduced formation of sur-
face mucus, e.g. after taking pain medication containing the transversum
active substance acetylsalicylic acid, which promotes the for- The contact surfaces are highly variable, because the stomach is
mation of gastric ulcers. Accordingly, treatment involves re- well supported in comparison to adjacent organs. Even an altered
moving bacteria with antibiotics, together with inhibiting the stomach filling can change the contact surfaces.
secretion of gastric acid. In addition to a perforation in adja-
cent organs or the abdominal cavity with the risk of life-threat-
ening peritonitis, erosion of a gastric artery is also possible, Clinical remarks
which can lead to heavy bleeding. In the case of these compli-
cations, surgical treatment is indicated. The stomach field is clinically used in terms of nutrition to in-
sert a PEG tube (percutaneous endoscopic gastrostomy). In
the case of a gastroscopy, the light passing through the ab-
dominal wall is used for orientation on the body surface in or-
der to introduce the probe through the skin.
The gastric contact surfaces are of clinical relevance, as stom-
7.1.7 Topography ach ulcers or gastric tumours may lead to a perforation into
adjacent organs, which can lead to organ damage and associ-
The stomach is positioned intraperitoneally in the left epigastrium ated symptoms or can complicate the removal of tumours.
between the left lobe of the liver and the spleen. The stomach is

Fornix
gastricus

Incisura cardialis Fundus

gastricus
Oesophagus,
Pars abdominalis

Cardia [Pars cardiaca],

Ostium cardiacum Corpus
gastricum
Curvatura minor
Curvatura
Plicae gastricae
major
Incisura angularis

Duodenum, Pars
superior, Ampulla

Plicae circulares

Duodenum, Pars pylorica, Canalis

Pars descendens M. sphincter pyloricus, Antrum pyloricum
pyloricus Fig. 7.5 Stomach and duode-
num. Ventral view.

306
 7.1 Stomach

The stomach is connected by various peritoneal duplicatures with Table 7.2 Arteries of the stomach.
the adjacent organs, which are referred to as ligaments (Ligamenta)
Anatomical Arterial blood supply
and which partially surround the various vessels and nerves of the
structure
stomach. The course of these ligaments can be understood from
looking at the development (› Chap. 7.1.3): Lesser curvature • A. gastrica sinistra (directly from the Truncus coeliacus)
• Lesser curvature (part of the Omentum minus): • A. gastrica dextra (from the A. hepatica propria)

– Lig. hepatogastricum Greater curvature • A. gastroomentalis sinistra (from the A. splenica)

• Greater curvature (part of the Omentum majus): • A. gastroomentalis dextra (from the A. gastroduodenalis
of the A. hepatica communis)
– Lig. gastrocolicum
These vessels also supply the Omentum majus!
– Lig. gastrosplenicum
– Lig. gastrophrenicum Fundus Aa. gastricae breves (in the area of the hilum of the spleen
from the A. splenica)
At the lesser curvature, the Lig. hepatogastricum links the stom-
ach with the Facies visceralis of the liver. The ligament extends cau- Posterior side A. gastrica posterior (present in 30–60% of cases, origi-
nates behind the stomach from the A. splenica)
dally into the Lig. hepatoduodenale, with which it forms the less-
er omentum (Omentum minus). Under the Lig. hepatoduodenale
is the entrance to the Bursa omentalis (Foramen omentale), a while the A. gastroomentalis sinistra is somewhat thinner. The A.
peritoneum-lined recess of the abdominal cavity (› Chap. 7.7.3). gastrica sinistra, after its origin from the Truncus coeliacus, first pro-
The largest part of the Bursa omentalis is located dorsal to the duces the Plica gastropancreatica that delimits the atrium from the
Omentum minus and extends behind the stomach. main space of the Bursa omentalis. After the distribution of branches
The ligaments on the greater curvature form the Omentum majus for the Pars abdominalis of the oesophagus (Rr. oesophageales) and
with a free, apron-shaped section (› Chap. 7.7.2). The Lig. gas- occasionally (20%) for the left hepatic lobe, it then reaches the stom-
trocolicum is thereby only a narrow bridge to the Colon transver- ach in the Lig. hepatogastricum. The fundus receives 5–7 of its own
sum and continues left into the Lig. gastrosplenicum, which is po- Aa. gastricae breves, which, in addition to the A. gastrica posterior,
sitioned on the spleen. The cranial continuation of the Omentum exit into an inconstant vessel in the middle of the posterior wall from
majus into the diaphragm is known as the Lig. gastrophrenicum. the A. splenica. The A. gastroomentalis sinistra and the Aa. gastricae
In anatomical terminology, many other peritoneal duplicatures are breves run in the Lig. gastrosplenicum.
named and assigned to the two omenta. Since this is not useful in a
medical sense, we will forgo it here.
Clinical remarks
Since the gastric arteries run directly to and, in some cases,
7.1.8 Arteries of the stomach also in the stomach wall, gastric ulcers (Ulcera ventriculi) can
sometimes cause fatal gastric haemorrhages.
All three main branches of the Truncus coeliacus (A. gastrica sinis- In the case of a surgical removal of the oesophagus due to
­oesophageal cancer, the stomach is most often selected as a
tra, A. hepatica communis, A. splenica) collectively give rise to six
replacement (gastric pull-up). In this case a stomach tube is
gastric arteries (› Table 7.2, › Fig. 7.7). formed for which the A. gastroomentalis dextra alone is suffi-
The gastric arteries form vascular arcades at both curvatures in the cient for supply.
Omentum majus and Omentum minus, in which the arteries of
both sides are joined by anastomoses. The branches to the anterior
and posterior of the stomach (Rr. gastrici) emerge from the arcades.
At the lesser curvature, the A. gastrica sinistra is significantly stron-
ger in structure than the A. gastrica dextra and usually forms an an- 7.1.9 Veins of the stomach
terior and posterior main stem. Conversely, it is positioned in the
greater curvature where the A. gastroomentalis dextra is the The veins correspond to the arteries and support them along the
dominant vessel and therefore on its course in the Lig. gastrocolicum curvature of the stomach; however, they differ in their connection
also supplies the largest part of the Omentum majus (Rr. omentales), to the portal vein: only the Vv. gastricae dextra and sinistra drain di-

Lobus hepatis sinister

A. hepatica communis
Truncus coeliacus
A. gastrica sinistra
Vesica biliaris [fellea]
Gaster
A. gastrica posterior
A. cystica
Spleen [Lien]
A. hepatica propria

V. portae hepatis Aa. gastricae breves

A. gastroduodenalis A. splenica [lienalis]

A. gastrica dextra A. gastroomentalis sinistra
Duodenum A. mesenterica superior
A. gastroomentalis dextra Fig. 7.7 Arteries of the stom-
ach. Ventral view.

307
7 Abdominal viscera

Table 7.3 Veins of the stomach. The lymph flows from these regional lymph nodes along the curva-
ture through 2 more stations, before they are guided through the
Receiving vessel Inflows
Trunci intestinales to the Ductus thoracicus.
Confluence directly into the • V. gastrica sinistra Thus, in the 3 major lymphatic areas are 3 lymphatic drainage sta-
portal vein • V. gastrica dextra and over this V. prepylorica
tions in series:
(inconstant), which cross the pylorus ventrally
• First station (› Fig. 7.8, green): regional lymph nodes of the 3
Confluence into V. splenica • V. gastroomentalis sinistra (from the V. splenica) drainage areas
• Vv. gastricae breves
• Second station (› Fig. 7.8, yellow): lymph nodes along the
• V. gastrica posterior (inconstant, usually pres-
ent if artery is formed)
branches of the Truncus coeliacus
• Third station (› Fig. 7.8, blue): lymph nodes at the exit of the
Confluence into V. mesenter- • V. gastroomentalis dextra
ica superior
Truncus coeliacus (Nodi lymphoidei coeliaci]; from there, the
lymph flows via the Truncus intestinalis into the Ductus thoraci-
cus
rectly into the portal vein, while all other veins lead the blood into
the main stems of the portal vein (› Table 7.3).
Clinical remarks
Clinical remarks The lymphatic drainage stations (› Fig. 7.8) of the stomach
are of clinical relevance in the surgical treatment of gastric
In the case of high-pressure in the portal vein (portal hyper- cancer (D-level of surgeons). The lymph nodes of the first and
tension), e.g. in the case of cirrhosis of the liver, portocaval second stations are usually removed together with the stom-
anastomoses can form from the connections of the V. gastrica ach, which is known as a D2 gastrectomy. If, however, during
sinistra to the oesophageal veins, which in turn are connected surgery it is detected that the lymph nodes of the third station
via the Azygos vein to the superior vena cava. These connec- with the surrounding retroperitoneal lymph nodes along the
tions are highly dangerous because the widened oesophageal Aorta and the V. cava inferior (D3 level) are affected, no cure is
veins (oesophageal varices) burst and can lead to life-threat- possible. Hence in this case, the patient should be spared the
ening bleeding. removal of the stomach. The decision on which the patient's
life depends must be made by the surgeon at the operating
table. This example very clearly illustrates how important
knowledge of the lymphatic drainage pathways is in some or-
gans.

7.1.10 Lymph vessels of the stomach

The stomach has 3 lymphatic drainage areas and 3 lymphatic NOTE

drainage stations arranged in series (› Fig. 7.8): The stomach has 6 arteries of its own and 3 lymphatic drainage ar-
Lymphatic drainage areas are: eas with 3 lymphatic drainage stations.
In accordance with its development from the Mesogastrium dorsale
• Cardia area and lesser curvature: Nodi lymphoidei gastrici di- the Omentum majus is supplied by the vessels and nerves on the
rectly to the lesser curvature greater curvature of the stomach and therefore belongs to the
• Upper left quadrant: Nodi lymphoidei splenici at the hilum of stomach, not the colon.
the spleen
• Bottom two thirds of the greater curvature and pylorus: Nodi
lymphoidei gastroomentales and Nodi lymphoidei pylorici

A. gastrica sinistra

Nodi lymphoidei
coeliaci
A. hepatica propria Nodi lymphoidei
splenici

A. gastrica dextra

A. gastroduo-
denalis A. splenica
[lienalis]

Nodi lymphoidei
pylorici A. gastroomentalis
sinistra

Nodi lymphoidei
gastroomentales
A. gastroomen- Nodi lymphoidei Fig. 7.8 Lymph drainage sta-
talis dextra gastrici tions of the stomach. Ventral
view. (according to [S010-1-16])

308
 7.2 Intestines

Truncus vagalis posterior

R. coeliacus Truncus vagalis anterior
Ganglia coeliaca

N. splanchnicus

Postganglionic
sympathetic nerve fibres

Rr. hepatici

Preganglionic parasym-
pathetic nerve fibres

Fig. 7.9 Autonomic innervation

Rr. gastrici
of the stomach (Gaster); sympa-
thetic innervation (green), para-
sympathetic innervation (pur-
ple) (according to [S010-1-16]).

7.1.11 Innervation of the stomach coeliacus, where they are not switched but join the gastric arteries
from the Truncus coeliacus.
The stomach is innervated both sympathetically and parasympa- The postganglionic parasymphatic neurons are located mostly in
thetically (› Fig. 7.9): the stomach wall and are not therefore depicted in the dissection.
• The parasympathetic nervous system promotes gastric acid For general organisation of the autonomic nervous system in the
production as well as peristalsis and gastric emptying. abdomen see › Chap. 7.8.5.
• The sympathetic nervous system acts antagonistically to the
parasympathetic nervous system by reducing gastric acid secre-
tion, peristalsis and blood circulation and preventing gastric
Clinical remarks
emptying by activating the M. sphincter pyloricus. Previously, severance of the N. vagus (vagotomy) was the only
The autonomic nerve fibres form nerve plexuses (Plexus gastrici) effective way to reduce acid secretion in the event of stomach
on the anterior and posterior of the stomach. ulcers. A former therapy in patients with peptic ulcers was to
Sympathetic nerve fibres from the Nn. splanchnici to the Ganglia sever the entire N. vagus [X] inferior to the diaphragm (total
vagotomy) or its branches to the stomach (selective vagot­
coeliaca run along the arteries after switching over. Preganglionic
omy) to reduce the production of gastric acid. The course of
sympathetic fibres act as Nn. splanchnici major and minor on both the nerve fibres explains why this often leads to disruption of
sides through the lumbar branches of the diaphragm and reach the gastric emptying (Rr. pylorici) and the formation of gallstones
Ganglia coeliaca at the exit of the Truncus coeliacus, where they are (Rr. hepatici); however, since the option of blocking acid with
switched to postganglionic neurons. They reach the various sections medication and the removal of the triggering Helicobacter
of the stomach along with the preganglionic parasympathetic nerve ­ ylori bacteria with antibiotics, this procedure has become
p
fibres as periarterial plexus along the gastric arteries. The sympathic significantly less important.
nervous system also has afferent pain fibres. The zone of the trans-
mitted pain in the abdominal wall (HEAD zone) corresponds with
the dermatomes T5–8 in the left epigastric region, in which the
stomach lies in the stomach field of the ventral wall. 7.2 Intestines
Parasympathetic fibres reach the small curvature, as well as the
posterior and anterior of the stomach as the Trunci vagales but
reach the greater curvature indirectly through the Plexus coeliacus
Skills
as periarterial plexus. Preganglionic parasympathetic fibres reach After working through this chapter you should be able:
the stomach as Trunci vagales descending anterior and posterior • to show the sections of the small and large intestines on the
along the oesophagus and run along the lesser curvature. From dissection and explain their structural features
there, the Rr. gastrici radiate over the posterior and anterior wall of • to explain the origin of the individual intestinal segments,
including the boundaries of their innervation and vascular
the stomach and supply the majority of the corpus and fundus.
supply and the positional changes they undergo during
Due to the stomach rotation at the time of development, the Trun- ­development
cus vagalis anterior is predominantly derived from the left N. vagus • to understand the positional relationships of the individual
[X] and the Truncus vagalis posterior from the right. The Pars py- sections of the intestines with respect to the other abdomi-
lorica is innervated by its own branches (Rr. pylorici), that initially nal organs in a dissected specimen and in the case of the
proceed with the Rr. hepatici from the Truncus vagalis anterior to appendix in particular, the projection on the surface of the
the liver and then move into the pyloric region in the Omentum body in terms of clinical importance
minus. Individual nerve fibres go to the greater stomach curvature
from the Truncus vagalis posterior and take a detour via the Plexus

309
7 Abdominal viscera

• to illustrate the blood supply to the individual intestinal sec- In addition to the resorption, the cells of the intestinal mucosa
tions in detail on the dissection specimen and recognise have additional functions. Especially in the small intestine many
clinically important anastomoses of arteries messenger substances and hormones are formed, which enable
• to explain the venous and lymph node drainage areas, as the coordinated interaction of the stomach, liver, gall bladder and
well as the innervation areas of individual sections of the
pancreas, which is necessary for digestion. Through food, the body
intestine on the dissection specimen.
is constantly faced with foreign substances and pathogens, which
are rendered harmless in the stomach, but still require that the cells
of the immune system mount an immune defence in the intestinal
mucosa if necessary.
7.2.1 Overview

The intestines join to the stomach and are divided into the small 7.2.3 Development
intestine (Intestinum tenue) and the large intestine (Intestinum
crassum), which each show different sections with varying posi- The intestinal system develops in the 4th week from the entoderm
tional relationships (› Fig. 7.10). and a part of the yolk sac, which is included in the body at the time
of embryonic cleavage. Thereby the entoderm forms the epithelium
of the intestine, while connective tissue and smooth muscles are
7.2.2 Functions of the intestine formed from the surrounding mesoderm. The link to the yolk sac
around the navel is thus restricted to the vitelline duct (Ductus om-
While the small intestine in essence serves the digestion and ab- phaloentericus /vitelline duct) (› Chap. 6.5.5). As a result, the in-
sorption of nutrients, particularly in the large intestine a thicken- testinal system is divided into three sections, each of which are
ing of the food bolus and controlled excretion through faecal mat- supplied by their own artery and later form different sections of the
ter takes place. Therefore, it is understandable why at least a part of small and large intestines:
the small intestine (approx. 1 m) is essential for life, while the large • Foregut (cranial to the vitelline duct, supplied by the Truncus
intestine is not essential. In clinical terms, the English names are coeliacus): forms the proximal half of the duodenum
used for the two parts of the intestine, while the Latin terms are • Midgut (at the level of the vitelline duct, supplied by the A. mes-
predominantly used for the individual sections. enterica superior): forms the remaining sections of the small
Functions of the intestine are: intestine, as well as the proximal large intestine including the
• Transport and breaking down of food Colon transversum
• Digestion of food and absorption of nutrients • Hindgut (caudal to the vitelline duct, supplied by the A. mesen-
• Immune defence terica inferior): forms the large intestine from the Colon de-
• Distribution of messenger substances and hormones for regula- scendens to the proximal half of the anal canal. The distal half of
tion of digestion the anal canal is everted from the ectoderm of the anal depres-
• Thickening of the food bolus sion (Proctodeum).
• Intermediate storage and controlled excretion of faecal matter The result of this is that the 3 parts and thus also the innervation
After gastric emptying, the chyme is further transported through and supply areas of the 3 arteries and other vascular, lymphatic and
the peristaltic movement of the intestine and broken down. In the nervous systems do not correspond to the final intestinal sections.
first section of the small intestine, the enzymes of the pancreas and There are therefore 3 clinically important areas in terms of the
the bile acids from the gall bladder are added to the duodenum and small and large intestines, which the innervation and supply areas
cause the digestion of nutrients that are then absorbed by the cells of the vessels and nerves switch:
of the mucosa. After this resorption, the nutrients travel in the • Transition between proximal and distal duodenum (border be-
blood and reach the portal vein and lymph vessels of the liver, the tween the foregut and midgut, not visible in the intestine):
central metabolic organ of the body. In the large intestine fluid is BÜHLER's anastomosis connects the innervation and supply
extracted from the chyme and is used to thicken the faecal matter. ­areas of the Truncus coeliacus and A. mesenterica superior
In the last sections of the large intestine (rectum and anal canal), the
faecal matter is then stored and released in a controlled manner.

Oesophagus

Hepar
Gaster
Pancreas

Vesica biliaris [fellea] Duodenum

Colon transversum Intestinum

Colon ascendens Jejunum tenue
Colon descendens
Intestinum Ileum
Colon sigmoideum
crassum
Caecum
Rectum
Appendix vermiformis Canalis analis
Fig. 7.10 Projection of the
Anus intestinal sections onto the
body surface. Ventral view.

310
 7.2 Intestines

• Left colic flexure (border between midgut and hindgut): receive a secondary retroperitoneal location. With the duodenum,
­ IOLAN's anastomosis connects the innervation areas of the
R this already happens in the 5th week in the context of the stomach
Aa. mesentericae superior and inferior rotation. A special feature here is that in the 5th and 6th week the
• Linea pectinata (clinically: Linea dentata) at the transition be- lumen of the duodenum is closed by excess epithelial proliferation
tween proximal and distal anal canal (border between behind and is only re-channelled at the end of the embryonic period.
hindgut and anal depression). Here, the A. mesenterica inferior
communicates with the flow area of the A. iliaca interna from
the pelvis.
Clinical remarks
If the re-channelling fails or is incomplete, a complete occlu-
sion can occur at birth (duodenal atresia) or a constriction (du-
Clinical remarks odenal stenosis) of the duodenum can occur, which can be
The anastomoses between the three unpaired visceral arteries identified as early as a few hours after birth by severe vomiting.
enable bypass circulations, if a vessel is closed, e.g. through
a displaced blood clot (embolism) or by arteriosclerosis and
can therefore prevent intestinal infarctions. In the surgical re- The development of the midgut is determined by the intestinal ro-
moval of large intestine sections, the left colic flexure is often
tation (› Fig. 7.11). First, the midgut undergoes rapid growth and
chosen as the border (right or left sided hemicolectomy).
Also in the event of the spread of tumours the various innerva- in the 5th week forms a ventrally oriented umbilical loop, the sagit-
tion and vascular supply areas play a role by the formation of tal axis of which forms the A. mesenterica superior and from its
metastases. peak the Ductus omphaloentericus branches off (› Fig. 7.11a).
The midgut rotates around this axis by a total of 270° counterclock-
wise. In the late foetal period the caecum, which was formed in the
The proximal duodenum arises from the last section of the foregut 6th week as the caecum bud at the distal leg of the umbilical loop,
and therefore has a ventral mesentery in addition to a dorsal mes- descends and extends to the right lower abdomen. Due to the lack
entery, which later develops to the Lig. hepatoduodenale as part of of space in the 6th week the umbilical loop is relocated in the body
the Omentum minus. The distal intestinal sections are only an- stalk (development-related umbilical hernia) by the navel and only
chored to the dorsal wall of the peritoneal cavity by a dorsal mes- returns in the 10th week into the abdominal cavity (reposition;
entery. All intestinal sections are therefore initially intraperitoneal › Fig. 7.12). Since the Mesenterium is reformed at an early stage
and are, apart from the attachment of the Mesenterium, covered by in the area of the later Colon ascendens and Colon descendens,
a serous membrane (Tunica serosa), on the surface of which the these sections achieve a secondary retroperitoneal position.
Peritoneum viscerale forms. The Mesenterium is a peritoneal du- The hindgut forms the left-sided colon and ends in the cloaca, in
plicature, from which the serosa of the intestinal surface passes which the genitourinary canal flows. The cloaca reaches the cloacal
through to the Peritoneum parietale of the abdominal cavity wall. depression (Proctodeum), which represents an invagination of the
During the switching processes of intestinal sections, individual ectoderm and which is initially closed by the cloacal membrane. In
sections later become closely adjacent to the dorsal torso wall and the 7th week the cloaca and the cloacal membrane are divided by a

Umbilical loop
Umbilical loop
Ductus vitellinus
a b

Fig. 7.11 Intestinal rotation.

Schematic representation, View
from the left side. Intestinal seg-
ments and their mesenteries are
highlighted in different colours:
stomach and mesogastrium
(purple), duodenum and
mesoduodenum (blue), jejunum
and ileum with associated mes-
enteries (orange), colon and
mesocolon (ochre) (according to
[S010-1-16]). Rotation and dis-
placement of the midgut
between the 6th (a) and 11th (c)
c d
developmental weeks, as well
as in the late foetal period (d).

311
7 Abdominal viscera

cloacal depression communicates with the hindgut and forms the

Liver Aorta distal anal canal.
abdominalis

Stomach
Spleen Clinical remarks
Dorsal In the event of disturbances of the intestinal rotation, a malro-
pancreatic tation can occur (hyporotation and hyperrotation). This can
bud cause an intestinal obstruction (ileus), but also leads to an ab-
Umbilical normal positioning of the various intestinal segments, which
loop Upper
arm can, e.g. complicate the diagnosis of appendicitis. In the event
of Situs inversus all of the organs are reversed (mirror image).
If the repositioning of the intestine is incomplete, newborns can
be born with an umbilical hernia (omphalocele). In addition to
the intestinal sections, the hernial sac can also contain other
Yolk sac abdominal organs, such as the liver and spleen, which have
stem/Ductus a a1 been secondarily displaced. The hernial sac is not covered by
omphalo Lower
entericus arm skin, but only by the amniotic membrane of the umbilical cord.
Umbilical loop A. mesenterica In contrast, a navel hernia occurs in the first month after
superior birth if the navel does not close completely. It contains the
Omentum majus and intestinal sections that are covered by
skin on the outside. Navel hernias usually resolve sponta-
Liver neously.
Aorta
abdominalis Remnants of the Ductus omphaloentericus can remain as a
MECKEL's diverticulum. This is a common occurrence (3% of
Bursa the population) and is usually located in the part of the small
omentalis intestine that is located approximately 100 cm cranial of the
Spleen
ileocecal valve. Because they often contain dispersed gastric
mucosal or pancreatic tissue, the inflammation and bleeding
Caecum often presents an incorrect clinical picture of appendicitis.
Colon
transversum If the Septum urorectale deviates dorsally, an anal stenosis
can occur. An imperforate anus is when the anal membrane
does not break down.

b b1
7.2.4 Structure and projection of the small
i­ ntestine

The small intestine is usually 4–6 m long and is divided into 3 sec-
tions (› Fig. 7.10):
Omentum • Duodenum (25–30 cm) with Pars superior (5 cm), descendens
minus
(10 cm), horizontalis (10 cm), ascendens (2.5 cm)
• Jejunum (approx. 2 m)
• Ileum (approx. 3 m)
Colon Colon The sections of the small intestine have different topographical re-
ascendens descendens lationships in the abdominal cavity and are therefore covered to
various degrees with peritoneum (› Chap. 7.7.1).
Small intestine
Intraperitoneal (i.e. in the peritoneal cavity of the abdominal cavi-
MECKELʼs Sigmoid ty) are found the Pars superior of the duodenum, jejunum and ile-
diverticulum um. Secondarily retroperitoneal (in the dorsal wall of the perito-
Rectum
c neal cavity, the retroperitoneum) are the Pars descendens, Pars
Caecum and
Appendix vermiformis
horizontalis and the Pars ascendens of the duodenum.
The duodenum is the shortest section at 25–30 cm (› Fig. 7.13). It
Fig. 7.12 Rotation of the midgut; View from the left side. a Sagittal is relatively fixed in its position because only the first part (Pars su-
section (start of the 6th week): the umbilical loop has not yet rotated perior) is located intraperitoneally and is connected here by a peri-
and has already entered the body stalk. a1 Schematic cross-section toneum duplicature (Lig. hepatoduodenale) with the liver, while the
through the umbilical loop before intestinal rotation takes place. following parts (Partes descendens, horizontalis and ascendens) are
b 11th week: intestinal rotation has been completed and the intes-
in a secondary retroperitoneal position and therefore surrounded by
tine has already shifted back into the body. b1 Schematic cross-sec-
tion through the umbilical loop upon completion of the intestinal connective tissue. The duodenum therefore creates a C-shaped loop
rotation. c Late foetal period: the caecum is relegated to its final posi- that encompasses the head of the pancreas. The Pars superior is of-
tion [E347-09]. ten extended (ampulla or bulbus) and is therefore projected like the
pylorus of the stomach onto the I. lumbar vertebra. It passes into the
Septum urorectale into the ventral Sinus urogenitalis (precursor of Flexura duodeni superior in the Pars descendens. Connected to the
urinary bladder and urethra) and the dorsally located rectum and Flexura duodeni inferior runs the Pars horizontalis at the level of
upper anal canal. The rear part of the cloacal membrane becomes the III. lumbar vertebra, before the Pars ascendens runs up to the
the anal membrane which ruptures in the 8th week, so that now the II. lumbar vertebra again. Here, together with the Flexura duodeno-

312
 7.2 Intestines

jejunalis is the transition into the following small intestine bundle of plaques) and only specific absorption functions are found here,
the jejunum (approximately two fifths of the total length and the ile- such as the uptake of vitamin B12 and bile acids.
um (approximately three fifths of the total length). These two sec-
tions are located intraperitoneally and have no sharp boundary in
relation to each other. The ileum ends at the ileocecal valve ‘Valva
Clinical remarks
ileocaecalis’ (BAUHIN's valve) at which it joins the caecum as the The terminal ileum is often affected by CROHN's disease, a
first section of the large intestine. chronic inflammatory disease of the intestine with autoim-
The most important section is the Pars descendens. Here, the bile mune components, which may cause anaemia due to a vita-
duct (Ductus choledochus) opens out together with the excretory min B12 deficiency.
duct of the pancreas, Ductus pancreaticus (Ductus WIRSUNG-
IANUS), to a mucosal elevation (Papilla duodeni major, Papilla
VATERI), which is located 8–10 cm from the pylorus. Shortly be-
fore the papilla, the mucous membrane often runs into a longitudi- 7.2.5 Structure and projection of the large intestine
nal mucosal fold (Plica longitudinalis duodeni). In most cases, 2
cm proximal of the Papilla VATERI is a smaller Papilla duodeni The large intestine is about 1.5 m long and is divided into 4 sec-
minor, on which the Ductus pancreaticus accessorius (Ductus tions (› Fig. 7.14):
SANTORINI) emits secretions. • Caecum (appendix) 7 cm with Appendix vermiformis, 8–9 cm
• Colon with Colon ascendens (15 cm), Colon transversum (50
cm), Colon descendens (15 cm) and Colon sigmoideum (35–45
Clinical remarks cm)
An obstruction of the bile ducts may occur as a result of a gall- • Rectum, 12 cm
stone, which is stuck to the Papilla VATERI, or jaundice (icter- • Canalis analis (anal canal), 3–4 cm
us) that can occur as a result of tumours of the pancreas and The sections of the large intestine alternate strictly in relation to
bile ducts in which the bile fluid can flow back into the liver their position in the abdominal cavity.
and the bile pigment (bilirubin) enters the blood vessel sys-
• Intraperitoneal (in the peritoneal cavity of the abdominal cavi-
tem. For diagnostic evaluation and removal of gallstones, en-
doscopic retrograde cholangiopancreatography (ERCP) is car- ty) are:
ried out, as part of which the papilla is examined and the ex- – Caecum with appendix (mostly)
cretory ducts are represented using x-ray contrast agent. Here, – Colon transversum
the Plica longitudinalis duodeni can be used as a landmark for – Colon sigmoideum
the identification of the papilla. • Secondary retroperitoneal (in the dorsal wall of the peritoneal
cavity, the retroperitoneum) are:
– Colon ascendens
The adjacent intraperitoneal parts of the small intestine bundle of – Colon descendens
the Jejunum and Ileum are fixed over a peritoneal duplication, the – Rectum (proximal)
mesentery), in the form of 14–16 intestinal loops at the dorsal ab- • Subperitoneal (in the connective tissue below the peritoneal
dominal wall. Within the mesentery can be found the vessels and cavity) are:
nerves. Due to the length of the small intestine, the origin of the – Rectum (distal)
mesentery, the mesenteric root (Radix mesenterii), is much shorter – Anal canal
than the attachment to the intestines. The latter is not sharply The appendix (Caecum) is usually approximately 7 cm long and is
­defined and an approx. 30 cm long section of the small intestine is joined at the ileocecal valve ‘Valva ileocaecalis’ (BAUHIN's valve)
known as the terminal Ileum (Pars terminalis). This is where sec- to the ileum (› Fig. 7.15, › Fig. 7.16): the opening (Ostium ile-
tions of the intestine's immune system frequently occur (PEYER's ale) is limited by 2 lips, which after coming together, continue as

Ductus hepaticus
communis
Ductus cysticus
Duodenum,
Pars superior
Duodenum,
Pars descendens

Ductus pancreaticus
accessorius
Vesica
biliaris
Ductus pan-
creaticus
Papilla duodeni
minor
Ductus chole-
dochus [biliaris]
Duodenum,
Papilla duodeni
major
Pars ascendens Fig. 7.13 Sections of the duo-
denum; extrahepatic bile ducts
Duodenum,
Pars horizontalis
and excretory ducts of the pan-
creas. Ventral view.

313
7 Abdominal viscera

Flexura coli
sinistra
Flexura coli Colon transversum
dextra

Colon Colon
ascendens descendens

Ileum

Caecum

Appendix
vermiformis Colon
sigmoideum
Rectum Fig. 7.14 Structure of the large
Canalis analis intestine (Intestinum crassum).
Ventral view.

the Frenulum ostii ilealis. The valve has a sympathetically activated Clinical remarks
circular musculature and can prevent the reflux of chyme to a cer- Diagnosis of appendicitis (in German often referred to incor-
tain degree; a real sphincter is not yet formed. The caecum projects rectly as ‘inflammation of the Blinddarm’) is a clinical diagno-
onto the lumbar vein or the Os sacrum. sis that the surgeon must make mainly dependent on the find-
At the blind end of the caecum (hence the German name Blind- ings because other signs, such as an increased number of
darm), approximately 2–3 cm below the junction with the Ileum, white blood cells or ultrasound findings, are often unclear.
The diagnosis is often difficult as pain in the right lower abdo-
hangs the mostly 8–9 cm long vermiform appendix (Appendix
men can be a result of enteritis, or in women can be caused by
vermiformis), which is frequently erroneously called the ‘Blind- inflammation of the ovaries and fallopian tubes. On the other
darm’ (even by doctors). Since the 3 taenia of the Caecum come hand, a correct diagnosis is important because in a case of
together at the exit of the appendix, it is usually easy to locate missed appendicitis, perforation with potentially fatal perito-
during an operation. The appendix (in an intraperitoneal position nitis may occur but it is also best to avoid unnecessary surgery
of the caecum) usually has its own mesentery (Mesoappendix) in with possible complications or subsequent adhesions. There-
which the vessels and nerves run. fore, pressure pain at McBURNEY's point or LANZ's point is a
very important clue in diagnosis.

Clinical remarks
Appendicitis is a common disease in the 2nd and 3rd decades NOTE
of life. It is an endogenous infection, mostly caused by the McBURNEY's point and LANZ's point are important projection
covering of the lumen by faeces or (rarely) other foreign bod- points of the appendix on the abdominal wall. Your examination is
ies or the passage through the wall by bacteria from the intes- important for the diagnosis of appendicitis and should be part of
tinal flora. A perforation with life-threatening peritonitis can every complete physical examination of the abdominal region.
be a consequence.

Taenia libera
Colon ascendens
Of particular importance, therefore, are the location and projec- Haustra coli
tion of the appendix (› Fig. 7.16): Plicae semilunares coli
• The appendix is mostly (65%) tilted backwards to the caecum
(retrocaecal). (Valva ileocaecalis)
• With the second most frequent variant (30%) the appendix Ileum
stretches down and reaches the small pelvis and therefore in Noduli lymphoidei
women, lies in the immediate vicinity of the ovarian and fallopi- Ostium ileale aggregati
an tube (pendulous).
Frenulum
These positional variants have an impact on the projection of the ostii ilealis Ostium appendicis
appendix onto the abdominal wall. The base of the Appendix ver- Caecum
vermiformis
miformis projects onto McBURNEY's point (located in the right
Appendix
third of a line connecting the Spina iliaca anterior superior and the Taenia libera vermiformis
navel). The tip of the hanging Appendix vermiformis projects onto
LANZ's point (located in the right third of a line connecting both
Fig. 7.15 Caecum with vermiform appendix (Appendix vermiformis)
sides of the Spinae iliacae anteriores superiores). and terminal Ileum. Ventral view after removal of the anterior parts of
the wall.

314
 7.2 Intestines

≈ 30 %

Colon ascendens Anulus umbilicalis Colon

ascendens Ileum
Ileum
McBURNEY’s point

Caecum Appendix
Spina iliaca Spina iliaca
vermiformis
anterior superior anterior superior
b
Appendix
vermiformis ≈ 65 % ≈2% <1%

Caecum

LANZ’s point

a c d e

Fig. 7.16 Projection of the appendix (caecum) and Appendix vermiformis onto the ventral torso wall. Positional variants of the Appendix veri-
formis. Ventral view. a and b Appendix descending into the small pelvis (pendulous). c Retroceceal appendix (most frequent case). d Pre-ileal
appendix. e Retro-ileal appendix.

The caecum continues without borders into the Colon ascendens, however, the folds of the large intestine do not include the entire
which rises in a secondary retroperitoneal position and passes be- lumen of the intestine, but are more crescent-shaped (Plicae semi-
low the liver in the right colic flexure (Flexura coli dextra) and lunares).
merges into the Colon transversum that runs intraperitoneally.
It is anchored by its transverse mesocolon and then after connect-
ing to the left colic flexure (Flexura coli sinistra) descends as the
Colon descendens which again is in a secondarily retroperitoneal
position. The right colic flexure is usually projected over the I–II.
lumbar vertebrae but the left colic flexure is higher (XI.–XII).
thoracic vertebrae).
The border to the Colon sigmoideum is, however, easy to discern
because this section resembles an S-shaped course (hence the
name) and has its own Mesocolon sigmoideum. The transition to
the rectum at the level of the II–III. sacral vertebrae can be rec-
ognised since it varies at various points from the construction fea-
tures of the colon (see below).
The various sections of the large intestine surround the small intes- Plicae
tine like a picture frame surrounds a picture; however, the length of circulares

the sections and the position of the colon flexure, and thus also the a

shape of the large intestine, are very variable. The left flexure usual-
ly extends further cranially and, due to the change in the course of
direction of the intestine by almost 180°, can be difficult to over-
come when performing enteroscopy. In addition, the Colon ascen-
dens and Colon descendens can also lie intraperitoneally and then
have their own Mesocolon ascendens and Mesocolon descendens.
The Rectum and anal canal lie in the pelvis and due to various pe-
culiarities in topography, their structure and vessels and nerves will
be covered along with the pelvic organs in (› Chap. 8.4).

7.2.6 Structural features of the small and large

i­ ntestines b
Plicae circulares
The intestinal mucosa has an inner relief that differs depending on
the individual sections. The inner relief of the small intestine has Fig. 7.17 Small intestine mucosa. a Section from the jejunum.
circular folds (Plicae circulares, KERCKRING's folds; › Fig. 7.17); b Plicae circulares in an endoscopic image of the small intestine.

315
7 Abdominal viscera

The majority of the large intestine (caecum and colon) can there- TREITZ ligament) at the exit of the A. mesenterica superior. The
fore be clearly distinguished from the small intestine by 4 structur- TREITZ ligament can also contain striated and smooth muscles
al features (› Fig. 7.18): (M. suspensorius duodeni, TREITZ muscle). Bulges of the perito-
• Larger diameter (it is ‘large’ whereas the small intestine is neal cavity often occur here (Recessus duodenales superior and
‘small’) ­inferior). Behind the Pars ascendens are the left kidney with its
• Taenia: the longitudinal muscle layer is reduced to three bands. ureter, as well as the left Vasa testicularia/ovarica.
Of these the Taenia libera is visible, while the Mesocolon trans- The jejunum and the ileum have a positional relationship to both
versum is attached to the Taenia mesocolica and the Omentum kidneys and different sections of the large intestine and lie on the
majus is attached to the Taenia omentalis. pelvis of the urinary bladder and in women, the intraperitoneal
• Sacculations of the colon and Plicae semilunares: the saccula- sections of the internal genitalia (womb, ovaries and fallopian
tions (Haustra coli) are protrusions that are caused by contrac- tube). The Radix mesenterii is approx. 12–16 cm long and extends
tions of the Plicae semilunares. from the Flexura duodenojejunalis up to the iliac fossa (Fossa ilia-
• Appendices epiploicae: adhesions from the adipose tissue con- ca). It crosses over the duodenum and the right ureter.
tained in the Tela subserosa
The vermiform appendix, rectum and anal canal differ from the
other sections of the large intestine:
Clinical remarks
• No taenia, but rather a closed longitudinal muscular layer Because as a rule, the distal suspension of the Pars ascen-
• No Haustra coli dens of the duodenum does not lead to reflux of chyme, the
• Folds: not present in the appendix but in the rectum as 3 irregu- TREITZ muscle also marks the boundary between upper and
lar horizontal folds (Plicae transversae recti), in the anal canal as lower intestinal bleeding. This classification is of clinical rele-
vance since for both forms of haemorrhage experiences are
longitudinal folds (Columnae anales)
available on the most frequent causes and the most meaning-
• No Appendices epiploicae ful diagnostic steps for clarification. A frequent source of
bleeding (erosion of the A. gastroduodenalis) is ulcers of the
duodenum (Ulcera duodeni), which clinically do not clearly
7.2.7 Topography of small and large intestines differ from stomach ulcers (› Chap. 7.1.6). Malignant tumors,
however, are rare in the duodenum.
Topography of the small intestine For the evaluation of these diseases, there are various diag-
nostic options. The x-ray contrast imaging has become less
The Pars superior of the of the duodenum is located behind the
important in recent years, since it is inferior to colonoscopy
neck of the gall bladder and is in direct contact with the Facies vis- (duodenoscopy) which in addition to an inspection of the mu-
ceralis of the liver, with which it is also connected via the Lig. he­ cosa, also allows a biopsy to be taken.
patoduodenale. The Lig. hepatoduodenale contains the vessels and
nerves of the liver as well as the extrahepatic bile ducts and borders
the entrance to the Bursa omentalis (Foramen omentale/epiploi-
cum). The Ductus choledochus runs dorsal to the Pars superior Topography of the large intestine
duodeni. The caecum is in the right Fossa iliaca (› Fig. 7.19a). In the transi-
Behind the Pars descendens of the duodenum, albeit separated by tion area between the caecum and the terminal ileum, there are of-
their different fascial systems, are the right kidney and adrenal ten bulges in the peritoneal cavity (Recessus ileocaecales superior
gland. The pancreatic head adjoins its medial surface, which is ori- and inferior). The Appendix vermiformis usually lies in the Reces-
ented to the left. The Colon ascendens ascends lateral to the Pars sus retrocaecalis.The caecum and appendix lie on the right M. ilio-
descendens. psoas and thus have a positional relationship to various nerves of
The Pars horizontalis of the duodenum crosses the spine below the Plexus lumbalis (N. cutaneus femoris lateralis, N. femoralis and
the pancreatic head, the aorta and the V. cava inferior with the N. genitofemoralis) as well as the A. testicularis/ovarica. In this
right Vasa testicularia/ovarica and the right ureter. The Pars hori- area, the pendulous type of Appendix vermiformis may come in
zontalis is thereby covered ventrally by the jejunum and ileum, the close proximity to the ovaries and fallopian tubes.
Colon transversum and the mesenteric root (with A. and V. mesen- The Colon ascendens then rises, covered by the small intestine
terica superior). convolute and in front of the Nn. cutanei femoris lateralis, iliohy-
The Pars ascendens rises to the Flexura duodenojejunalis and is pogastricus and ilioinguinalis up to the lower surface of the right
fixed via a peritoneal duplicature (Lig. suspensorium duodeni, lobe of the liver, thereby also touching the fundus of the gall blad-

Plicae semi-
Omentum majus lunares coli

Taenia omentalis

Taenia
Haustra coli mesocolica

Mesocolon
transversum Fig. 7.18 Structural features of
Taenia libera the large intestine (Intestinum
crassum) exemplified by the
Appendices epiploicae transverse colon. Ventral caudal
view.

316
 7.2 Intestines

der at the right colic flexure (also called the hepatic flexure). Behind the Taenia omentalis of the Colon transversum hangs the apron-
the right colic flexure (Flexura colica dextra) is the right kidney shaped section of the Omentum majus and covers the small and
and medial thereof the Pars descendens of the duodenum (› Fig. large intestines. Behind the Colon transversum to the right lies the
7.19a). Pars descendens of the duodenum and the pancreatic head, in the
The Colon transversum is connected via the Mesocolon transver- middle the small intestine convolute from the jejunum and ileum,
sum with the posterior abdominal wall and via the Lig. gastrocoli- and the Flexura duodenojejunalis to the right.
cum with the stomach. The Mesocolon transversum lies on the The left colic flexure (Flexura colica sinistra; › Fig. 7.19b) is usually
posterior wall of the stomach and thereby limits the main space of further cranial and dorsal than the right colic flexure and is gen­
the Bursa omentalis both to the rear and below (› Fig. 7.3d). From erally at more of an acute angle. It is connected via the Lig. phren-

Spleen [Lien]

Cauda pancreatis
Ren [Nephros]

M. transversus Duodenum,
abdominis Pars descendens

Flexura
coli dextra
Flexura
N. iliohypo-
coli sinistra
gastricus
N. ilioinguinalis A.; V. testi- Ren
cularis/ovarica [Nephros]
Crista iliaca Colon ascendens

M. iliacus M. psoas major

Colon trans-
versum Ureter

N. cutaneus
V. mesenterica
femoris lateralis
inferior Colon
Caecum descendens

a b
N. femoralis
Appendix vermiformis
N. genitofemoralis

Spleen [Lien]
Ren
[Nephros]
A.; V. testicularis/ovarica Ureter
Flexura coli
M. psoas major
sinistra
N. subcostalis

N. iliohypogastricus

M. transversus
abdominis N. genito-
femoralis
N. ilioinguinalis
A.; V. testi-
cularis/ovarica
Colon descendens A.; V. iliaca
interna
Colon
M. psoas major
M. iliacus sigmoideum

N. cutaneus
femoris lateralis A.; V. iliaca externa
N. genito-
femoralis M. piriformis N. obturatorius

N. femoralis
c d

Fig. 7.19 Positions of the various sections of the colon. a Caecum, Colon ascendens and right colic flexure b Colon transversum and left colic
flexure c Colon descendens d Colon sigmoideum [G210].

317
7 Abdominal viscera

icocolicum with the abdominal wall and in the thus formed splenic lis from the catchment area of the Truncus coeliacus from crani-
niche, is in direct contact with the Facies visceralis of the spleen (in al. The A. gastroduodenalis runs directly behind the Pars superi-
English therefore ‘splenic flexure’). Behind the left colic flexure are or duodeni (various small branches of the A. gastroduodenalis
the pancreatic tail and, separated by their sheaths, the left kidney. above and below the Pars superior duodeni are known as A. su-
The Colon descendens then rises ventral to the kidney into the left praduodenalis and Aa. retroduodenales).
Fossa iliaca and thereby crosses the nerves of the Plexus lumbalis • A. pancreaticoduodenalis inferior (with R. anterior and R. pos-
(› Fig. 7.19c). terior) from the A. mesenterica superior from caudal.
In the left lower abdomen the Colon sigmoideum bulges outwards
with its Mesocolon sigmoideum variably deep into the peritoneal Arteries of the jejunum and ileum
cavity of the pelvis and makes contact with the small intestine and The small intestine convolute of jejunum and ileum is supplied by
urinary bladder (› Fig. 7.19a); in women, contact is also made with the A. mesenterica superior which runs with its branches (usually
the intraperitoneal internal genital organs (uterus, ovarian and 4–5 Aa. jejunales and 12 Aa. ileales) within the mesentery of the
fallopian tube). In doing so, it forms a Recessus intersigmoideus small intestine (› Fig. 7.21). The vessels form a series of 3 (jeju-
that can vary greatly in size. The Colon sigmoideum crosses the left num) to 5 arcades (ileum) in descending order of size along the in-
Vasa testicularia/ovarica, the left N. obturatorius, the ureter, as well testine, from which the vascular branches extend up to the intes-
as the Vasa iliaca externa and interna. tine wall.

Arteries of the large intestine

7.2.8 Intestinal arteries • Caecum and Appendix vermiformis: A. ileocolica as the end
section of the A. mesenterica superior results in the following
The small and large intestines are made up of the 3 major un- branches:
paired visceral arteries that emerge ventrally from the abdominal – R. ilealis to the terminal ileum (connected with the last A. ile-
aorta (Truncus coeliacus, A. mesenterica superior, A. mesenterica alis)
inferior). Since the arteries can communicate with each other – R. colicus (proximally connected with the A. colica dextra)
through well-formed anastomoses (BÜHLER's and RIOLAN's – A. caecalis anterior and A. caecalis posterior ventral and
anastomoses) at the boundaries of their innervation and supply ar- dorsal to the caecum
eas, bypass circulations are enabled that can fully compensate for – A. appendicularis, which almost always (99%) runs dorsal to
the closure of an artery in a particular instance. The innervation the ileum before it enters the mesoappendix, via which it sup-
and supply areas correspond to the evolutionary divisions of the plies the Appendix vermiformis
intestine in the foregut, midgut and hindgut and not the macro- • Colon ascendens and Colon transversum:
scopic divisions into the small and large intestines. It is therefore – A. colica dextra with an ascending and descending branch
easy to understand why anastomoses are found between the vessels (for Colon ascendens)
in the area of the duodenum and the left colic flexure. – A. colica media with a right and left branch (for Colon trans-
versum)
Arteries of the duodenum Both arteries originate (often with a common stem) from the A.
The blood supply of the duodenum takes a double vascular arch, mesenterica superior and anastomose with each other
ventrally and dorsally that is fed cranially and caudally, respectively • Colon descendens and Colon sigmoideum: A. mesenterica infe-
(BÜHLER’s anastomosis; › Fig. 7.20): rior with the following branches:
• Aa. pancreaticoduodenales superiores anterior and posterior, – A. colica sinistra with an ascending and descending branch
which represent the terminal branches of the A. gastroduodena- for the Colon descendens

Truncus coeliacus
A. hepatica communis

A. hepatica propria A. gastrica

sinistra
A. gastroduodenalis
A. splenica
A. pancreaticoduodenalis [lienalis]
superior posterior

A. pancreatico-
duodenalis
superior anterior

A.; V. mesenterica
superior
BÜHLER's
anastomosis

R. posterior
A. pancreaticoduodenalis inferior Fig. 7.20 Arteries of the duode-
R. anterior num. Ventral view. (according to
[S010-1-16])

318
 7.2 Intestines

Colon ascendens

A. colica media A. mesenterica

superior
A. colica dextra
Jejunum
A. ileocolica

R. colicus Aa. jejunales

R. ilealis

A. caecalis anterior

A. appendicularis

Caecum Aa. ileales

Appendix vermiformis
Fig. 7.21 Arteries of the jeju-
Ileum num and ileum. Ventral view.
Colon transversum folded
upwards. (according to
[S010-1-16])

Colon transversum RIOLAN’s anastomosis

DRUMMOND’s
anastomosis

Colon descendens
Colon ascendens

A. colica media A. mesenterica superior

A. mesenterica inferior
A. colica dextra
A. colica sinistra
A. ileocolica

R. colicus

A. caecalis Aa. sigmoideae

anterior

Caecum Colon sigmoideum

Appendix
vermiformis
Fig. 7.22 Arteries of the large
intestine. Ventral view. Colon
A. appendicularis Rectum A. rectalis superior transversum folded upwards.
(according to [S010-1-16])

– Aa. sigmoideae (2–5) for the Colon sigmoideum (93%) connection in one of the arcades close to the intestines is re-
– A. rectalis superior, supplies the rectum and the upper anal ferred to as DRUMMOND’s anastomosis. This designation is,
canal however, seldom used in clinical practice in English and the term
Between the left third of the Colon transversum and the left colic ‘DRUMMOND's artery’ is not specifically used for vascular con-
flexure the innervation and supply areas of the Aa. mesentericae nections on the left colic flexure, but refers to the vessels as the
superior and inferior do not end abruptly, but the A. colica media marginal artery (A. marginalis coli) which directly flows from the
almost always has a connection to the A. colica sinistra (RIOLAN's different sections of the large intestine (therefore also, e.g. the Co-
anastomosis; › Fig. 7.22). Occasionally, the mostly available lon ascendens).

319
7 Abdominal viscera

NOTE
The innervation and supply areas between the intestinal arteries
Clinical remarks
correspond to the developmental history of the intestinal sections. In the case of high pressure in the portal vein (portal hyperten-
At the borders in the area of the duodenum and the left colic flex- sion), e.g. in cirrhosis of the liver, connections to the drainage
ure, anastomoses enable sufficient bypass circulations. The most area of the V. cava superior and V. cava inferior (portocaval
important vascular connection in terms of surgery is RIOLAN's anastomosis) can open up or be formed (› Fig. 7.32). This
anastomosis. In contrast, the terms BÜHLER's and DRUMMOND's also includes connections of the V. rectalis superior to the
anastomosis are not used everywhere in clinical practice. V. rectalis media and V. rectalis inferior, which take blood to
the V. cava inferior. These do not lead, as was previously as-
sumed, to the formation of haemorrhoids; however, when us-
Clinical remarks ing suppositories, it must be borne in mind that active ingredi-
ents can be administered via the inferior veins of the rectum
The short circuit connections between the A. colica media and and into the systemic circulation in order to avoid the portal
A. colica sinistra, which in clinical terms are usually collectively vein and thus the liver, which partially breaks down and elimi-
known as RIOLAN's anastomosis, take on a role in the event of nates the active substances.
circulatory disorders, e.g. with arteriosclerosis or displaced
blood clots (emboli). Similar connections exist in the area of
the duodenum and the rectum. Even complete occlusion of
one of the 3 unpaired abdominal arteries (Truncus coeliacus,
A. mesenterica superior, and A. mesenterica inferior) can large-
ly be compensated for without intestinal infarction occurring. 7.2.10 
Lymph vessels of the intestine
Circulatory disorders of the intestine are usually characterised
by abdominal pain which occurs after eating (postprandial The intestine has 2 large drainage areas, in which 100–200 lymph
pain). The collateral circulations through the rectum not only nodes in multiple lymphatic drainage stations are connected in se-
serve to supply the large intestine but at the closure of the dis- ries (› Table 7.4, › Fig. 7.23).
tal aorta or the A. iliaca communis can also maintain a certain The lymph from the entire intraperitoneal small intestine convolute,
amount of blood supply to the legs via the A. mesenterica infe-
rior (and its A. rectalis media) and via the A. iliaca interna.
as well as from the ‘right-sided colon’ (Caecum, Colon ascendens
In the case of colon cancer a hemicolectomy is usually car- and transversum) ultimately lead to the Nodi lymphoidei mesen-
ried out. In the case of a tumour in the Colon descendens, terici superiores along the A. mesenterica superior, before they are
within the context of a left-sided hemicolectomy, the Colon carried via the Trunci intestinales to the Ductus thoracicus.
descendens, together with the entire A. mesenterica inferior is In contrast, the ‘left-sided colon’ (Colon descendens and Colon
removed. In contrast, in a right-sided hemicolectomy for treat- ­sigmoideum, proximal rectum) drain to the Nodi lymphoidei
ment of a tumour in the Colon ascendens, the intestine with mesenterici inferiores, of which the lymph arrives via the two
the entire A. mesenterica superior will not be removed, since
these also supply the largest part of the small intestine. Accord-
Trunci lumbales in the Ductus thoracicus.
ingly, in addition to the Colon ascendens, only the A. colica In contrast, the lymph from the duodenum is routed via the Nodi
dextra, and in the event of an extended right-sided hemicolec- lymphoidei pancreaticoduodenales and the Nodi lymphoidei he-
tomy, the Colon transversum with the A. colica media will also patici along the respective arteries either to the Nodi lymphoidei
be resected. coeliaci or even the Nodi lymphoidei mesenterici superiores.

Clinical remarks
7.2.9 Veins of the intestine The lymphatic drainage plays a role in the diagnosis of colon
carcinomas since the therapeutic approach depends on the
The veins correspond to the arteries and drain into the main tribu- stage of the disease (staging). In the case of a tumour in the
taries of the portal vein (V. portae hepatis) (› Fig. 7.31). The Colon ascendens or in the Colon transversum, lymph nodes in
the drainage area of the Nodi lymphoidei mesenterici superi-
V. mesenterica superior joins behind the pancreatic neck with the
ores should be looked for; however, for tumours in the Colon
V. splenica to the V. portae hepatis. It has the following branches: descendens, the lymph nodes in the drainage area of the infe-
• V. gastroomentalis dextra rior mesenteric lymph nodes are relevant, which, based on the
• Vv. pancreaticoduodenales (the V. pancreaticoduodenalis supe- retroperitoneal course of the A. mesenterica inferior along
rior posterior drains directly into the portal vein) which they lie, frequently prove to connect to other retroperi-
• Vv. pancreaticae toneal lymph nodes (Nodi lymphoidei lumbales).
• Vv. jejunales and ileales
• V. ileocolica
• V. colica dextra
• V. colica media 7.2.11 Innervation of the intestine
The V. mesenterica inferior mostly drains (70% of cases) into the
V. splenica, in some cases (30%) into the V. mesenterica superior or The intestine is, like most viscera, innervated both by the sympa-
the origin of the portal vein. Branches of the V. mesenterica inferi- thetic nervous system as well as the parasympathetic nervous sys-
or are: tem. The parasympathetic nervous system promotes the peristal-
• V. colica sinistra tic movement and the secretion of the glands of the intestinal mu-
• Vv. sigmoideae cosa. The sympathetic nervous system, on the other hand, inhibits
• V. rectalis superior: drains the majority of the blood from the this function, as well as the circulation of the mucosa and thus nu-
rectum and the upper anal canal – the vein is connected to the trient absorption, but activates the muscles of the ileocecal valve.
V. rectalis media and to the V. rectalis inferior, which lead blood The intestine is innervated by the Plexus coeliacus as well as the
into the V. cava inferior Plexus mesenterici superior and inferior (Plexus aorticus abdomi-
nalis with sympathetic ganglions). The plexus contains sympathetic

320
 7.2 Intestines

Trunci Ductus
Cisterna chyli intestinales thoracicus
Nodi lymphoidei
mesenterici superiores
Trunci lumbales

Nodi lymphoidei
mesocolici
Nodi lymphoidei
colici medii

Nodi lymphoidei Nodi lymphoidei

paracolici colici sinistri

Nodi lymphoidei
Nodi lymphoidei mesenterici inferiores
colici dextri

Nodi lymphoidei Nodi lymphoidei

ileocolici iliaci interni

Nodi lymphoidei
juxtaintestinales
Fig. 7.23 Lymph vessels and
Nodi lymphoidei
regional lymph nodes of the
lumbales small intestine and the large
intestine. The individual groups
Nodi lymphoidei of lymph nodes are coloured dif-
inguinales ferently according to their catch-
ment areas. (according to
[S010-1-16])

Table 7.4 Lymphatic drainage stations of the intestine.

Drainage station Location

Lymphatic drainage stations of the duodenum
Nodi lymphoidei pancreaticoduodenales At the pancreas head
Nodi lymphoidei hepatici Along the A. hepatica
‘Nodi lymphoidei gastroduodenales’ Along the A. gastroduodenalis
Nodi lymphoidei coeliaci Retroperitoneal
Nodi lymphoidei mesenterici superiores Along the A. mesenterica superior to the outlet (predominantly intraperitoneal)

Lymphatic drainage stations from the Jejunum and Ileum

Nodi lymphoidei juxtaintestinales Directly at the attachment of the mesentery on the intestines
Nodi lymphoidei superiores centrales Along the A. mesenterica superior
Nodi lymphoidei mesenterici superiores Along the A. mesenterica superior to the outlet (predominantly intraperitoneal)

Lymphatic drainage stations from the caecum, appendix, Colon ascendens and Colon transversum
Nodi lymphoidei paracolici At the vascular arcade directly on the intestines
Nodi lymphoidei precaecales At the vascular arcade directly on the intestines
Nodi lymphoidei retrocaecales At the vascular arcade directly on the intestines
Nodi lymphoidei appendiculares At the vascular arcade directly on the intestines
Nodi lymphoidei ileocolici Along the A. ileocolica
Nodi lymphoidei colici dextri Along the A. colica dextra
Nodi lymphoidei colici medii Along the A. colica media
Nodi lymphoidei mesocolici On the Mesocolon transversum
Nodi lymphoidei superiores centrales Along the A. mesenterica superior
Nodi lymphoidei mesenterici superiores Along the A. mesenterica superior to the outlet (predominantly intraperitoneal)

Lymphatic drainage stations from Colon descendens and Colon sigmoideum and proximal rectum
Nodi lymphoidei paracolici At the vascular arcade directly on the intestines
Nodi lymphoidei rectales superiores At the vascular arcade directly on the intestines
Nodi lymphoidei mesenterici inferiores At the trunk and exit of the A. mesenterica inferior (retroperitoneal)

321
7 Abdominal viscera

Table 7.5 Innervation of the intestine. in pain. Accordingly, diseases in the Colon descendens and Co-
lon sigmoideum, e.g. inflammation of bulges in the intestinal
Section of the Innervation wall (diverticulitis), which are very common in older people,
intestine
can lead to pain radiating into the left lower abdomen and via
Duodenum Sympathetic (T5–12) and parasympathetic (N. vagus) the Plexus lumbalis, to the front of the left thigh.
via the Plexus coeliacus and Plexus mesentericus supe-
rior (Partes superior and descendens up to the Papilla
duodeni major directly from the Truncus vagalis anteri-
or via the Rr. hepatici) NOTE
In terms of developmental history, there is a necessary switch to
Jejunum to Colon Sympathetic (T5–12) and parasympathetic (N. vagus)
the left colic flexure of the innervation and supply areas of all ves-
transversum via the Plexus mesentericus superior
sels and nerves:
Colon descendens to Sympathetic (L1–2) via the Plexus mesentericus inferi- • Blood vessels: A. and V. mesenterica superior ↔ A. and V. mesen-
upper anal canal or, parasympathetic (S2–4) via the Plexus hypogastri- terica inferior
cus inferior • Lymph nodes: Nodi lymphoidei mesenterici superiores ↔ Nodi
lymphoidei mesenterici inferiores
• Sympathetic innervation: Plexus mesentericus superior ↔ Plexus
and parasympathetic fibres, whereby the sympathetic fibres are mesentericus inferior
switched to postganglionic fibres in the ganglia of the same name • Parasympathetic innervation: N. vagus ↔ N. splanchnici pelvici
(CANNON's point)
(Ganglia coeliaca, Ganglia mesenterica superius and inferius),
while the parasympathetic nerve fibres are preganglionic and only
encounter postganglionic neurons (› Fig. 7.52) in the nerve plex-
uses within the intestinal wall (enteral nervous system). 7.3 Liver
While the sympathetic neurons descend from the Plexus coeliacus
to the Plexus mesentericus superior from cranial to caudal and for
the Plexus mesentericus inferior also receive additional nerve fibres
Skills
from the Nn. splanchnici lumbales, the innervation and supply area After working through this chapter you should be able to:
of the N. vagus (cranial parasympathetic nervous system) ends on • identify the vital importance of the liver with its different
the left colic flexure and, therefore, with the Plexus mesentericus functions
superior (traditionally known as the CANNON's point). • show the location of the liver and its peritoneal duplication
in the epigastrium and to describe the development
The left-sided colon sections receive nerve fibres from the sacral
• show the differences between the anatomical and function-
parasympathetic nervous system (S2–4) where they leave as Nn. al structure of the liver, including the liver segments on a
splanchnici pelvici and then in the Plexus hypogastricus inferior specimen and explain the clinical significance
in the vicinity of the rectum are switched to postganglionic neu- • know the arterial, lymphatic and autonomic supply to the liver
rons. Only a small part of the postganglionic nerve fibres ascend to • explain the sensory innervation of the liver capsule
the Plexus mesentericus inferior, as the majority arrive as direct • set out in detail the portal vein system with portocaval anas-
branches to the Colon descendens and Colon sigmoideum and the tomoses and their clinical significance
proximal rectum (› Fig. 7.52). The perivascular nerve plexus then
reach the respective intestinal sections (› Table 7.5).
Sympathic and parasympathic nervous systems also have afferent
nerve fibres. The zone of the transmitted pain in the abdominal 7.3.1 
Overview
wall (HEAD zone) for the small intestine corresponds to der-
matome T10 and for the large intestine, dermatomes T11–L1; how- The liver (Hepar) is the main metabolic organ, the largest digestive
ever, pain localisation is usually very vague in the periumbilical organ and the largest gland (1200–1800 g) in the body.
and epigastric region, and with the Colon ascendens and Colon de- It is located intraperitoneally in the right epigastrium (› Fig. 7.24),
scendens more to the right or left. is divided into two large lobes and is brown in colour. Due to its size,
For the general organisation of the autonomic nervous system in structure and, last but not least, the way it is fixed into the surround-
the abdomen see › Chap. 7.8.5. ings, it determines the entire site of the upper abdomen. Due to the
adhesion with the diaphragm, it follows the respiratory movements.
Clinical remarks
The Plexus coeliacus is the strongest plexus on the Aorta ab- 7.3.2 Functions of the liver
dominalis and is also colloquially known as the ‘solar plexus’.
A blow to the abdomen can mean that visceral reflexes lead to The liver has a wide range of functions and is absolutely essential.
a drop in blood pressure and shortness of breath. Functions:
For the diagnosis of appendicitis, the typical changes to the
• Central metabolic organ and nutrient storage (glycogen, fats,
projection of pain are important. Initially, the pain will diffuse
periumbilically or in the central epigastrium because the map- amino acids, vitamins, metals)
ping of vegetative afferents to specific sections of the abdomi- • Detoxification and excretion function
nal wall is very vague. If subsequently the parietal peritoneum • Production of bile (exocrine gland)
on the fascia of the M. iliopsoas is irritated, the pain shifts • Production of plasma proteins (coagulation, oncotic pressure,
into the right lower abdomen. hormones)
The positional relationship to the M. iliopsoas also explains • Formation of hormones (endocrine gland)
‘psoas signs’, which depending on movement, mostly due to
• Immune defence
tension of the muscle during hip flexion, can lead to an increase
• Breakdown of red blood cells (in the event of haemolysis), as
well as formation of blood (foetal period)

322
 7.3 Liver

Costa V
Hepar, Lobus sinister
Diaphragma
Lig. teres hepatis
Hepar, Lobus dexter

Vesica biliaris [fellea]

*
Fig. 7.24 Projection of the liver
on the ventral torso wall in cen-
tral respiratory position;∗ Posi-
tion of the needle during liver
puncture.

The liver takes up the nutrients absorbed in the intestines, which bud (hepatic diverticulum), which divides into a superior liver
are predominantly transported via the portal vein (glucose, amino ­primordium and an inferior primordium for the bile system (gall
acids, fatty acids, vitamins) or in the same way as lipids are trans- bladder and Ductus cysticus; › Fig. 7.25). The stalk of the liver
ported as lipoproteins by way of the systemic blood circulation. ­diverticulum becomes the Ductus choledochus. The epithelium of
The importance of the liver as the central metabolic organ is also the liver system continues to grow into the Septum transversum,
evident from the fact that some metabolic processes (e.g. the urea which provides the connective tissue of the liver and the islets for
cycle) take place exclusively in the liver. blood formation. The blood vessels formed are connected to the
Glucose is converted into glycogen as needed, which is how vari- umbilical vein (V. umbilicalis), which carries the oxygenated blood
ous vitamins (vitamin A, vitamin B12, folic acid) and iron and cop- from the placenta.
per are stored. The liver is then gradually displaced into the Mesogastrium ven-
A wide variety of plasma proteins, such as albumin, blood coagula- trale, which initially corresponds to the Septum transversum and is
tion factors, hormones and their precursors, and complement pro- thus divided into a Mesohepaticum ventrale and a Mesohepaticum
teins of the non-specific immune system, are synthesised from the dorsale. As a result of stomach rotation, the Mesohepaticum dor-
amino acids. The liver converts lipoproteins from the intestine so sale is drawn out to the Omentum minus, which binds the liver
that they can be used by the tissues of the body and is also the cen- with the stomach and duodenum. Since the abdominal cavity also
tral formation point for cholesterol that is formed depending on increases, the liver separates largely from the ventral wall, so that
the food intake. the Mesohepaticum ventrale is also extended into a thin peritone-
Cholesterol is also converted to bile acids , which as the main com- al duplicature. The liver is thereby largely covered by Peritoneum
ponents of bile undertake diverse tasks. After discharge into the viscerale and only remains fused cranially with its Area nuda at the
bile duct, bile is stored in the gallbladder and in the case of food diaphragm, which partly emerges from the Septum transversum.
intake, it is emptied into the intestine. As a result, it is possible for The Lig. falciforme hepatis forms from the Mesohepaticum ven-
the body to distribute cholesterol and, at the same time to support trale as a connection to the anterior torso wall, in which the V. um-
fat digestion. bilicalis is embedded under the lower free edge, which later obliter-
In addition to the kidneys, the liver is the second major excretory ates to the Lig. teres hepatis.
organ. Some substances generated within the body (e. g. bilirubin)
or exogenous substances (e. g. medications) are detoxified and dis-
charged via the bile into the intestine or are discharged into the 7.3.4 Projection of the liver
blood for excretion via the kidneys.
In addition to plasma proteins, there are also specific cell types in The liver lies in an intraperitoneal position and takes up the ma-
the liver (e. g. KUPFFER cells) that are involved in regulation of jority of the right upper abdomen (› Fig. 7.24). On the left side
the immune system. The liver can, under special circumstances, the liver and the left hepatic lobe reaches as far as the left epigastri-
also be involved in the formation and breakdown of blood cells. In um (approximately up to the left midclavicular line, MCL) where it
this way it can provide support if there is an increase in red blood lies anterior to the stomach.
cells (erythrocytes) that are to be broken down or in the case of de- When the diaphragm is in a normal position, which the liver di-
ficiency can assist the bone marrow in blood formation. Normally, rectly lies underneath, the upper edge of the right hepatic lobe
the liver is like the spleen responsible for the formation of the projects onto the 4th intercostal space (ICS) and the left lies some-
blood but only during the foetal period. what deeper on the Vth rib. Because of the domed shape of the dia-
phragm, the anterior and posterior sides of the liver are covered in
part by the pleural cavity. With a normal anatomy the lower edge of
7.3.3 Development of the liver and gall bladder the liver is covered by the costal arch up to the right MCL.
Overall, it has to be noted that the position of the liver is depen-
The epithelial tissues of the liver (hepatocytes) and gall bladder are dent on breathing as a result of its adhesion to the diaphragm (it
derived from the entoderm of the foregut at the level of the future lowers on inhalation and rises on exhalation).
duodenum. In the 4th week the entoderm forms a ventrally-oriented

323
7 Abdominal viscera

Gaster
Dorsal mesentery
Ventral
mesenterium Foregut section
of the duodenum Hepar
Hepar Dorsal
Dorsal pancreatic pancreatic bud
Ductus choledochus
bud
Vesica biliaris [biliaris] Duodenum
[fellea]
Midgut section Vesica biliaris dorsal
Ventral pancreatic bud of the duodenum [fellea] Mesenterium

a b

Aorta
Gaster Ren
Mesogastrium
Omentum minus dorsale
Spleen [Lien]
Hepar
Truncus
coeliacus

Ventral and dorsal

Lig. falciforme pancreatic buds
V. umbilicalis
c

Fig. 7.25 Developmental stages of the liver (Hepar) and gall bladder (Vesica biliaris) in the 4th–5th weeks. [E581]

Clinical remarks 7.3.5 Structure

The examination of the liver with determination of the liver The liver is divided into a large right and a small left hepatic lobe
size is part of every complete physical examination, as its con- (Lobus hepatis dexter and Lobus hepatis sinister), that are sepa-
sistency and size can provide the first evidence of abnormal
rated anteriorly by the Lig. falciforme hepatis. On the bottom
changes, e.g. fatty liver (in the case of obesity, diabetes melli-
tus, alcohol abuse), inflammation (hepatitis) in the case of edge of the Lig. falciforme, which runs to the front of the abdomi-
infection with hepatitis virus or alcohol abuse or liver cirrhosis nal wall, lies the Lig. teres hepatis (relic of the V. umbilicalis).
as a pathological end stage of most chronic liver diseases. De- A differentiation is made between the upper side lying underneath
termination of the position of the lower liver margin alone is the diaphragm (Facies diaphragmatica) and the lower side facing
not sufficient for estimation of the size of the liver, since the down towards the viscera (Facies visceralis), which anteriorly is de-
size of the lungs and the position of the diaphragm influence limited by the inferior margin (Margo inferior) (› Fig. 7.26). The
the position of the liver margins. If the lungs are enlarged, e.g.
Facies diaphragmatica is partially fused to the diaphragm and is
in the case of pulmonary emphysema in smokers, the liver
may be palpable without it being enlarged. Therefore, on ex- not covered with Peritoneum viscerale (Area nuda).
amination not only the bottom edge of the liver should be On the Facies visceralis, the incision (Fissura ligamenti teretis)
checked by touching (palpation) when breathing in, but also caused by the Lig. teres hepatis continues up to the hepatic porta
the upper edge of the liver by tapping (percussion) of the (Porta hepatis).
chest. When estimating the size of the liver, as a rule of thumb In the Porta hepatis the right and left main tributaries of the vessels
the liver in the right MCL should not have a craniocaudal di- and nerves of the liver mostly enter or leave in the following order:
ameter of more than 12 cm.
• Ductus hepaticus communis (right ventral arrangement)
The projection of the liver is also important for diagnostic pro-
cedures, such as liver puncture, in which it must be ensured • A. hepatica propria (left ventral)
that other organs such as the lungs and kidneys are not acci- • V. portae hepatis (dorsal)
dentally damaged. The Lig. venosum (remnant of the Ductus venosus of foetal circu-
lation) continues the course of the Lig. teres hepatis in a cranial di-
rection.
On the right side of the Porta hepatis the V. cava inferior is located
NOTE
The liver is located intraperitoneally in the right upper abdomen
above in a groove and the gall bladder (Vesica biliaris) is located
and in a central respiratory position with normal anatomy, is not below in the gall bladder fossa (Fossa vesicae biliaris). This close
palpable under the right costal arch. Its position is still largely in- relationship of the V. cava inferior and its afferent hepatic veins is
fluenced by the size of the lungs and the position of the dia- important for the stability of the liver. The Lig. teres hepatis, Lig.
phragm, so an enlargement of the liver does not always need to be venosum, V. cava inferior and gall bladder create an H-shaped
present if the liver is palpable. structure, whose horizontal beams represents the Porta hepatis. Ven-
tral and dorsal of the Porta hepatis, 2 approximately square areas

324
 7.3 Liver

Lig. coronarium

Lig. falciforme Diaphragma

Lig. triangulare
sinistrum
Lig. triangulare
dextrum

Lobus hepatis sinister,

Lobus hepatis dexter, Facies diaphragmatica
Facies diaphragmatica

Lig. falciforme

Lig. teres hepatis

a
Margo Vesica biliaris
inferior [fellea]

Appendix fibrosa hepatis (Lig. venae

Lig. veno- V. cava Area nuda
cavae)
sum inferior
Impressio suprarenalis
Impressio oesophagea

Lobus caudatus Lig. coronarium

V. portae hepatis
Impressio gastrica
Impressio renalis

Ductus choledochus
[biliaris]
A. hepatica propria
A. lobi caudati
Lobus hepatis sinister
Impressio duodenalis
Margo inferior
A. cystica
Porta hepatis
Impressio colica
Fissura ligamenti teretis
Incisura ligamenti teretis Lobus hepatis
Lobus Vesica biliaris dexter
b Lig. teres hepatis quadratus [fellea]

Fig. 7.26 Liver (Hepar). a Ventral view. b Dorsocaudal view.

are defined on the underside of the right hepatic lobe, which are portalis principalis. Then to the right side follow the Divisio medi-
designated ventrally as the Lobus quadratus and dorsally as the alis dextra and the Divisio lateralis dextra, which are separated
Lobus caudatus. These designations are misleading, since they are by the right hepatic vein in the Fissura portalis dextra but there is
more a continuation rather than an independent lobe. no visible landmark for this on the outer surface.
The liver is not covered by peritoneum in 4 larger areas: These 4 vertical divisions are divided by the branches of the liver
• Area nuda triad (V. portae hepatis, A. hepatica propria, Ductus hepaticus com-
• Porta hepatis munis) into 8 liver segments. Segment I corresponds to the Lobus
• Gall bladder bed caudatus, segments II and III the anatomical left hepatic lobe, seg-
• Groove of the V. cava inferior ment IV the Divisio medialis sinistra and segments V–VIII the rest
of the anatomical right hepatic lobe, where the latter are numbered
in a clockwise direction. The Lobus quadratus is a part of segment
7.3.6 
Parts and segments of the liver IVb. Subsequently, a ninth segment, which lies between segment
VIII and I could be described, but is so far hardly taken into account
The liver is divided into 8 functional segments. Thereby, the 3 ver- in surgery.
tically running hepatic veins (Vv. hepaticae; › Fig. 7.27), which In functional terms it is important that segments I–IV are supplied
together with their surrounding connective tissue are referred to as by the left branches of the liver triad and, therefore, in contrast to
fissures, divide the liver into four adjacent divisions. The Divisio the macroscopically visible hepatic lobes, collectively belong to the
lateralis sinistra corresponds to the left anatomical lobe of the liv- left part of the liver (Pars hepatis sinistra), while segments V–VIII
er and reaches as far as the Lig. falcifome hepatis, behind which the are dependent on the right branches of the liver triad and represent
left hepatic vein runs into the Fissura umbilicalis. The Divisio me- the functional right side of the liver (Pars hepatis dextra). Only
dialis sinistra extends between the Lig. falciforme and the gall segment I is regularly supplied from the branches of both sides.
bladder, at which height the middle hepatic vein lies in the Fissura

325
7 Abdominal viscera

V. cava inferior

V. hepatica dextra V. hepatica intermedia

V. hepatica
sinistra
VIII
VII IVa II

I I

Ductus hepaticus
communis III

IVb

V Lig. falciforme
VI I Segmentum posterius (Lobus caudatus)
hepatis
II Segmentum posterius laterale sinistrum
Lig. teres III Segmentum anterius laterale sinistrum
Vesica biliaris V. cava inferior
hepatis IV (a/b) Segmentum mediale sinistrum
[fellea] Ductus A. hepatica propria V Segmentum anterius mediale dextrum
cysticus VI Segmentum anterius laterale dextrum
Ductus choledochus
VII Segmentum posterius laterale dextrum
Lig. hepatoduodenale V. portae hepatis VIII Segmentum posterius mediale dextrum

Fig. 7.27 Liver segments and their relationship with the intrahepatic vessels and bile ducts. Ventral view. (according to [S010-1-16])

Thus, the border between the functional right and the functional such as plasma proteins into the blood. It should be taken into ac-
left part of the liver in the sagittal plane is between the V. cava infe- count that the blood flows to the centre of the lobules and therefore
rior and the gall bladder (‘Cava gall bladder plane’) and not at the flows in the reverse direction to bile, which is routed between the
level of the Lig. falcifome hepatis. hepatocytes to the periphery where it flows into the intrahepatic
bile ducts in the periportal field.
NOTE
The liver is divided into 8 segments, of which segments I–IV in line
with their blood supply, belong to the functional left part of the
Clinical remarks
liver and segments V–VIII to the functional right part. Thus, the The blood flow in the hepatic lobules is extremely important
functional left part of the liver is greater than the anatomical left for maintenance of the liver function. If the structure of the
hepatic lobe. lobules in the event of liver cirrhosis are destroyed by nodu-
lar, connective tissue reorganisation (pseudo-lobules), the
blood flow is impaired. The high parenchymal resistance
Clinical remarks in the liver results in an increased blood pressure in the
­portal vein (portal hypertension). As a result, bypass circuits
The liver segments have a great clinical significance in viscer- can form (portocaval anastomoses, › Chap. 7.3.11) (› Fig.
al surgery, as they make it possible to carry out resections of 7.29).
individual parts of the liver with little loss of blood, as long as
the segment borders are observed. This means that in patho-
logical processes, e.g. liver metastases, several individual
segments in different parts of the liver can be resected with- A = central vein lobe V. hepatica
out compromising the liver function as a whole. In practical B = portal lobe
terms, the surgeon proceeds in the removal of the segments C = acinus of liver
V. sublobularis
by ligating individual branches of the afferent vessels in order
to be able to clearly identify the dependent liver segments by
their discoloration due to the reduced blood flow.
V. centralis
A.; V.; Ductus
interlobularis

7.3.7 Fine structure of the liver

Tip: The following brief explanation of the histology serves to un- B

derstand the blood flow through the liver and the understanding of C A
how a portal hypertension occurs when it stops working: the he-
patic parenchyma is divided into hepatic lobules (› Fig. 7.28). At
the corners are the periportal fields, in which the terminal branch­
es of the liver triad are found. In the centre of the liver lobules the
V. centralis, which collects the blood from the blood vessels of the
A. hepatica propria,
liver triad again after it has flowed past the liver cells (hepatocytes) ramus
and carries it via the Vv. sublobulares to the Vv. hepaticae. This al- Ductus hepaticus, ramus V. portae, ramus
lows the hepatocytes to extract nutrients and substances to be
eliminated from the blood and to secrete synthesised substances, Fig. 7.28 Lobular subdivision of the liver parenchyma. [L126]

326
 7.3 Liver

Liver cirrhosis
a

Compressed branches Pseudo-lobes

of the Vv. hepaticae

Branch of the
A. hepatica propria
Short circuit connection
("shunt") between
portal vein and hepatic vein Fig. 7.29 Liver cirrhosis. [L266]
Branch of the a Section through the liver.
Arteriovenous portal vein
b anastomosis b Formation of pseudo-lobules.
[L266]

7.3.8 Topography outflow. Vice versa, cleavage of the Lig. triangulare dextrum or

Lig. triangulare sinistrum enables mobilisation of the respec-
In vivo the liver is malleable and adjusts to the shape of the surround- tive hepatic lobes when access to the V. cava inferior, the oe-
ing organs. In a fixed state the adjacent organs leave marks (impres- sophagus or diaphragm is necessary. Due to the arterial con-
sions), which are regarded as fixation artefacts and are not significant; nections between segment IV and the supply area of the A.
however, they provide information about the positions of the liver. thoracica interna in the Lig. teres hepatis, this ligament must
generally be ligated or coagulated in all operations in the right
The liver has direct positional links to the following adjacent or- upper abdomen that require mobilisation of the liver, in order
gans (› Fig. 7.26): to avoid bleeding.
• Right hepatic lobe: kidneys, adrenal glands, duodenum, colon
• Left hepatic lobe: oesophagus, stomach
The liver is connected through a series of peritoneal duplicatures, The origin of the lesser omentum (Omentum minus), is on the Fa-
which are referred to as ligaments (Ligamenta), above with the dia- cies visceralis, which after its attachment, is divided into a Lig.
phragm near the Area nuda, anteriorly with the abdominal wall hepatogastricum and a Lig. hepatoduodenale. In the Lig. hepato-
and caudally with the neighbouring organs. These ligaments origi- gastricum the parasympathetic Rr. hepatici run from the Trunci
nate from the ventral ‘Meso’ of the intestine (Mesogastrium ven- vagales to the liver and in this way the Rr. pylorici to the stomach.
trale). On the Facies diaphragmatica the Lig. falciforme hepatis In the Lig. hepatoduodenale the components of the liver triad run
continues cranially to the Lig. coronarium. This surrounds the in the following arrangement to the liver:
Area nuda and runs on the right and left each into a Lig. triangu- • right: Ductus choledochus
lare as a connection to the diaphragm. The Lig. triangulare sinis- • left: A. hepatica propria
trum runs over into the peak-shaped Appendix fibrosa hepatis. Be- • dorsal: V. portae hepatis
low the Lig. teres hepatis (a relic of the V. umbilicalis from the foe- • in addition: lymph vessels, lymph nodes and autonomic nerves
tal circulation) joins the Lig. falciforme. Both ligaments run to the (Plexus hepaticus)
ventral wall and contain fine arteries, veins (Vv. paraumbilicales) Under the Lig. hepatoduodenale is the entrance to the Bursa
and lymph vessels, via which the liver connects to the vessels and omentalis (Foramen omentale/epiploicum), which represents a re-
nerves of the anterior torso wall. cess (Recessus) of the peritoneal cavity behind the Omentum mi-
nus or the stomach.
Clinical remarks
The liver connections are of great importance in surgery. The 7.3.9 Arteries of the liver
Lig. triangulare sinistrum stabilises the left hepatic lobe if the
(functional) right half of the liver must be removed and there The liver is supplied with blood by the A. hepatica propria (› Fig.
by prevents a rotation of the lobe and disruption of the venous 7.30). This is the continuation of the A. hepatica communis, a main
branch of the Truncus coeliacus. After branching of the A. gastrica

327
7 Abdominal viscera

A. hepatica propria Lobus hepatis sinister

Lig. teres hepatis Truncus coeliacus

Ductus hepaticus communis A. gastrica sinistra
Vesica biliaris [fellea] Gaster
A. cystica Spleen [Lien]
Ductus cysticus
A. hepatica
V. portae hepatis communis

Ductus choledochus A. splenica [lienalis]

[biliaris]

A. gastrica dextra A. gastroomentalis sinistra

Duodenum
A. mesenterica superior Fig. 7.30 Arteries of the liver
A. gastroduodenalis A. gastroomentalis dextra (Hepar) and the gall bladder
(Vesica biliaris).

dextra, the A. hepatica propria runs in the Lig. hepatoduodenale In the area of the hepatic porta the portal vein divides into its right
together with the V. portae hepatis and the Ductus choledochus to and left main stem.
the hepatic portal. There it is normally divided into a R. dexter and Branches of the V. splenica (collect blood from the spleen and
a R. sinister for the two functional liver parts. from parts of the stomach and pancreas):
In 10–20% of cases, the A. mesenterica superior contributes to the • Vv. gastricae breves
blood supply of the right hepatic lobe, and the A. gastrica sinistra • V. gastroomentalis sinistra
contributes to the supply of the left hepatic lobe (accessory hepatic • V. gastrica posterior (inconstant)
arteries). Rarely, the entire A. hepatica communis or propria origi- • Vv. pancreaticae (from the tail and body of the pancreas)
nates from the A. mesenterica superior (3%). Branches of the V. mesenterica superior (collect blood from parts
of the stomach and pancreas, from the entire small intestine, the
Colon ascendens, and Colon transversum):
Clinical remarks • V. gastroomentalis dextra with Vv. pancreaticoduodenales
The variations of the arterial liver supply are of clinical impor- • Vv. pancreaticae (from the head and body of the pancreas)
tance: • Vv. jejunales and ileales
• Accessory hepatic arteries can be injured during surgical • V. ileocolica
procedures in the right upper abdomen and can cause • V. colica dextra
bleeding (e.g. the right accessory artery, in surgery of the
• V. colica media
pancreatic head or left accessory artery during cleavage of
the Omentum minus, in which it runs). Branches of the V. mesenterica inferior (collect blood from the
• Accessory hepatic arteries can be decisive for survival in pa- Colon descendens and the upper rectum):
tients with bile duct carcinoma, as they are further away • V. colica sinistra
from the main stems of the Ductus hepaticus communis and • Vv. sigmoideae
are therefore not infiltrated by the tumour. • V. rectalis superior: the vein is connected to the V. rectalis media
• For liver transplantations the supply pattern must be known. and the V. rectalis inferior, which belong to the catchment area
of the V. cava inferior.
In addition, there are also veins which drain directly into the por-
tal vein after the main venous branches have merged:
7.3.10 Veins of the liver • V. cystica (from the gall bladder)
• Vv. paraumbilicales (via veins in the Lig. teres hepatis from the
The liver has an afferent and an efferent venous system. abdominal wall around the umbilicus)
• The portal vein (V. portae hepatis) leads the nutrient-rich blood • Vv. gastricae dextra and sinistra (from the small stomach curva-
from the unpaired abdominal organs (stomach, intestines, pan- ture)
creas, spleen) to the liver (› Fig. 7.31). • V. pancreaticoduodenalis superior posterior (dorsal from the
• The 3 hepatic veins (Vv. hepaticae) transport the blood from the pancreatic head)
liver to the V. cava inferior.
The portal vein is approximately 7 cm long and has 3 main tribu-
taries (V. mesenterica superior, V. splenica, V. mesenterica inferi- 7.3.11 
Portocaval anastomoses
or):
• The V. mesenterica superior joins with the V. splenica behind Connections of the V. portae hepatis to the drainage area of the Vv.
the pancreatic neck to become the V. portae hepatis. cavae superior and inferior are referred to as portocaval anastomo-
• The V. mesenterica inferior mostly drains (70% of all cases) into ses. These vascular connections are clinically important (and ex-
the V. splenica, in some cases (30%) into the V. mesenterica su- tremely relevant for examinations).
perior or the confluence of the main stems. There are 4 possible bypass circulations through portocaval anasto-
After the joining of its main stems, the portal vein initially runs moses:
secondarily retroperitoneally behind the pancreas and duodenum • V. gastrica dextra and V. gastrica sinistra connected through
and after the entry into the Lig. hepatoduodenale intraperitoneal. oesophageal veins and azygos veins to the V. cava superior. In

328
 7.3 Liver

Oesophagus Vv. oesophageae

V. cava inferior
Vv. hepaticae
Gaster
Hepar

V. gastrica sinistra V. splenica [lienalis]

V. portae hepatis
Vv. gastricae
V. gastrica dextra breves

Spleen [Lien]
V. cystica

Vesica biliaris [fellea] V. gastroomentalis

sinistra
V. mesenterica
superior V. mesenterica
inferior
V. gastroomentalis
dextra V. colica media

Vv. pancreatico-
V. colica sinistra
duodenales

Colon ascendens Duodenum

V. colica dextra
Vv. jejunales;
Vv. ileales
V. ileocolica
Colon descendens

Vv. sigmoideae
V. appendicularis

Rectum V. rectalis superior

Fig. 7.31 Veins of the liver
(Hepar) and the gall bladder
(Vesica biliaris). Ventral view.

this case, expansion of the submucosal veins of the oesophagus ble. Alternatively, a balloon catheter can be introduced from
(oesophageal varices) can occur. the V. cava inferior through the liver tissue to establish a con-
• Vv. paraumbilicales are connected via the veins of the anterior nection between the Vv. hepaticae and the blocked branches
torso wall (deep: V. epigastrica superior and V. epigastrica inferi- of the portal vein (transjugular intrahepatic portosystemic
or; superficial: V. thoracoepigastrica and V. epigastrica superfi- shunt, TIPS).
cialis) to the superior and inferior vena cava. The dilation of the
superficial veins may lead to Caput medusae.
• V. rectalis superior via veins of the lower rectum and the V. ilia-
ca interna to the V. cava inferior. Rarely, varicosities form around 7.3.12 Lymph vessels of the liver
the anus and so this must not be confused with haemorrhoids.
• Retroperitoneal anastomoses via the V. mesenterica inferior to The liver has 2 lymphatic vascular systems (› Fig. 7.33):
the V. testicularis/ovarica with connection to the V. cava inferior. • the superficial subperitoneal system on the surface of the liver
• the deep intraparenchymatous system that follows the compo-
nents of the hepatic triad to the hepatic porta.
Clinical remarks With respect to the regional lymph nodes, there are 2 major lymph
In the case of high pressure in the portal vein circulation (por- drainage routes:
tal hypertension), e.g. in cirrhosis of the liver, the connections • Caudally to the hepatic porta (most important drainage route)
to the drainage area of the V. cava superior and V. cava inferior via the Nodi lymphoidei hepatici on the hepatic porta and from
(portocaval anastomosis) can become opened up or dilated there through lymphatic vessels in the Lig. hepatoduodenale to
(› Fig. 7.32). Clinically important are the connections to the
the Nodi lymphoidei coeliaci at the outlet of the Truncus coelia-
oesophageal veins because rupture of oesophageal varices
may result in life-threatening haemorrhaging, the most com- cus and from there to the Trunci intestinales.
mon cause of death in patients with liver cirrhosis. The con- • Cranially through the diaphragm (through the Foramen v. ca-
nections to superficial veins of the ventral abdominal wall are vae and the Hiatus oesophageus) via the Nodi lymphoidei
only of diagnostic value. Although a Caput medusae is rare, phrenici inferiores and superiores in the Nodi lymphoidei medias-
the appearance is so characteristic that liver cirrhosis cannot tinales, which connect to the Trunci bronchiomediastinales. In
be overlooked. In contrast, the retroperitoneal connections this way, liver carcinomas can also result in thoracic lymph node
and anastomoses between the veins of the rectum are not
metastases. Individual lymphatic vessels within the Lig. coronari-
clinically significant.
In terms of treatment, a ligature and sclerotherapy of oesoph- um and the Ligg. triangularia can also draw directly into the
ageal varices in the event of high portal hypertension is possi- Ductus thoracicus.

329
7 Abdominal viscera

Vv. oesophageales

Bypass circuit via

Vv. gastricae Oesophagus
dextra and sinistra (with oesophageal varices)

Gaster
Hepar (with
liver cirrhosis)
Spleen [Lien]
(with splenomegaly)

Bypass circuit
via Vv. para- V. splenica [lienalis]
umbilicales

V. mesenterica inferior
Caput medusae
Retroperitoneal
bypass circuit
to the V. testicularis

V. rectalis
superior V. mesenterica
superior
Rectum V. cava inferior

V. rectalis media

Bypass circuit via

Vv. rectales

Fig. 7.32 Clinical aspects of formation of portocaval anastomoses. The oesophageal varices and the Caput medusae are significant.
The enlargement of the spleen (splenomegaly) is a result of a build up of blood due to the portal hypertension. [L238]

Nodi lymphoidei phrenici inferiores Nodi lymphoidei phrenici superiores

Cranial
lymph drainage path

Subperitoneal
lymph vessel system

Caudal lymph
Intraparenchymatous drainage path
lymph vessel system

Nodus lymphoideus Nodi lymphoidei

cysticus coeliaci

Nodi lymphoidei
hepatici

Fig. 7.33 Lymph vessels and lymph nodes of the liver and bile duct system. The green arrows depict the direction of lymph drainage from the
parenchyma via the cranial or caudal route.

Clinical remarks 7.3.13 Innervation of the liver

Liver tumours can also lead to the formation of lymph node The liver is innervated by the Plexus hepaticus a separate auto-
metastases in the chest cavity. nomic nerve plexus around the A. hepatica propria, which rep-
resents a continuation of the Plexus coeliacus:

330
 7.4 Gall bladder and bile ducts

• Sympathetic: postganglionic nerves, whose nerve bodies sit in Clinical remarks

the Ganglia coeliaca (under exertion these nerves initiate a
Due to their close relationships with the duodenum and colon,
breakdown of glycogen in order to increase the level of blood
during an inflammation of the gall bladder (cholecystitis)
sugar and the secretion of the bile is throttled) caused by gall-stones (Cholecystolithiasis), these gall-stones
• Parasympathetic: preganglionic nerves, which additionally can enter the intestine through perforations in the wall and
branch out as Rr. hepatici in the Omentum minus from the are then excreted or lead to a blockage (gall-stone ileus).
Trunci vagales and are switched in the Plexus hepaticus (these
nerve fibres convey the production of bile on food intake)
• Sensory: the peritoneum on the surface of the liver capsule is
innervated by the right N. phrenicus (R. phrenicoabdominalis)
and the lower intercostal nerves. 7.4.3 Construction of gall bladder and
For general organisation of the autonomic nervous system in the extrahepatic bile ducts
abdomen, see › Chap. 7.8.5.
The gall bladder is 7–10 cm long and is divided into the body of
gall bladder (Corpus vesicae biliaris) with a fundus (Fundus vesi-
Clinical remarks cae biliaris) and a neck portion (Collum vesicae biliaris). It usually
Due to the sensory innervation of the liver capsule by the N. holds approximately 40–70 ml of bile. At the neck, it joins the 3–4
phrenicus (Plexus cervicalis), in the event of a liver puncture cm long excretion duct (Ductus cysticus) which, by means of a
or rupture of the liver capsule this can lead to pain sensations fold (Plica spiralis HEISTER) is closed before it merges with the
on the right side of the abdominal wall, as well as in the right main bile duct of the liver (Ductus hepaticus communis) into the
shoulder (projection pain).
Ductus choledochus (› Fig. 7.34). The Ductus hepaticus commu-
nis is formed in the Porta hepatis from its right and left main stem
(Ductus hepatici dexter and sinister). At the neck there is a perito-
neal duplicature to the liver, in which the A. cystica runs.
7.4 Gall bladder and bile ducts The Ductus choledochus is on average 6 cm long and 0.4–0.9 cm in
diameter. The length is very variable and depends on the height of
the Ductus cysticus which joins the Ductus hepaticus communis.
Skills In rare cases, the Ductus cysticus can be duplicated or even missing.
After working through this chapter, you should be able to: The Ductus choledochus initially runs ventrally and right of the
• explain the location and the projection of the gall bladder portal vein in the Lig. hepatoduodenale then behind the Pars supe-
on a dissection specimen rior of the duodenum to finally reach the Pars descendens of the
• illustrate the structure of the gall bladder and bile ducts with duodenum via the head of the pancreas. The confluence is located
their exact course
in the Papilla duodeni major (Papilla VATERI; › Fig. 7.35),
• describe the opening and the closure mechanisms of the
Ductus choledochus which lies 8–10 cm away from the pylorus of the stomach on the
• locate the vessels and nerves of the gall bladder and bile dorsomedial wall in the middle third of the Pars descendens of the
ducts
• Illustrate the topography of CALOT's triangle on a dissection
specimen and explain its clinical relevance Ductus hepaticus dexter Ductus hepaticus sinister

Collum vesicae
Ductus hepaticus
biliaris
communis
7.4.1 Overview and function Plicae Ductus cysticus
mucosae
Plica spiralis
The gall bladder (Vesica biliaris) is located intraperitoneally in
the right upper abdomen directly under the liver, where it merges Tunica
mucosa
into the gall bladder bed (Fossa vesicae biliaris). It is connected
Corpus
with the liver and duodenum via the bile ducts. vesicae
The gall bladder is used for the storage and the concentration of biliaris Ductus choledochus
Tunica [biliaris]
the bile produced by the liver. It is remarkable that the gall bladder serosa
is filled by backflow when the sphincter at the opening into the
­duodenum is closed. Therefore, the gall bladder, in contrast to the Fundus vesicae
biliaris
liver, is not essential to life.
For the development of the gall bladder, see › Chap. 7.3.3.

Ductus pancreaticus
7.4.2 Projection and topography of the gall bladder

The fundus of the gall bladder overlies the lower edge of the liver
and projects onto the IX. rib (› Fig. 7.24). Here it lies immediately
Papilla duodeni
on the abdominal wall. The gall bladder is only palpable if it is sig- major
nificantly enlarged as a result of a build-up of bile. The fundus of
the gall bladder is in contact with the right flexure of the colon; the Fig. 7.34 Gall bladder (Vesica biliaris) and extrahepatic bile ducts.
body and neck area lie ventrally to the duodenum. Ventral view.

331
7 Abdominal viscera

Ductus choledochus [biliaris] bladder. The A. cystica can also originate from other branches or
Pancreas the stem of the A. hepatica propria or the A. gastroduodenalis
(4%). In 80% of cases there is only one A. cystica but in up to 20%
an accessory A. cystica occurs. This good supply explains why ne-
crosis of the gall bladder is rare.
Duodenum

Arterial blood supply to the bile ducts

Whereas the Ductus hepaticus communis is only supplied by
M. sphincter branches of the A. cystica and from the R. dexter of the A. hepatica
ductus choledochi propria, the Ductus choledochus additionally has ascending arter-
ies to complement these two descending arteries, which originate
M. sphincter from the A. gastroduodenalis. The distal third, as well as the Papil-
ductus pancreatici la duodeni major are fed from a vascular plexus from the A. pan-
creaticoduodenalis superior posterior (› Fig. 7.36).
Ampulla hepato-
pancreatica
Clinical remarks
Papilla duodeni
major [VATERI] Due to the variations in the origin of the A. cystica, in the
event of a gall bladder removal (cholecystectomy) a high de-
M. sphincter
ampullae [ODDI] Ductus pancreaticus gree of preparatory care is necessary. The existence of a sec-
[WIRSUNGIANUS] ond A. cystica should always be ruled out in order to avoid
bleeding. The good perfusion of the Papilla duodeni major ex-
Fig. 7.35 Confluence of the Ductus choledochus and Ductus pan­ plains why in the event of surgical removal of a trapped gall-
creaticus into the duodenum. Ventral view. [L238] stone (papillotomy) heavy bleeding from the A. pancreati-
coduodenalis superior posterior may occur.

duodenum. Before the confluence, the Ductus choledochus mostly

(in 60% of cases) combines with the Ductus pancreaticus to the
Ampulla hepatopancreatica. The smooth muscles of the wall Venous drainage
form a M. sphincter ductus choledochi, whose lower section, the The V. cystica runs along the peritoneal side of the gall bladder and
M. sphincter ampullae (ODDI) also includes the ampulla and their enters directly into the portal vein. On the side facing the liver,
confluence. Together with the M. sphincter ductus pancreatici this there are many small branches, which also drain the proximal sec-
forms a sphincter complex 3 cm in length. tions of the bile ducts. The blood from the distal sections flows via
the veins at the pancreatic head to the portal vein.
Clinical remarks Lymph vessels
As the Ductus choledochus runs through the pancreatic head On the gall bladder there is usually an individual Nodus lym-
and a bottleneck is formed at the Papilla duodeni major by the phoideus cysticus at the neck portion from which the lymph flows
M. sphincter ampullae ODDI, in cases of pancreatic cancer via the lymph nodes of the hepatic porta to the Nodi lymphoidei
(mostly painless), this can lead to bile backflow (cholestasis) coeliaci. The lymph vessels from the portions of the gall bladder
into the blood, just as a gall-stone trapped in the papilla (usu-
adjoining the liver, on the other hand, enter the liver tissue and
ally painful with biliary colic). Due to the deposition of the bile
pigment bilirubin in the connective tissue, there is usually a connect here with the lymph drainage channels of the liver.
yellowing of the sclera of the eye and later the skin (jaundice, The lymph from the Ductus choledochus also passes from the
icterus). In these cases, the efferent bile ducts are examined proximal section to the Nodus lymphoideus cysticus, distal to the
with ultrasound or x-ray contrast agent for clarification (endo- lymph nodes on the pancreatic head.
scopic retrograde cholangiopancreatography, ERCP). An en-
largement of the Ductus choledochus of over 1 cm in diameter
is indicative for cholestasis. Due to the amalgamation of the
A. pancreaticoduodenalis
Ductus choledochus with the Ductus pancreaticus, it can si- superior posterior
multaneously lead to a backflow of pancreatic secretions with
inflammation of the pancreas (pancreatitis), which is caused Ductus choledochus
[biliaris]
by partial self-digestion of the organ.

Ductus pancreaticus
[WIRSUNGIANUS]

7.4.4 Pathways of the gall bladder and bile ducts

Papilla duodeni
Arterial supply of the gall bladder major [VATERI]
The A. cystica usually originates (63–75%) from the R. dexter of
the A. hepatica propria and is divided into a superficial branch for
the gall bladder itself and a deep branch to the gall bladder bed, the
branches of which anastomose with each other. In addition, fine Wall of the duodenum
branches of the liver tissue (from the branches of the R. dexter of
the A. hepatica propria to liver segment V) to the body of the gall Fig. 7.36 Arteries of the Ductus choledochus. [L126]

332
 7.5 Pancreas

Innervation all relevant structures are identified before the A. cystica and
The innervation corresponds to the supply of the liver: the Ductus cysticus are ligated. This makes it possible to re-
• Sympathetic and parasympathetic via the Plexus hepaticus. The duce the risk of erroneously inhibiting the Ductus choledochus,
parasympathetic-mediated contraction supports the hormone-­ which would cause a bile backflow (cholestasis).
induced contraction of the gall bladder wall musculature, inhibits
the M. sphincter ampullae and thus promotes emptying of bile.
The sympathetic nervous system has antagonistic functions.
• Sensory: the peritoneum on the surface away from the liver is 7.5 Pancreas
innervated by the right N. phrenicus (R. phrenicoabdominalis).
For general organisation of the autonomic nervous system in the
abdomen › Chap. 7.8.5.
Skills
After working through this chapter, you should be able to:
• know the vital importance and explain the function of the
Clinical remarks exocrine and endocrine pancreas
As with the liver, pain can radiate into the right shoulder on • show the classification of the pancreas on the dissection
inflammation of the gall bladder (cholecystitis) due to the specimen and explain the development, including malfor-
sensory innervation of the liver capsule through the N. phreni- mations
cus (Plexus cervicalis). • describe the topography of the individual sections of the
pancreas and explain the relationship with the adjacent or-
gans
• describe the system of ducts with confluence into the duo-
denum
7.4.5 
CALOT’s triangle • explain the different supply of the sections of the pancreas
by arteries, veins, lymph vessels and autonomic nerves and,
as far as possible, to demonstrate on the dissection speci-
The Ductus cysticus, Ductus hepaticus communis, and inferior men
surface of the liver together form the cystohepatic triangle, also
­referred to as CALOT’s triangle. (› Fig. 7.37). Its limits are:
• Ductus cysticus
• Ductus hepaticus communis
• Inferior surface of the liver 7.5.1 Overview
In 75% of cases, the A. cystica originates in the CALOT’s triangle
from the R. dextra of the A. hepatica propria and runs posteriorly The pancreas is a combined exocrine and endocrine gland of the
through this triangle to reach the Ductus cysticus and the neck of digestive system and in living people, is salmon pink in colour. Due
the gall bladder. In the remaining cases there are different origins to rearrangement processes during development, the pancreas is
and course patterns of the A. cystica. secondarily retroperitoneal in the central upper abdomen. This
position, the confluence behaviour of the excretory ducts of the
exocrine gland section, and the supply patterns for the respective
Clinical remarks vessels and nerves are of major clinical relevance (› Fig. 7.38).
CALOT’s triangle is an important orientation point for every
r­ emoval of the gall bladder. Prior to removal of the gall bladder

Vesica biliaris [fellea]

Ductus hepaticus
communis

A. cystica
Trigonum cystohepaticum
A. hepatica propria
[CALOT's triangle]
V. portae hepatis

Ductus cysticus A. hepatica communis

A. gastroduodenalis

Ductus choledochus
[biliaris] Fig. 7.37 CALOT's triangle
(­ cystohepatic triangle). Caudal
view. (according to [S010-1-16])

333
7 Abdominal viscera

M. sphincter pyloricus
Corpus pancreatis

Ductus choledochus [biliaris] Ductus

pancreaticus
Cauda
Ductus pancreaticus pancreatis
accessorius

Papilla duodeni minor

Ductus choledochus [biliaris]

Proc. uncinatus
Duodenum, Pars descendens

Plica longitudinalis duodeni Flexura duodenojejunalis

Papilla duodeni major

Fig. 7.38 Structure and excreto-
Duodenum, Pars ascendens
ry duct system of the pancreas.
Ventral view; Ductus pancreati-
Caput pancreatis cus after opening of the pancre-
Duodenum, Pars horizontalis
as and duodenum.

7.5.2 Functions of the pancreas sal bud thereby forms the upper part of the head and the entire
body and tail of the pancreas; the ventral bud, however, only forms
The pancreas is a gland that has both exocrine (90% of organ the lower part of the head and the Proc. uncinatus.
weight) as well as endocrine (10%) sections. The endocrine cell The excretory duct of the pancreas (Ductus pancreaticus) arises
groups are distributed as islets in the organ (Islets of LANGER- from the union of the distal duct portion of the dorsal pancreatic
HANS) and are especially common in the tail section. bud with the ventral pancreatic duct and confluences at the Papilla
The production of the hormone insulin that is essential for the reg- duodeni major. The proximal section of the dorsal pancreatic duct
ulation of blood sugar levels and metabolism, makes the pancreas predominantly (65%) opens into the accessory pancreatic duct
an essential and vital organ. Functions of the pancreas are: (Ductus pancreaticus accessorius), which leads into the Papilla du-
• Formation of digestive enzymes, which are predominantly odeni minor in the duodenum.
emitted as inactive precursors (exocrine pancreatic section)
• Secretion of hormones for regulation of blood sugar levels, me-
tabolism and digestion (endocrine pancreatic section)
Clinical remarks
As soon as the chyme passes from the stomach into the duodenum, The development of the pancreas is clinically very important
it will hormonally stimulate the release of the exocrine pancreatic because it leads to disease-relevant malformations:
secretions, which are released via the two excretory ducts of the • Pancreas anulare: when the pancreatic tissue grows in a cir-
pancreas into the duodenum. The alkaline pancreatic juice con- cular form around the duodenum, occlusion of the intestine
(ileus) with vomiting may occur, particularly in newborns
tains mainly enzyme precursors, which are first activated in the
(› Fig. 7.40a). In this case, the duodenum has to be sev-
­intestinal lumen. This is a protection mechanism to prevent the ered and sewn back next to the pancreas system.
­destruction of pancreatic tissue. • Pancreas divisum: as a general rule (65%) there are 2 excre-
The endocrine pancreas forms different hormones and releases tory ducts that connect but enter the duodenum separately.
them into the blood through veins. The release of the blood sugar The accessory duct can (35%) also be very thin and only
regulating hormones insulin and glucagon are controlled directly lead into the Ductus pancreaticus (› Fig. 7.40b and c). If
by the blood sugar level. the two systems do not completely merge and the excretory
ducts do not connect (10% of cases), the accessory duct can
be too narrow for secretions to be delivered or for the dorsal
Clinical remarks system duct of the main excretory duct to be formed (› Fig.
7.40d, e); in both of these instances, a build-up of secretions
The function of the pancreas makes it easy to understand why can cause recurrent inflammation (pancreatitis).
tissue destruction (necrosis) of the pancreas, e.g. if inflamma-
tion occurs (pancreatitis), can lead to digestive disorders cul-
minating in diarrhoea, and in the case of extensive damage
(loss of 80–90% of the tissue) can also lead to diabetes melli-
tus as a result of reduced insulin production.
7.5.4 
Projection and structure of the pancreas

The pancreas is a 14–20 cm long (mostly 16 cm), parenchymatous

organ with a lobular structure and an average weight of approx. 70 g
7.5.3 
Development (40–120 g). Due to its well-fixed position in the retroperitoneum, the
pancreas projects relatively constantly in the central upper abdomen
At the end of the 4th week at the level of the duodenum, a ventral on the I.–II. lumbar vertebrae and is surrounded by the duodenum.
and a dorsal pancreatic bud emerge from the entoderm of the fore- The pancreas is divided into the head (Caput pancreatis), neck
gut (› Fig. 7.39). Together with the stomach rotation, the ventral (Collum pancreatis), body (Corpus pancreatis) and tail (Cauda
pancreatic bud folds to the left behind the duodenum and fuses pancreatis) (› Fig. 7.38). The head runs downwards into a process
there in the 6th–7th week with the dorsal pancreatic bud. The dor- that surrounds the A. and V. mesenterica superior. Due to its

334
 7.5 Pancreas

Dorsal pancreatic
bud
Hepar
Section plane
Ductus choledochus of d
[biliaris]
Duodenum
Vesica biliaris [fellea]
Dorsal
Ventral pancreatic bud mesenterium

a
Dorsal mesentery
Spleen [Lien]

Fusion of
Free margin of the
dorsal and ventral
Omentum minus
pancreatic buds
Section plane Section plane
of e of f
Duodenum
b c
Caput pancreatis Cauda pancreatis

Caput pancreatis Ductus pancreaticus

Ventral pancreatic
Ventral Ductus choledochus
bud
pancreatic bud [biliaris]

Duodenum Cauda
Duodenum pancreatis
Corpus
pancreatis
Ductus choledochus Dorsal Mouth of the Ductus Ductus
[biliaris] pancreatic bud choledochus and the pancreaticus
d e f Ductus pancreaticus accessorius

Fig. 7.39 Stages of development of the pancreas, in weeks 5–8 of development. a–c Fusion of both pancreatic buds; view from the left side.
d–f Formation of the excretory ducts from both buds and representation of the confluence into the duodenum; schematic cross-sections
through the pancreatic system and duodenum. [E581]

shape, it is referred to as a hook process (Proc. uncinatus). It is sep-

Clinical remarks
arated from the pancreas body by a notch (Incisura pancreatis). To The behaviour of the confluence of the excretory ducts has an
the left, the head merges into the neck, which represents a narrow impact on the progression of diseases of the pancreas. In ad-
transition area (2 cm) to the body. The body is approximately trian- dition to alcohol abuse, gall-stones in the Papilla duodeni ma-
gular. The upper and lower edges (Margines superior and inferior) jor are the most common cause of inflammation of the pancre-
as (pancreatitis), which is caused by a tailback of secretions
limit the anterior and posterior sides, whereby the anterior side is with self-digestion. A Ductus pancreaticus accessorius with a
additionally divided into an upper and a lower section (Facies an- separate confluence, which is formed in 65% of cases, can
terosuperior, anteroinferior and posterior) by an anterior border then prove to be useful when it communicates with the main
(Margo anterior), which is not always clearly visible. duct, permitting an outflow of the digestive secretions.

7.5.5 
Excretory duct system of the pancreas NOTE
The presence of a main and an accessory duct, as well as the join-
In general (65%), the pancreas has 2 excretory ducts (› Fig. 7.38): ing of the main excretory duct with the Ductus choledochus, is the
• Ductus pancreaticus (Ductus WIRSUNGIANUS): the main ex- norm and not the exception. The behaviour of the joining and con-
cretory duct transfers pancreatic secretions from the body and fluence is of functional and clinical relevance.
tail and together with the bile duct (Ductus choledochus), con-
joins with the Papilla duodeni major (Papilla VATERI) in the
Pars descendens of the duodenum. Before the confluence the
Ductus choledochus mostly (in 60% of cases) combines with the 7.5.6 Topography
Ductus pancreaticus to the Ampulla hepatopancreatica and also
the sphincter muscle (M. sphincter ductus pancreatici), which The pancreas is secondarily retroperitoneal in the central upper
continues as the M. sphincter ampullae (ODDI) to the ampulla. abdomen. The pancreatic head is covered at the top by the Pars su-
• Ductus pancreaticus accessorius (Ductus SANTORINI): the perior of the duodenum and adjoins the medial side of the Pars de-
accessory duct conducts the secretions from the pancreas head scendens of the duodenum (› Fig. 7.38). Here, the head is pene-
and confluences 2 cm further orally on the Papilla duodeni minor. trated by the Ductus choledochus before joining with the Ductus

335
7 Abdominal viscera

Ductus chole-
dochus [biliaris]
Pancreas
Pancreas
anulare

Duodenum
Ductus pancreaticus
accessorius
[SANTORINI]

Ductus choledochus
[biliaris]

Papilla duodeni minor

[SANTORINI]

Duodenum

Ductus pancreaticus
accessorius [SANTORINI]

b Papillla duodeni c
major [VATERI] Ductus pancreaticus Ductus pancreaticus
[WIRSUNGIANUS] [WIRSUNGIANUS]

Ductus pancreaticus
accessorius [SANTORINI]

Ductus pancreaticus
accessorius
Fig. 7.40 Malformations of pan-
[SANTORINI] creatic development. a Pancreas
annulare: annular formation,
which can lead to disorders of
passage as a result of reposi-
tioning of the duodenum.
d e
b–e Normal (b, c) and incom-
Ductus pancreaticus Ductus pancreaticus plete (d, e) association of excre-
[WIRSUNGIANUS] [WIRSUNGIANUS] tory ducts (Pancreas divisum).
[L126]

pancreaticus. In front of the head is the Colon transversum. the left. On the lower edge the Pars horizontalis of the duodenum
The Proc. uncinatus is appended downwards and encompasses is positioned on the left side.
­the A. and V. mesenterica superior, which are accompanied by The body runs left to the pancreatic tail and makes contact here with
the lymphatic Trunci intestinales and pass behind the vessels the hilum of the spleen behind the left colic flexure (› Fig. 7.42). On
(› Fig. 7.41). The head continues to the left in the pancreatic the dorsal side are the left renal blood vessels and the anterior side of
neck, which lies in front of the Vasa mesenterica superior. The the left kidney, separated by their different sheath systems.
­portal vein is formed behind the neck by fusion of its main tribu-
taries (V. mesenterica superior and V. splenica, which previously
usually integrate the V. mesenterica inferior).
Clinical remarks
The pancreatic body then transverses the aorta and the vertebral As the Ductus choledochus runs through the head of the pan-
column behind it and bends into the Bursa omentalis, which forms creas to the duodenum, this can result in a bile tailback with
the posterior wall of the pancreas. This bulging is also called the jaundice (icterus) in the event of a pancreatic carcinoma in the
Tuber omentale. The front side of the pancreas is covered by peri- head of the gland. Tumours in other sections do not usually
cause symptoms for a long time, so the prognosis on diagno-
toneum and thus has a broad contact surface with the rear of the
sis is therefore often poor.
stomach, which forms the front wall of the Bursa omentalis The close positional relationship of the pancreatic head to the
(› Fig. 7.3). The posterior side of the pancreas is located on the A. and V. mesenterica superior and to the portal vein also har-
right side directly on the V. cava inferior and has connections to bours the danger that in the event of an endoscopic examina-
the right V. renalis and the right A. and V. testicularis/ovarica, as tion of the Papilla duodeni major for removal of a gall-stone or
well as to the adrenal glands on the left and the left lymphatic by contrast agent imaging of the biliary and pancreatic ducts
Trunci lumbales. The V. splenica is often embedded in the glandu- (endoscopic retrograde cholangiopancreatography, ERCP)
these vessels can be damaged, a situation that can normally
lar parenchyma. At the top right edge of the body of the pancreas,
only be resolved by emergency surgery.
the A. hepatica communis runs to the right, and the A. splenica to

336
 7.5 Pancreas

7.5.7 Vessels and nerves of the pancreas Lymph vessels

The different sections of the pancreas have 3 groups of regional
Arterial and venous supply lymph nodes (› Fig. 7.42). From there, the lymph flows into the
The pancreas is supplied via 2 separate arterial systems, one for Nodi lymphoidei coeliaci and Nodi lymphoidei mesenterici superi-
the head and the other for the body and tail (› Fig. 7.41): ores, before feeding into the Ductus thoracicus via the Trunci in-
• Head and neck: the double vascular ring consists of the Aa. testinales. The retroperitoneal location with its close proximity to
pancreaticoduodenales superiores anterior and posterior (from various groups of lumbar lymph nodes (Nodi lymphoidei lum-
the A. gastroduodenalis and thus the supply area of the Truncus bales) and the left Trunci lumbales necessitates that there are ex-
coeliacus) and the A. pancreaticoduodenalis inferior with R. tensive connections to other lymph nodes.
anterior and R. posterior (from the A. mesenterica superior, • Head and neck: Nodi lymphoidei pancreaticoduodenales
BÜHLER's anastomosis) along the same arteries (Aa. pancreaticoduodenales superiores
• Body and tail: Rr. pancreatici from the A. splenica, which form anterior and posterior), connect from there via the Nodi lym-
the A. pancreatica dorsalis behind the pancreas and the A. pan- phoidei hepatici to the Nodi lymphoidei coeliaci or directly to
creatica inferior on the lower edge of the pancreas. the Nodi lymphoidei mesenterici superiores.
This intensive perfusion makes it clear why infarcts of this vital • Body: Nodi lymphoidei pancreatici superiores and inferiores
gland are rare. at the lower and upper edge of the organ and thus along the A.
The veins correspond to the arteries and form a vessel arcade ven- and V. splenica, and from there to the Nodi lymphoidei coeliaci
trally and dorsally. These drain via the V. mesenterica superior and and the Nodi lymphoidei mesenterici superiores.
the V. splenica into the hepatic portal vein. The V. pancreaticoduo- • Tail: drainage to the Nodi lymphoidei splenici and from there
denalis superior posterior connects directly to the portal vein and to the Nodi lymphoidei coeliaci.
does not open into one of the preceding main stems.

A. hepatica communis Truncus coeliacus

A. hepatica propria A. gastrica sinistra
A. gastroduodenalis A. splenica Rr. pancreatici
[lienalis]
A. pancreaticoduodenalis superior
A. pancreaticoduodenalis
superior posterior
A. gastroomentalis dextra
A. pancreatica inferior
A. pancreaticoduodenalis
superior anterior A. pancreatica dorsalis

A. pancreatico-
duodenalis inferior
R. anterior A. mesenterica
A. pancreatico-
superior
duodenalis inferior R. posterior
Fig. 7.41 Arteries of the pancre-
as. (according to [S010-1-16])

Nodi lymphoidei
coeliaci

Nodi lymphoidei
splenici
Nodi lymphoidei Nodi lymphoidei
hepatici pancreatici superiores

Nodi lymphoidei
pancreatici inferiores

Nodi lymphoidei
Nodi lymphoidei mesenterici superiores
pancreatico-
duodenales

Fig. 7.42 Lymphatic drainage

paths of the pancreas. Ventral
view.

337
7 Abdominal viscera

Clinical remarks
The diverse lymphatic drainage pathways explain why in cases
of pancreatic carcinoma extensive lymph node metastases
usually exist at the time of diagnosis. Because they usually
cannot be completely removed, surgical treatment is rarely
possible.
Pulmo

Cor

Innervation Diaphragma

The pancreas is innervated by the sympathetic and parasympathet-

Hepar
ic nervous systems. The parasympathetic nervous system promotes
the formation of digestive enzymes, which results in secretions and Gaster
Spleen [Lien]
insulin formation, while the sympathetic nervous system inhibits
Ren [Nephros]
these functions.
Colon
Sympathic nervous system: the postganglionic nerve fibres, once
switched, pass through the Plexus coeliacus as perivascular plexus, Intestinum tenue
together with the various arteries, to the pancreas.
Parasympathetic nervous system: preganglionic nerve fibres
sometimes reach the pancreas via perivascular plexus from the
Plexus coeliacus, and sometimes directly from the Truncus vaga-
lis posterior (and anterior) for the head. Fig. 7.43 Projection of the spleen on the body surface. View from the
The sympathetic and parasympathetic nervous systems also in- left side.
clude afferent nerve fibres. The zone of the transmitted pain in the
torso wall is not precisely localised. Pain will often be felt radiating The defence function is undertaken by the ‘white pulp’, which is
like a belt around the central and left upper abdomen and if the visible on the cut surface as white nodules. The initiation of a spe-
retroperitoneal structures are involved, this is often dorsal to the cific immune defence system against pathogens that have already
left of the lower thoracic vertebral column. reached the bloodstream, makes the spleen a very important organ.
For general organisation of the autonomic nervous system in the The spleen is not absolutely essential, but removing it predisposes
abdomen, see › Chap. 7.8.5. to life-threatening infections. In addition, the spleen also has vari-
ous functions with respect to renewal of blood cells, which are un-
dertaken by the ‘red pulp’, the blood-filled parenchyma. Here, just
7.6 Spleen as in bone marrow and the liver, old and in particular defective red
blood cells (erythrocytes) are broken down. Although the spleen is
very well supplied with blood, in humans it is not used to store
Skills larger quantities of blood but stores up to 30% of all platelets
After working through this chapter, you should be able to: (thrombocytes) in the body. Together with the liver, it is responsi-
• understand the various functions of the spleen ble for blood formation during the foetal period and this can also
• demonstrate the location and projection of the spleen on a support life in the event of bone marrow insufficiency.
dissection specimen and to know its classification in seg-
ments
• demonstrate the vessels and nerves of the spleen and Clinical remarks
­explain their supply function for the surrounding organs
The functions explain why injuries to the spleen (splenic rup-
ture), e.g. in blunt abdominal trauma, can lead to life-threat-
ening bleeding. In contrast to previously, attempts are made
to preserve the spleen or at least parts of it since the risk of
life-threatening infections (sepsis) significantly increases af-
7.6.1 
Overview ter its removal. Manipulation of the spleen, e.g. while being
removed, can release large quantities of thrombocytes into
The spleen (or Lien) is located intraperitoneally in the left upper the circulation, so that the risk of blood clots (thrombi) needs
abdomen (› Fig. 7.43) and belongs to the secondary lymphatic to be prevented as these can lead to a stroke or heart attack.
organs together with all lymph nodes, the pharyngeal tonsils and
the mucosa-associated lymphoid tissue, e.g. in the intestines.

7.6.2 Functions of the spleen 7.6.3 Development

Out of the different functions of the spleen, the most important is Connective tissue and capsule of the spleen are formed in the 5th
the defence function: week from the Mesogastrium dorsale from where it receives its
• Immune defence against pathogens in the blood coating from the Peritoneum viscerale (› Fig. 7.3). The connec-
• Degradation of defective and aging erythrocytes tion to the stomach becomes the Lig. gastrosplenicum. The lym-
• Storage of blood cells (thrombocytes) phocytes settle in the spleen in the 4th month.
• Blood formation (foetal period)

338
 7.6 Spleen

7.6.4 Projection, construction and topography of A special feature is the existence in 5–30% of cases of an accessory
the spleen spleen that is separated from the main organ, which is mostly lo-
cated close to the hilum in one of the peritoneal duplicatures.
The spleen is reddish-grey to blueish-purple in colour in living
people, is approximately 11 cm long, 7 cm wide and 4 cm thick,
and weighs 150 g (80–300 g). It is located in the left upper abdo-
Clinical remarks
men and is well protected intraperitoneally by the costal arch in a On removal of the spleen (splenectomy) investigations should
separate compartment, which is known as the splenic niche be carried out to determine the existence of an accessory
(› Fig. 7.43). Here, the spleen sits on the Lig. phrenicocolicum, spleen. An accessory spleen can undertake the functions of
which connects the left colic flexure with the diaphragm. The posi- the main organ on its removal, which may prevent the loss of
the defence function; however, if the reason for the splenecto-
tion of the spleen is strongly dependent on breathing as a result of
my is defective red blood cells, because they have been ab-
its position under the diaphragm and it projects in a respiratory normally broken down in the spleen and have therefore
central position onto the IXth–XIth ribs, from where it follows the caused anaemia, any possible accessory spleen must also be
Xth rib with its longitudinal axis. Therefore, the spleen is only pal- removed.
pable if enlarged.
The spleen has a convex Facies diaphragmatica (› Fig. 7.44),
which has contact to the diaphragm, and a concave Facies
­visceralis with contact to various organs:
• to the posterior gastric wall (Facies gastrica, posterior, above), 7.6.5 Vessels and nerves of the spleen
separated by the Recessus splenicus of the Bursa omentalis
• to the left colic flexure (Facies colica, anterior, above) Arterial and venous supply
• to the lateral margin of the kidneys (Facies renalis, below) The A. splenica is the only supplying vessel and originates as a
• to the pancreatic tail (Facies pancreatica, at the hilum) branch of the Truncus coeliacus. It follows a winding path at the
The edge facing upwards (Margo superior), which separates these upper edge of the pancreas along to the hilum of the spleen, where
two areas is usually irregular while the bottom edge (Margo inferi- it branches into 2–3 main branches and then several terminal
or) appears smooth. From their position in the upper abdomen, branches (› Fig. 7.42). On the way, the A. splenica supplies the
one pole is directed forwards (Extremitas anterior) and the other pancreas (Rr. pancreatici) and the stomach (A. gastrica posterior,
directed backwards (Extremitas posterior). The Facies visceralis is Aa. gastricae breves, A. gastroomentalis sinistra).
divided into two halves by the Hilum splenicum, the point at The terminal branches of the A. splenica are functional terminal
which the peritoneal duplicatures insert and the vessels and nerves arteries and subdivide the spleen into 3–6 variable, wedge-shaped
enter and exit. The Lig. gastrosplenicum, as part of the Omentum arranged segments. (› Fig. 7.45).
majus, connects the spleen forwards with the stomach, while the The V. splenica has tributaries that correspond to the arteries,
Lig. phrenicosplenicum and the Lig. splenorenale connect back- which run in the Lig. splenorenale and then on the posterior side
wards with the diaphragm and kidney, from which they are sepa- of the pancreas to its neck area, where it joins with the V. mesenter-
rated by their sheaths (› Fig. 7.3).

Margo superior V. splenica [lienalis] Margo superior

A. splenica [lienalis] Facies visceralis,
Facies colica Facies
Facies visceralis, diaphragmatica
Hilum splenicum
Facies gastrica

Lig. gastro- Lig. spleno-

splenicum renale

Extremitas Extremitas
Extremitas anterior
posterior anterior
Extremitas
posterior
a Margo inferior
Facies visceralis, b Margo inferior
Facies renalis

Fig. 7.44 Spleen. a Medial ventral view. b Cranial lateral view.

Fig. 7.45 Segments of the

A. splenica spleen. Schematic representa-
[lienalis] tion of 3, 4 or 5 segments.
[L126]

339
7 Abdominal viscera

ica superior to the portal vein. In the majority of cases (70%) it pre- The individual peritoneal duplicatures are described with respect
viously receives the V. mesenterica inferior. to the respective organs. For the development of the peritoneal cav-
ity, see › Chap. 6.5.5.
Lymph vessels Intraperitoneal are:
The regional lymph nodes are the Nodi lymphoidei splenici on • Pars abdominalis of the oesophagus
the hilum of the spleen, which also receive lymph from the fundus • Stomach
of the stomach and the pancreatic tail. From there, the lymph flows • Pars superior of the duodenum
via the Nodi lymphoidei coeliaci and the Trunci intestinales into • Jejunum
the Ductus thoracicus. • Ileum
• Caecum
Innervation • Appendix vermiformis
The spleen is largely innervated by the sympathetic nervous sys- • Colon transversum
tem but also by the parasympathetic nervous system (Plexus sple- • Colon sigmoideum
nicus). After switching in the Plexus coeliacus, the postganglionic • Liver
sympathetic nerve fibres continue as a perivascular network to- • Gall bladder
gether with the preganglionic parasympathetic fibres of the A. • Spleen
splenica. The sympathetic nervous system throttles the perfusion, as well as the pelvic organs:
otherwise little is known about autonomic regulation. • Body of the uterus
The sympathic and parasympathic nervous systems also have affer- • Adnexe (Ovarium and Tuba uterina)
ent nerve fibres. The zone of the transmitted pain on the torso wall Retroperitoneal organs are mostly only covered on their anterior
is diffuse and projects onto the central or left upper abdomen, on side by the Peritoneum parietale. These organs can also be created
dermatomes T8–9. as a primary retroperitoneal organs outside of the abdominal cavi-
For general organisation of the autonomic nervous system in the ty, such as:
abdomen, see › Chap. 7.8.5. • Kidneys
• Adrenal glands
The primary retroperitoneal organs and subperitoneal located or-
7.7 Peritoneal cavity gans are described in › Chap. 8. In contrast, the secondary retro-
peritoneal organs are only shifted to the dorsal torso wall during
development. These include:
Skills • Other parts of the duodenum
After working through this chapter, you should be able to: • Colon ascendens
• explain the structure of the abdominal cavity and elucidate • Colon descendens
the peritoneal relationships of the individual abdominal or- • Proximal Rectum (up to Flexura sacralis)
gans on a dissection specimen • Pancreas
• describe the construction of the Omentum majus and Omen-
The secondary retroperitoneal organs can be bluntly separated
tum minus with functions and vessels and nerves
• illustrate the recesses of the peritoneal cavity and to explain from the primary retroperitoneal organs in the preparation.
their clinical relevance
• know the location and structure of the Bursa omentalis in
detail and to illustrate it on a dissection specimen
Clinical remarks
This differences in location are important in terms of access
routes during surgery because an organ situated retroperito-
neally is also accessible from the dorsal side without opening
7.7.1 
Overview the peritoneal cavity. This allows the risk of infection of the
abdominal cavity (peritonitis) or postoperative adhesions to
be reduced.
The abdominal cavity (Cavitas abdominalis) is divided by the Co-
lon transversum into the upper and lower abdomen. In accordance
with its positional relationships, the abdominal cavity is divided
into a peritoneal cavity (Cavitas peritonealis), which is lined with NOTE
peritoneum and an extraperitoneal space (Spatium extraperitone- Intraperitoneal:
• are located in the peritoneal cavity (Cavitas peritonealis) of the
ale) between the Peritoneum parietale and the torso wall. Dorsally,
abdominal cavity or of the pelvis
the extraperitoneal space is expanded to the retroperitoneum • covered from all sides with Peritoneum viscerale
(Spatium retroperitoneale), which continues caudally into the pel- • secured with peritoneal duplicatures (mesentery and ligaments)
vic cavity in the subperitoneal space (Spatium extraperitoneale Extraperitoneal:
pelvis) (› Chap. 8.7.1). This results in different positional relation- • are located outside the peritoneal cavity in the retroperitoneal
ships for the organs. space of the abdominal cavity (Spatium retroperitoneale) or the
Intraperitoneal organs are covered on their entire surface by Perito­ subperitoneal space of the pelvis (Spatium extraperitoneale pel-
neum viscerale, which represents the Tunica serosa of the respec- vis)
• are not or only partially covered by Peritoneum parietale
tive organs. The organs have small suspensory ligaments (mesentery
and ligaments) that contain the supplying vessels and nerves as
peritoneal duplicatures; at their root, the Peritoneum viscerale of The abdominal cavity is subdivided by the Colon transversum with
the organs changes into the Peritoneum parietale of the abdominal its Mesocolon transversum into the upper and the lower abdomen.
cavity wall. The upper abdomen (‘glandular abdomen’) is occupied to the right
by the liver and the gallbladder and to the left by the stomach which

340
 7.7 Peritoneal cavity

Bursa omentalis, Lobus hepatis sinister,

Lobus hepatis dexter,
Vestibulum Facies diaphragmatica
Facies diaphragmatica
Bursa omentalis, Recessus superior
Lig. teres hepatis
Plica gastro-
pancreatica

Spleen [Lien],
Margo superior
Lobus caudatus
Bursa omentalis,
Recessus splenicus
Vesica biliaris
Bursa omentalis
Foramen omentale (main space)

Omentum minus, Corpus gastricum,

Lig. hepatoduodenale Paries anterior

Omentum minus,
Plica hepato- Llg. hepatogastricum
pancreatica
Gaster, Curvatura major
Pancreas

Omentum majus, Gaster, Mesocolon Bursa omentalis,

Lig. gastrocolicum Curvatura minor transversum Recessus inferior

Fig. 7.46 Location of the viscera in the upper abdomen. Ventral view.

continues in the Pars superior of the duodenum. Behind the stom- Vessels and nerves of the Omentum majus:
ach is the spleen and the pancreas in the retroperitoneum. Between The Omentum majus is supplied by the vessels and nerves along
the liver and stomach/duodenum extends the Omentum minus as a the greater stomach curvature:
frontal peritoneal duplication (› Fig. 7.46). • Aa. and Vv. gastroomentales dextra (predominantly with 5–8
The lower abdomen (‘intestinal abdomen’) contains the other Rr. omentales) and sinistra (usually only one branch)
­sections of the small and large intestines and is overlaid to the front • Nodi lymphoidei gastroomentales dextri and sinistri, from here
by the large Omentum majus that originates on the stomach. In ad- via lymph nodes along the branches of the Truncus coeliacus to
dition to the various sections of duodenum and large intestine, also the Nodi lymphoidei coeliaci
located in the retroperitoneum are the kidneys and adrenal glands. • Sympathetic and parasympathetic nervous systems from the
Plexus coeliacus via the periarterial plexus

7.7.2 
Omentum majus and Omentum minus Clinical remarks
Omentum majus The apron-shaped section can cover inflammation or perfora-
The Omentum majus is an apron-shaped peritoneal duplicature tion of the stomach and intestines and thus prevent inflam-
with an area of approximately 1 m2, which overlays the organs of mation of the abdominal cavity (peritonitis).
the lower abdomen. Depending on the type of constitution, differ- Due to the large surface and thus very effective turnover of
peritoneal fluid, in the event of kidney failure or poisoning by
ent amounts of fat are stored in the network, so that its colour var-
the repeated introduction of electrolyte solutions peritoneal
ies from translucent to yellowish. The Omentum majus consists of dialysis can be used to removed toxins from the blood.
four parts: As a result of its developmental history, the Omentum majus
• Lig. gastrocolicum belongs to the stomach and is supplied by the vessels and
• Lig. gastrosplenicum nerves at the greater curvature of the stomach. It must there-
• Lig. gastrophrenicum fore, e.g. in the case of a colonisation of tumour cells (perito-
• Apron-shaped section neal carcinomatosis) be separated at the stomach and not at
the colon.
The most important peritoneal duplicature is the Lig. gastrocoli-
cum, which connects the large curvature of the stomach with the
Taenia omentalis of the Colon transversum. This ligament is the ori­
gin of the Omentum majus, which develops dorsally in the Mesoga- Omentum minus
strium and contains the supplying vessels and nerves. To the left it The Omentum minus is a frontal peritoneal duplicature, which
continues in the Lig. gastrosplenicum and up into the Lig. gastro- connects the liver with the stomach and duodenum and forms the
phrenicum. The apron-shaped part is highly variable in its extent anterior wall of the Bursa omentalis (see below). Parts of the
and can take up very different positions. Omentum minus are:
Functions of the Omentum majus: • Lig. hepatogastricum to the small curvature of the stomach
• Secretion and absorption of peritoneal fluids • Lig. hepatoduodenale to the Pars superior of the duodenum
• Immune defence: arteriovenous anastomoses (‘milk stains’) for The Lig. hepatogastricum contains the vessels and nerves, making
the outflow of leukocytes it the largest part of the omentum minus. Under the Lig. hepatodu-
• Mechanical protection odenale is the opening of the Bursa omentalis (Foramen omentale/
• Thermal insulation epiploicum).

341
7 Abdominal viscera

In the Lig. hepatoduodenale the liver triad runs in the following bulges of the peritoneal cavity. Due to their clinical relevance, the
order to the liver: main recesses are described briefly (› Fig. 7.47).
• Ductus choledochus (right)
• A. hepatica propria (left) Recessus of the epigastrum (supramesocolic compartment)
• V. portae hepatis (posterior) The largest and in terms of its extent, the most complex of these re-
• Lymph vessels, lymph nodes and autonomic nerves (Plexus he- cesses, is the Bursa omentalis. The Bursa omentalis is a sliding
paticus) space between the stomach and the pancreas, which only commu-
The Omentum minus is supplied by the vessels and nerves along nicates with the abdominal cavity via the Foramen omentale (Fora-
the lesser stomach curvature: men epiploicum) under the Lig. hepatoduodenale. Due to its ex-
• Aa. and Vv. gastricae dextra and sinistra tent, the Bursa omentalis is also referred to as the lesser sac of the
• Nodi lymphoidei gastrici dextri and sinistri, from here via peritoneal cavity.
lymph nodes along the branches of the Truncus coeliacus to the The Bursa omentalis is divided into 4 sections (› Fig. 7.46):
Nodi lymphoidei coeliaci • Foramen omentale (Foramen epiploicum): the entrance to the
• Sympathetic and parasympathetic nerve fibers from the Plexus Bursa omentalis has a diameter of approximately 3 cm and is
coeliacus via the periarterial plexus. The Truncus vagalis anteri- surrounded at the front by the Lig. hepatoduodenale, above by
or gives up the Rr. hepatici to the Plexus hepaticus, from which the Lobus caudatus of the liver, below by the Pars superior of the
the Rr. pylorici reach the pylorus of the stomach. duodenum and behind by the V. cava inferior.
In anatomical terminology, many other peritoneal duplicatures are • Vestibulum: the front of the Vestibulum is delimited by the
optionally named and assigned to the two omenta. Since this is not Omentum minus and with a Recessus superior reaches behind
useful in a medical sense, we will forgo it here. the liver.
• Isthmus: the narrowing between the first and main space is de-
limited by two peritoneal folds, on the right side through the Pli-
7.7.3 Recessus of the peritoneal cavity ca hepatopancreatica, which is raised by the A. hepatica commu-
nis, and on the left through the Plica gastropancreatica, in which
The peritoneal duplicatures, which raise up the relief of the rear the A. gastrica sinistra runs.
wall of the peritoneal cavity as folds (Plicae) and ligaments (Liga- • Main space: it lies between the stomach (in front) and the pan-
menta), form the various recesses (Recessus) that represent the creas or the parietal peritoneum of the abdominal wall (behind).

Lig. gastrophrenicum Ostium cardiacum

Plica gastropancreatica Lig. coronarium, Lig. triangulare sinistrum
Bursa omentalis, Recessus superior Bursa omentalis
Plica hepatopancreatica Lig. gastrosplenicum
Glandula suprarenalis
Spleen [Lien]
Lig. coronarium
Bursa omentalis,
Recessus splenicus

Lig. hepatoduodenale Cauda pancreatis

Ren [Nephros] Mesocolon transversum

Duodenum, Pars superior

Duodenum, Flexura
duodenojejunalis
Ren [Nephros]
Recessus duodenales
Duodenum, superior and inferior
Pars horizontalis
Plica duodenalis inferior
Radix mesenterii

Plica ileocaecalis

Recessus ileocaecalis
superior

Recessus ileocaecalis Recessus

inferior intersigmoideus

Mesoappendix
Mesocolon
Ureter sigmoideum

Colon sigmoideum
Ovarium
Excavatio rectouterina
Tuba uterina
Excavatio vesicouterina
Fundus uteri
Vesica urinaria,
Fundus vesicae

Fig. 7.47 Dorsal wall of the peritoneal cavity with recess spaces (Recessus). Ventral view.

342
 7.8 Vessels and nerves of the peritoneal cavity

The Recessus splenicus stretches to the left until the hilum of accumulate as a result of cranially oriented circulation of peri-
the spleen and the Recessus inferior under the Lig. gastrocoli- toneal fluid, especially in the right Recessus subphrenicus
cum up to the attachment of the mesocolon at the Colon trans- and the Recessus subhepaticus. On the left side, the circula-
versum. tion should be limited by the Lig. phrenicocolicum. With oper-
ations in the left upper abdomen, e.g. on the spleen, accumu-
Under the diaphragm above the Facies diaphragmatica of the liver
lation of fluid in the left recessus subphrenicus is very common.
is the Recessus subphrenicus, which is divided by the Lig. falci- Inflammatory exsudates must be removed using sonographic
forme hepatis into a right and left section, and by the Lig. triangu- or CT-guided drainage, as otherwise treatment resistant in-
lare dextrum/sinistrum into an upper and lower section. At the flammation centres (peritoneal collections of pus or abscess-
bottom right section, the Recessus subhepaticus follows, behind es) may form.
which in the upper section is the right kidney. This part is also
known as the Recessus hepatorenalis.

Recessus of the lower abdomen (inframesocolic compart- 7.8 Vessels and nerves of the peritoneal cavity
ment)
This compartment is divided by the mesenteric root of the small
intestine into a right and left infracolic space below the Mesocolon
Skills
transversum (› Fig. 7.47). Lateral of the Colon ascendens and de- After working through this chapter, you should be able to:
scendens are the paracolic trenches (Sulci paracolici) and below • understand the system of vessels and nerves of the perito-
the Mesocolon sigmoideum of the Recessus intersigmoideus. The neal cavity so that you can understand the origin of the sup-
right paracolic trench is directly connected to the Recessus subhe- ply in the individual organs
• recognise the visceral branches of the abdominal aorta with
paticus and the right Recessus subphrenicus, while on the left, the
their supply areas and identify them on a dissection speci-
Lig. phrenicocolicum represents a barrier. men
At the Flexura duodenojejunalis the Plicae duodenales superior and • explain the organisation of the autonomic nervous system
inferior form 2 recessed areas (Recessus duodenales superior and in the peritoneal cavity and understand the origin of the
inferior) (› Fig. 7.47). There are further recesses at the confluence nerve fibres in the individual organs
of the ileum, into the Caecum (Recessus ileocaecales superior
and inferior) and the Recessus retrocaecalis, in which the Appen-
dix vermiformis is usually raised behind the Caecum. In the pelvic
section of the peritoneal cavity, there are various recesses in front 7.8.1 Overview
of the rectum, dependention sex. In women, the space is limited
anteriorly by the uterus. This Excavatio rectouterina (DOUGLAS The vessels and nerves of the abdominal cavity serve to supply
pouch) is the lowest point of the female peritoneal cavity (› Fig. the viscera and also the dorsal abdominal wall. The major arterial,
7.47). The Excavatio vesicouterina located in front between the venous and lymphatic vessels run in the retroperitoneum and
bladder and uterus does not go quite as far caudally. In men there continue caudally to the pelvic cavity into the subperitoneal
is only one recess, which reaches at the front as far as the bladder space as well as cranially to the dorsal mediastinum of the tho-
and is accordingly known as the Excavatio rectovesicalis. racic cavity. The plexus of the autonomic nervous system that in-
nervate the organs of the abdomen and pelvic floor lie ventrally on
the aorta and are caudally connected with the ligaments in the
Clinical remarks connective tissue of the pelvis. The branches of the vascular stems
The Bursa omentalis is, like the rest of the peritoneal cavity and autonomic nerve plexus run dorsally via the peritoneal dupli-
recesses, of clinical significance as pathological processes catures (mesenteries) into the peritoneal cavity and supply the
can occur here: respective organs.
• Spreading of tumours (peritoneal carcinomatosis) In this chapter only the vessels and nerves of the peritoneal cavity
• Inflammation of the peritoneum (peritonitis)
are described in the overview. The individual vascular branches
• Entrapment of the small intestinal loops (internal hernias)
Therefore, during operations of the abdomen, the surgeon in- and their paths are explained alongside the vascular and nervous of
spects the Bursa omentalis in order to avoid overlooking any the respective organs.
symptoms. The large vascular stems are dealt with alongside the vessels and
During operations on the upper abdomen, e.g. procedures on nerves of the retroperitoneal space and pelvic cavity (› Chap. 8.8)
the pancreas, the surgeon has recourse to 3 access paths in and presented in their cranial continuation in the chapter on the
the Bursa omentalis: thoracic cavity (› Chap. 6.6).
• through the Omentum minus
• through the Lig. gastrocolicum
• through the Mesocolon transversum
In the Recessus duodenalis inferior (and superior) most fre- 7.8.2 Arteries of the peritoneal cavity
quently (over 50%) of all recesses, entrapment of small intes-
tinal sections occurs (TREITZ hernias). The incarceration can The abdominal viscera are supplied by the 3 unpaired arterial
cause a blockage (ileus) and bowel infarction. branches that originate ventrally from the abdominal section of
In an upright position inflammatory exudate or pus can accu- the aorta (Pars abdominalis aortae):
mulate in the deepest recesses of the peritoneal cavity, the
• Truncus coeliacus
Excavatio rectovesicalis in men and the Excavatio vesicouteri-
na (DOUGLAS pouch) in women if there is inflammation in
• A. mesenterica superior
the lower abdomen, which can be detected in sonography as • A. mesenterica inferior
free liquid. In bedridden patients, inflammatory secretions

343
7 Abdominal viscera

The 3 arteries, together with the branches of the A. iliaca interna, • A. hepatica communis: turns right and forms the Plica hepato-
enter vascular connections (anastomoses) one below the other. pancreatica of the Bursa omentalis, before dividing into its main
3 anastomoses are important: branches:
• Connections between Truncus coeliacus and A. mesenterica – A. hepatica propria: gives off the A. gastrica dextra then sup-
superior via the Aa. pancreaticoduodenales (BÜHLER's anasto- plies the liver and gall bladder (A. cystica)
mosis) – A. gastroduodenalis: descends behind the pylorus or duode-
• Connections between the Aa. mesentericae superior and infe- num, divides into the A. gastroomentalis dextra for the great-
rior: RIOLAN’s anastomosis between the A. colica media and er stomach curvature and into the A. pancreaticoduodenalis
sinistra superior anterior and posterior, which anastomose with the A.
• The plexus of the rectal arteries: this connects the A. rectalis su- pancreaticoduodenalis inferior from the A. mesenterica supe-
perior from the A. mesenterica inferior with the Aa. rectales rior and supplies the pancreatic head and duodenum. Various
media and inferior from the supply area of the A. iliaca interna, small branches of the A. gastroduodenalis on and behind the
which is part of the arteries of the pelvic cavity. Pars superior duodeni are described as A. supraduodenalis
and Aa. retroduodenales
• A. splenica: runs to the bottom left and on the upper margin of
Clinical remarks the pancreas, and on its way to the spleen gives off the following
The anastomoses can prevent an intestinal or pancreatic in- branches:
farction in the case of an occlusion of a vessel. In addition, – Rr. pancreatici to the pancreas
the blood vessels around the rectum can also maintain a cer- – A. gastrica posterior to the stomach (in 30–60%)
tain amount of blood supply to the legs if the blood supply is – A. gastroomentalis sinistra: runs from the left to the greater
impaired by a narrowing of the distal abdominal aorta or the
stomach curvature and anastomoses with the A. gastroomen-
proximal iliac arteries.
talis dextra
– Aa. gastricae breves: short branches to the fundus of the
stomach
Truncus coeliacus – Rr. splenici: terminal branches to the spleen
The Truncus coeliacus originates as the first unpaired branch of the
aorta (› Fig. 7.48).While still in the retroperitoneal space behind A. mesenterica superior
the Bursa omentalis the short stem (mostly 2–3 cm long) divides The A. mesenterica superior originates unpaired from the aorta di-
into the 3 major branches that supply the organs of the upper ab- rectly below the Truncus coeliacus (1–2 cm), initially runs retro-
domen (stomach, duodenum, liver, gall bladder, pancreas and peritoneally behind the pancreas and then into the Mesenterium
spleen): (› Fig. 7.49). It supplies parts of the pancreas and duodenum, the
• A. gastrica sinistra: runs to the upper left and gives up the Plica entire small intestine, and the large intestine up to the left colic
gastropancreatica in the rear wall of the Bursa omentalis. The flexure.
vessel is usually stronger than the A. gastrica dextra which it
anastomoses with on the small stomach curvature

R. sinister A. hepatica A. gastrica sinistra

communis
R. dexter Hepar Truncus
coeliacus
Trigonum cholecystohepaticum Gaster
[CALOT’s triangle]
A. gastrica
Ductus hepaticus posterior
communis
Spleen [Lien]

Vesica biliaris
Aa. gastricae
A. cystica breves

Ductus cysticus A. splenica

[lienalis]
A. hepatica propria

V. portae hepatis

A. gastrica dextra A. gastro-

omentalis sinistra
A. pancreatico-
duodenalis Omentum majus
superior posterior

A. gastro-
duodenalis

A. pancreatico- A. gastro- Rr. omentales

duodenalis superior omentalis dextra

Fig. 7.48 Branches of the Truncus coeliacus. [L238]

344
 7.8 Vessels and nerves of the peritoneal cavity

RIOLAN’s anastomosis

A. colica media

A. mesenterica superior
A. colica dextra

Jejunum
R. colicus
A. ileocolica Aa. jejunales
R. ilealis

A. ileocolica
A. appendicularis

Caecum Aa. ileales

Appendix vermiformis

Ileum

Fig. 7.49 A. mesenterica superior. Ventral view. Colon transversum folded upwards. (according to [S010-1-16])

Branches of the A. mesenterica superior: • A. rectalis superior: extends from above to the rectum, which
• A. pancreaticoduodenalis inferior: usually goes off to the up- predominantly supplies it and also feeds the cavernous body in
per right; R. anterior and R. posterior anastomose with the Aa. the upper section of the anal canal, which is a part of the conti-
pancreaticoduodenales superiores anterior and posterior from nence organ
the supply area of the Truncus coeliacus (A. gastroduodenalis)
• Aa. jejunales (4–5) and Aa. ileales (12): originate to the left
from the main vessel 7.8.3 Veins of the peritoneal cavity
• A. colica media: originates from the right side, anastomises with
the A. colica dextra and the A. colica sinistra (RIOLAN's anas­ In contrast to the arterial branches, which originate from the ab-
tomosis) from the A. mesenterica inferior dominal section of the aorta, the veins of the individual abdominal
• A. colica dextra: runs to the Colon ascendens organs are not connected to the lower vena cava inferior (V. cava
• A. ileocolica: supplies the distal ileum, caecum and Appendix inferior) in the retroperitoneum, but join together with the hepatic
vermiformis. Branches: portal vein (V. portae hepatis), which carries the nutrient-rich
– R. ilealis to the terminal ileum (connected with the last A. ile- blood from the intestine and the liver (› Fig. 7.31). The V. mesen-
alis) terica superior is joined with the V. splenica behind the neck of the
– R. colicus (anastomoses with the A. colica dextra) pancreas, which mostly (70%) has previously received the V. mes-
– A. caecalis anterior and A. caecalis posterior on both sides enterica inferior.
of the Caecum
– A. appendicularis, supplies the Appendix vermiformis
7.8.4 Lymph vessels of the peritoneal cavity
A. mesenterica inferior
The A. mesenterica inferior originates unpaired from the Aorta to The 3 stations of the collecting lymph nodes, which receive all the
the left, 6–7 cm below the A. mesenterica inferior branches off 6–7 lymph of the intraperitoneal and secondary retroperitoneal ab-
cm below the A. mesenterica superior and 3–5 cm above the aortic dominal organs, are in the retroperitoneal space at the outlets of
bifurcation and then descends, whereby it runs retroperitoneally the 3 large unpaired abdominal arteries (› Fig. 7.48). They there-
on the left colonic flexure except for a short end portion. It supplies by drain the following organs:
the Colon descendens and Colon sigmoideum, the rectum and the • Nodi lymphoidei coeliaci: stomach, duodenum and pancreas,
upper anal canal. After 3–4 cm, the artery divides into an ascend- liver, gall bladder, spleen
ing and a descending main branch. • Nodi lymphoidei mesenterici superiores: duodenum and pan-
creas, ‘right-sided large intestine’ (caecum, appendix, Colon
Branches of the A. mesenterica inferior ­ascendens and Colon transversum)
• A. colica sinistra: rises on the Colon descendens, anastomises • Nodi lymphoidei mesenterici inferiores: ‘left-sided large intes-
with the A. colica media from the A. mesenterica superior (RIO- tine’ (Colon descendens and Colon sigmoideum, proximal rec-
LAN’s anastomosis) › Fig. 7.50) tum)
• Aa. sigmoideae: several (2–5) branches to the Colon sigmoide- The lymph flows from the collecting lymph nodes via the Trunci
um intestinales, which run in the Radix mesenterii together with the

345
7 Abdominal viscera

Colon transversum RIOLAN’s anastomosis

DRUMMOND’s anastomosis

Colon ascendens Colon descendens

A. colica media
A. mesenterica superior

A. mesenterica inferior
A. colica dextra

R. colicus A. colica sinistra

A. ileocolica

A. caecalis anterior
Aa. sigmoideae

Caecum Colon sigmoideum

A. appendicularis

Appendix vermiformis Rectum A. rectalis superior

Fig. 7.50 A. mesenterica inferior. Ventral view. Colon transversum folded up. (according to [S010-1-16])

A. and V. mesenterica superior, as well as the exit of the Truncus in the sacral part of the spinal cord (S2–4), which is why the para-
coeliacus and join the retroperitoneum dorsal right of the aorta sympathetic nervous system as a craniosacral part of the auto-
with the Trunci lumbales to the Cisterna chyli from which the nomic nervous system is in opposition to the thoracolumbar sym-
Ductus thoracicus emerges cranially a main lymphatic stem of the pathetic nervous system.
body (› Fig. 7.23).
Sympathetic nervous system
The preganglionic neurons of the sympathetic nervous system en-
7.8.5 
Nerves of the peritoneal cavity gage with the anterior root of the spinal cord and go through the
Rr. communicantes albi of the spinal nerves to the sympathetic
The abdominal viscera are innervated by the plexus of the auto- trunk (Truncus sympathicus), which forms a chain of ganglia both
nomic nervous system, which lie anteriorly of the abdominal sec- sides of the vertebral column (paravertebral) (› Fig. 7.51); how­
tion of the aorta and in their entirety form the Plexus aorticus ab- ever, the nerve fibres for the abdominal cavity are not switched in
dominalis. The plexus, which therefore lies in the retroperitoneum, these ganglia of the sympathetic trunk; instead they run through
contains sympathetic and parasympathetic nerve fibres. Their them and run with the two visceral nerves (N. splanchnicus ma-
nerve fibres reach the target organs mainly as periarterial plexus, jor, T5–9, and N. splanchnicus minor, T10–11) through the dia-
which run in the peritoneal duplicatures of the mesenteries and phragm to the ganglia on the abdominal section of the Aorta (pre-
thus intraperitoneally. vertebral), where they are finally switched on the postganglionic
In order to understand the organisation of the autonomic nerve neurones. In addition, the prevertebral ganglia also receive nerve
plexus of the abdominal organs, it is important to look at the basic fibres from the lumbar spinal cord segments, which reach the
structure of the autonomic nervous system first. nerve plexus around the aorta via the abdominal part of the sym-
The fundamental difference of autonomic efference compared to pathetic trunk with its visceral nerves (Nn. splanchnici lumbales).
somatic efference is that 2 neurons are connected in series. The first
preganglionic neuron, along with its nerve cell body (Pericaryon) Parasympathetic nervous system
sits in the central nervous system (CNS) and sends its axon as a The preganglionic neurons of the parasympathetic nerves run with
nerve fibre into the peripheral nervous system (PNS), where the the N. vagus [X] from the base of the skull through the chest cavity
second postganglionic neurons sit in their nodular-shaped struc- and finally pass through the diaphragm as Trunci vagales anterior
tures (ganglia). The switch from preganglionic to postganglionic and posterior with the oesophagus. The Truncus vagalis anterior
neurons sitting in the ganglion happens via synaptic switching as a result of intestinal rotation, arises mainly from the left N. vagus,
(› Fig. 7.51). the Truncus vagalis posterior accordingly from the right N. vagus.
The preganglionic neurons of the sympathetic nervous system are In particular, branches (Rr. coeliaci) from the Truncus vagalis
located in the lateral horns of the thoracic and lumbar sections of posterior extend to the Plexus coeliacus and further to the Plexus
the spinal cord (C8–L3), whereas the parasympathetic neurons, mesentericus superior, which ventrally surrounds the abdominal
are in the nuclei of the cranial nerves III, VII, IX and X, as well as Aorta.

346
 7.8 Vessels and nerves of the peritoneal cavity

Ganglion
ciliare Glandula
lacrimalis

N. oculomotorius [III]
Oculus

Ganglion pterygopalatinum
Ganglion
submandibulare
N. facialis
[VII]
N. glossopharyngeus [IX]
Parasympathetic trunk
N. vagus [X] Ganglion
head part
oticum
Glandulae
oris

Sympathetic trunk
neck part Pulmo

Cor
Sympathetic trunk Ganglion stellatum
chest part [cervicothoracicum]
2

Sympathicus 1 3
C8/T1–L3
Ganglion
coeliacum
Enteric
nervous system

Ganglion
mesentericum
Sympathetic superius
trunk abdominal Ganglion
section mesen- Intestinum tenue
tericum
Plexus
inferius Glandula suprarenalis
Sympathetic hypogastricus
pelvic section superior

Parasympathetic
pelvic part S2–S4

“Preganglionic”

“Postganglionic” Rectum

1 Vasa
2 Mm. erectores pilorum Plexus hypogastricus inferior
Organa genitalia Fig. 7.51 Organisation of the
3 Glandulae
Vesica urinaria autonomic nervous system.
[L106]

Plexus aorticus abdominalis then in the Plexus hypogastricus inferior in the vicinity of the
The organisation of the autonomic nerve plexus of the abdominal rectum are switched to postganglionic neurons (› Fig. 7.52). The
Aorta (Plexus aorticus abdominalis) is easy to understand when postganglionic nerve fibres ascend only to a small part of the Plex-
you factor in that each plexus lies at the exit of the arterial branch us mesentericus inferior and predominantly reach the Colon de-
of the same name and reaches the arterial target organs with the scendens and Colon sigmoideum as well as the proximal rectum as
blood vessels (› Fig. 7.52, › Fig. 8.64). Therefore, the arterial and direct branches (› Fig. 7.52).
nervous supply areas are similar.
While the sympathetic neurons descend from the Plexus coeliacus NOTE
to the Plexus mesentericus superior from cranial to caudal and for The plexus of the abdominal aorta contains sympathetic and para-
the Plexus mesentericus inferior receives additional nerve fibres sympathetic neurons. The ganglia of the arteries of the same
from the Nn. splanchnici lumbales, the innervation and supply name, however, are purely sympathetic nerves. The result is that
area of the N. vagus (cranial parasympathetic nervous system) the perivascular nerve plexus around the visceral arteries contain
postganglionic sympathetic and preganglionic parasympathetic
ends on the left colic flexure and, therefore, with the Plexus mesen- nerve fibres.
tericus superior (traditionally known as CANNON's point).
The left-sided sections of the large intestine receive their nerve fi-
bres, as do all the pelvic organs, from the sacral parasympathetic
trunk (S2–4), where they leave as the Nn. splanchnici pelvici, and

347
7 Abdominal viscera

Truncus vagalis posterior

N. splanchnicus major dexter
Truncus vagalis anterior

N. splanchnicus major sinister

Plexus hepaticus
Ganglia coeliaca

N. splanchnicus minor
Plexus coeliacus
Plexus splenicus
Ganglion mesentericum Ganglion aorticorenale
superius
Plexus renalis

Plexus intermesentericus
Plexus mesentericus
superior Ganglion mesentericum
inferius

Truncus sympathicus Plexus uretericus

Plexus mesentericus
Plexus hypogastricus superior inferior

N. hypogastricus dexter

Branches of the Plexus hypogastricus

Nn. splanchnici pelvici (S2–4) inferior to Colon descendens
and sigmoideum
Plexus hypogastricus inferior

N. hypogastricus sinister

Fig. 7.52 Autonomic innervation of the abdominal organs. Ventral view.

348
8 Pelvic viscera
Jens Waschke

8.1 Kidneys . . . . . . . . . . . . . . . . . . 352 8.4.4 Continence organ . . . . . . . . . . 366

8.1.1 Overview . . . . . . . . . . . . . . . . . 352 8.4.5 Arteries of the rectum
8.1.2 Functions of the kidneys . . . . 352 and anal canal . . . . . . . . . . . . . 369
8.1.3 Development of the kidneys . 352 8.4.6 Veins of the rectum
and anal canal . . . . . . . . . . . . . 369
8.1.4 Projection and structure
of the kidney . . . . . . . . . . . . . . 354 8.4.7 Lymphatic vessels of the
rectum and anal ­canal . . . . . . 370
8.1.5 Fascial system of the kidney . 355
8.4.8 Innervation of the rectum
8.1.6 Topography . . . . . . . . . . . . . . . 356 and anal canal . . . . . . . . . . . . . 370
8.1.7 Vessels and nerves
of the kidney . . . . . . . . . . . . . . 357 8.5 Male genitalia . . . . . . . . . . . . . 371
8.5.1 Overview . . . . . . . . . . . . . . . . . 372
8.2 Adrenal gland . . . . . . . . . . . . . 358
8.5.2 Function of
8.2.1 Overview . . . . . . . . . . . . . . . . . 358 the male genitalia . . . . . . . . . . 372
8.2.2 Functions of the adrenal 8.5.3 Development of
gland and development . . . . . 358 the male genitalia . . . . . . . . . . 372
8.2.3 Structure, projection 8.5.4 Penis and scrotum . . . . . . . . . 375
and topography
of the adrenal glands . . . . . . . 359 8.5.5 Testis and epididymis . . . . . . 376
8.2.4 Vessels and nerves 8.5.6 Vas deferens
of the adrenal glands . . . . . . . 359 and spermatic cord . . . . . . . . . 377
8.5.7 Accessory sex glands . . . . . . . 378
8.3 Efferent urinary tracts . . . . . . 359 8.5.8 Vessels and nerves
8.3.1 Overview and function . . . . . . 359 of the external and
8.3.2 Development of ­internal male genitalia . . . . . . 379
the efferent urinary tracts . . . 359
8.6 Female genitalia . . . . . . . . . . . 383
8.3.3 Renal pelvis and ureter . . . . . 361
8.6.1 Overview . . . . . . . . . . . . . . . . . 384
8.3.4 Urinary bladder . . . . . . . . . . . . 362
8.6.2 Function of the
8.3.5 Urethra . . . . . . . . . . . . . . . . . . 362 female genitalia . . . . . . . . . . . 385
8.3.6 Closure mechanisms 8.6.3 Development of the external
of the urinary bladder and internal f­ emale genitalia . 385
and the urethra . . . . . . . . . . . . 363
8.6.4 Vulva . . . . . . . . . . . . . . . . . . . . 386
8.3.7 Vessels and nerves
of the efferent urinary tracts . 363 8.6.5 Ovary and fallopian tubes . . . 387
8.6.6 Uterus . . . . . . . . . . . . . . . . . . . 388
8.4 Rectum and anal canal . . . . . . 364 8.6.7 Vagina . . . . . . . . . . . . . . . . . . . 389
8.4.1 Overview and function . . . . . . 364 8.6.8 Vessels and nerves
8.4.2 Classification, projection of the external and
and structure of rectum ­internal female genitalia . . . . 390
and anal canal . . . . . . . . . . . . . 364
8.4.3 Mesorectum . . . . . . . . . . . . . . 365
8.7 Retroperitoneal space 8.8.3 Veins of the retroperitoneum
and pelvic cavity . . . . . . . . . . . 392 and pelvic cavity . . . . . . . . . . . 397
8.7.1 Overview . . . . . . . . . . . . . . . . . 392 8.8.4 Lymphatic vessels
8.7.2 Retroperitoneal space . . . . . . 392 of the retroperitoneum
and pelvic cavity . . . . . . . . . . . 398
8.7.3 Subperitoneal space . . . . . . . . 392
8.8.5 Nerves of the retroperitoneum
8.8 Vessels and nerves and pelvic cavity . . . . . . . . . . . 400
of the extraperitoneal
space and pelvic cavity . . . . . 394 8.9 Pelvic floor and
perineal region . . . . . . . . . . . . 401
8.8.1 Overview . . . . . . . . . . . . . . . . . 394
8.9.1 Overview . . . . . . . . . . . . . . . . . 401
8.8.2 Arteries of the retroperitoneum
and pelvic cavity . . . . . . . . . . . 394 8.9.2 Pelvic floor . . . . . . . . . . . . . . . 401
8.9.3 Perineal region . . . . . . . . . . . . 402
 CASE STUDY

Prostate cancer
The physical rectal findings are a strong indication for prostate
Medical history cancer, which constitutes the most common malignant tumour in
A 72-year-old man reports to his GP that he has been suffering from men over 70 years old. The urologist first confirms the diagnosis by
increasing pain in the pelvic area and his back for some months, means of a transrectal biopsy, in which parts of a prostate carcino-
and recently also in his chest. He also says he is constantly tired ma are detected by a pathologist. Corresponding to the diagnosis,
and worn out, which is unusual for him. the PSA level is far beyond the age-appropriate normal range. Since
the bone pain in this diagnosis can be seen as an indication of
extensive bone metastasis, a nuclear medicine physician carries out
Examination results a bone scintigraphy, which confirms metastases in pelvis, spine,
ribs and sternum.
His pelvis, lumbar and thoracic spine and also his ribs are tender.
All other physical examination findings are normal. As part of a
routine cancer screening, which the patient has never undergone Treatment
before, the GP carries out a rectal examination, in which the right
lobe of the prostate exhibits a very dense node. Due to the extensive metastasis and the poor prognosis, surgical
removal of the prostate is not meaningful. Because growth of
prostate cancer is hormone-dependent, drug therapy is started,
Diagnosis which restricts the distribution and effect of testosterone. In
addition, pain medication is given.
On the basis of the physical findings the GP orders that the
prostate-specific antigen (PSA) be tested in a previously taken
blood sample and refers the patient to a urologist. In order to Further developments
exclude coronary artery disease (CAD), which can also cause
tightness in the chest with pain (angina pectoris), an ECG is carried After 3 years the patient dies of the consequences of advanced
out, which is normal. To check for oesophagitis, which is associated stage tumour.
with retrosternal pain (heartburn) and could at least explain the
discomfort in the chest area, the GP also arranges an appointment
with a gastroenterologist in private practice for a gastroscopy.

Your first day of a mandatory placement with a GP. You were present at the appointment with
the patient. Now, the GP asks you to write a short letter for the urologist.
For this purpose, you make these bullet points:

First day – first doctor's letter…

Hx.: 72-year-old patient, with pain in pelvis,
back and chest, worsening over last few months
Patient very tired and worn out, otherwise known illnesses.
CE: pressure pain in pelvis, thoracic spine and lumbar spine
and ribs; rough nodes in right prostate lobes palpable
DD.: BE for PSA control carried out, result pending, ECG
(for the exclusion of AP) nothing evident, appt. for gastroscopy
agreed (above all gastroesophageal reflux disease)
Palpation and CE are highly suspect for metast. prostate cancer
→ request for biopsy to confirm diagnosis
PSA value will be sent as soon as available, with confirmation of
the suspected diagnosis: skeletal Scinti for metastases search
8 Pelvic viscera

8.1 Kidneys of fluid and electrolyte balance, it is an absolutely indispensable

organ. Its functions are:
• Excretion of urine, the body's own and foreign substances
Skills • Regulation of fluid, electrolytes and acid-base balance
After working through this chapter, you should be able to: • Endocrine function (erythropoietin, renin, calcitriol)
• know the vital importance of the kidneys and their functions The kidneys filter the blood and in the process form 170 litres of
• explain the development of the kidneys with potential defor- primary urine a day, which contains most of the bodily substances
mities to be excreted (e.g. urine) and also foreign substances (e.g. medi-
• show on a specimen the location and projection of the kid-
cines). From this primary urine the kidneys resorb over 90% of the
neys with their fascia system
• describe the vessels and nerves of the kidneys on a speci- liquid as well as the majority of electrolytes and nutrients, whilst
men other substances are excreted in a targeted way so that approxi-
mately 1.7 litres of urine a day is passed into the efferent urinary
tracts. This principle enables a very effective elimination on the one
hand and on the other hand, a delicately regulated recovery of
valuable substances which is controlled by hormones and thus can
8.1.1 Overview be adapted to each respective metabolic state. Because of this ex-
cretion function the kidneys control not only fluid and electrolyte
The kidney, ren, or nephros is a parenchymatous organ with a red- balance in the body, but also the pH level of the blood (acid-base
dish-brown colour, which, together with the efferent tracts, forms homeostasis); however, the kidneys also have endocrine func-
(› Chap. 8.3) the urinary system (› Fig. 8.1). It is located in tions: erythropoietin, which is required by bone marrow for the
close proximity to the adrenal glands (› Chap. 8.2), an endocrine production of red blood cells, as well as calcitriol, which regulates
organ, in the retroperitoneal space of the upper abdomen. the calcium levels, are produced in the kidneys. Renin, which itself
The kidneys and efferent urinary tracts are of particular impor- is not a hormone but an enzyme causes the formation of hor-
tance for the specialist field of urology. mones, which are of critical importance for fluid balance.

8.1.2 Functions of the kidneys 8.1.3 Development of the kidneys

The kidneys have a wide range of functions. Together with the liver The kidneys develop, as do the genitalia, from the intermediate
it is the essential excretion organ of the body. Due to its regulation mesoderm, which in the 4th week forms the urogenital ridge, the

Ren [Nephros]
Pelvis renalis

Ureter
Organa
urinaria
Ductus deferens
Glandula vesiculosa
Vesica Ductus deferens
urinaria Prostata
Organa genitalia
Glandula
Urethra masculina interna
bulbourethralis
masculina
Epididymis
Ductus deferens
Testis
a

Ren [Nephros]
Pelvis renalis

Ureter
Organa
urinaria Tuba uterina
[Salpinx]
Ovarium Organa genitalia
feminina interna
Uterus
Vesica urinaria
Vagina
Urethra feminina

Fig. 8.1 Structure of the urinary

system. Lateral view left. a Male
b urinary system. b Female urinary
system.

352
 8.1 Kidneys

lateral part of which is referred to as the nephrogenic cord. Be-

tween the 4th and 9th weeks 3 generations of kidneys (› Fig. 8.2)
form one after the other from cranial to caudal:
• Pronephros Pronephros
• Mesonephros
• Metanephros Gut
Whilst the pronephros remains functionless and completely degen- Mesonephros
erates, the mesonephros is different and functions temporarily be-
fore it also largely degenerates. The primitive ureter of the mesone- WOLFFIAN duct
phros remains (Ductus mesonephricus, WOLFFIAN duct) in exis-
tence and enters into the caudal part of the hindgut (cloaca)
(› Fig. 8.2). In men parts of the ductules system between testis Cloaca
Metanephros
and epididymis (Ductuli efferentes) also emerge from the mesone- Ureteric bud
phros. From the WOLFFIAN duct the ureteric bud develops as a
protrusion and forms the efferent urinary tracts and in the 5th Fig. 8.2 Development of the kidneys in the 5th week of development.
week induces the differentiation of the metanephros. The ureteric
bud becomes (› Fig. 8.3):
• The ureter bryonic body up until the 9th week (ascent), until they reach their
• The renal pelvis (Pelvis renalis) with renal calyces (Calices renal- final position (› Fig. 8.4). In the process they remain in a retro-
es) peritoneal location, but they rotate the hilum where blood vessels
• Collection ducts of the renal parenchyma and the ureter enter and exit by 90°, so that they are no longer
The definitive kidneys are thus formed from 2 parts, both of which aligned ventrally, but medially. During their ascent, several genera-
come from the mesoderm: tions of renal arteries develop one after the other, which first
• Metanephros: it forms the nephrons and the glomeruli become emerge from the pelvic artery (A. iliaca communis) and later from
embedded in their renal corpuscles. the abdominal aorta. These vessels usually degenerate, but may
• Ureteric bud: it forms the collection ducts, which are connected persist in some cases as accessory renal arteries.
to the nephrons.
The kidneys are thereby first divided into lobes, the boundaries of NOTE
which can be seen as furrows on the surface anatomy. During development the kidneys rise out of the pelvis (ascent) and
The metanephroses first differentiate at the level of the future pelvis in the process do not take the supplying vessels and nerves along
and ascend due to the strong growth of the lower half of the em- with them.

Calix renalis
major
Nephrons

Pelvis renalis

Ureter Calix renalis Collection duct

Fig. 8.3 Development of the
minor kidneys from the ureteric bud. a
a b c Renal pelvis. b Renal calix. c Col-
lecting duct. [L126]

Aorta Horseshoe
kidney
Ren
A. mesenterica
A. renalis inferior

Ureter Fig. 8.4 Ascent of the kidneys

with deformities. a Original
position of the kidneys. b Nor-
Vesica Pelvic mal final location of the kidneys.
urinaria kidney c Pelvic kidney, right. d Horse-
a b c d
shoe kidney.

353
8 Pelvic viscera

Clinical remarks Due to its proximity to the diaphragm, the location of the kidneys
depends on breathing so that both kidneys can sink by up to 3 cm
If ascent does not occur, this gives rise to a pelvic kidney
during inhalation.
(› Fig. 8.4c). What can also occur is that the inferior renal
poles merge and form a horseshoe kidney (› Fig. 8.4d).
Since this is hindered in its ascent by the unpaired A. mesen- Clinical remarks
terica inferior, the horseshoe kidney also remains displaced
caudally. Pelvic kidneys (1:2500 births) and also horseshoe In the clinical examination the kidneys are first examined us-
kidneys (1:400 births) are usually accidental findings and ing pain sensitivity as a rough guide, whereby finely-tuned fist
have no clinical relevance so long as the course of the ureter punches are applied to the lumbar region at the level of the
is not affected in the process. Displacement of the ureter can kidneys, i.e. on the posterior side just below the ribs; how­
cause urinary stasis, which can lead to kidney damage caused ever, the patient must not be warned beforehand because the
by increased pressure and by ascending infections. Similarly, back muscles would otherwise be tensed and thus dampen
malrotations, where the hilum points to ventral or dorsal, are the impact too much. In the case of an inflammation of the re-
usually clinically insignificant. nal pelvis (pyelonephritis) the patient will, for example, not
only wince in surprise but will also complain of experiencing
significant pain. In its correct execution this diagnostic meas­
ure also always constitutes a certain stress test for the doc-
tor–patient relationship.
8.1.4 Projection and structure of the kidney
The kidneys are divided into the cortex (Cortex renalis) and me-
The kidneys are a 10–12 cm long, 5–6 cm wide and 4 cm thick par­ dulla (Medulla renalis) (› Fig. 8.7). The medulla is divided into
enchymatous organ with a weight of 120–200 g (averaging 150 g). different sections, which, corresponding to their shape are desig-
They have a superior and inferior pole (Polus superior and Polus nated renal pyramids (Pyramides renales). Between the pyramids
inferior), an anterior and posterior surface (Facies anterior and are renal columns (Columnae renales). A pyramid with its adjoin-
Facies posterior) and a medial and lateral border (Margo medialis ing cortex segments is called a renal lobe (Lobus renalis). The bor-
and Margo lateralis). At the medial border is the Hilum renale, der between the usually ca. 14 lobes is not usually visible on the
where the vessels and nerves and the ureter enter and exit (› Fig. surface anatomy in adults. The tips of the pyramids (Papillae renal-
8.6). The kidneys are therefore kidney-shaped (!). They project es) flow into the renal calyces (Calices renales majores and mi-
(› Fig. 8.5) nores), where urine is released into the renal pelvis (Pelvis renalis).
• with the superior pole onto the XIIth thoracic vertebra and the The renal pelvis is located together with adipose tissue and vascu-
XIth rib; lar, lymphatic and nervous systems in a recess of the kidney paren-
• with the hilum onto the IInd lumbar vertebra and chyma (Sinus renalis), which is connected to the Hilum renale.
• with the inferior pole onto the IIIrd lumbar vertebra. Located in the hilum are the:
These specifications only apply to the left kidney. Due to the size of • V. renalis (anterior)
the liver the right kidney sits approximately half a vertebra deeper. • A. renalis (in the middle)
The superior pole is thus positioned to the right just below the XIth • Renal pelvis (posterior)
rib.

Glandula thyroidea
Oesophagus
Trachea

Pulmo
Cor
Dia-
phragma
Hepar
Glandula
suprarenalis
Gaster
Spleen [Lien]
Pancreas
Ren
Jejunum
Duodenum

Colon
Ileum
Appendix vermiformis
Rectum

Fig. 8.5 Projection of inner

organs onto the surface of the
a b body. a Ventral view. b Dorsal
view.

354
 8.1 Kidneys

Margo superior Capsula adiposa

Aa. suprarenales Capsula fibrosa
superiores
Ren
Margo medialis

Aa. suprarenales mediae

Glandula suprarenalis
V. suprarenalis

A. suprarenalis inferior

A. renalis, R. posterior Margo

lateralis
V. renalis
Hilum renale

A. renalis, R. anterior

V. testicularis/ovarica
sinistra

Ureter

Fig. 8.6 Kidney (Ren, Nephros)

Pelvis
renalis
and adrenal gland (Glandula
suprarenalis), left. Ventral view.

The kidney parenchyma consists of nephrons and collection ducts or layer of the renal fascia is referred to clinically as GEROTA's
(› Fig. 8.12), in which urine is altered by filtration out of the fascia. The posterior layer merges into the muscular fascia of the
blood with subsequent reabsorption and secretion. Finally, at the M. psoas major and M. quadratus lumborum.
top of the papillae the collection ducts release the urine into the re-
nal pelvis.
Clinical remarks
The fascial systems and the topographical relationships of the
8.1.5 Fascial system of the kidney kidneys are of clinical importance. The fat capsule secures the
kidneys during breathing. If the capsule, e.g. during anorexia,
The kidneys have a 3-fold fascial system (› Fig. 8.8): is greatly reduced then the kidneys may sink (nephroptosis) or
rotate, in which case the ureter bends down and the kidneys
• Capsula fibrosa: organ capsule of dense connective tissue di-
can be damaged by urinary backflow. In a nephrectomy due to
rectly on the surface anatomy of the parenchyma malignant tumours of the kidneys, the kidneys and adrenal
• Capsula adiposa: fat capsule that surrounds the kidney and ad- glands, including GEROTA’s fascia, are removed.
renal gland
• Fascia renalis: fascial sac that is open in the inferior medial as-
pect for the passage of vessels and nerves and ureter. The anteri-

Medulla renalis,
Pyramides renales

Capsula fibrosa
Cortex renalis

Area cribrosa,
Foramina papillaria
Aa. interlobares

A. renalis

V. renalis Columnae
renales
Pelvis renalis

Sinus renalis

Ureter

Fig. 8.7 Kidney (Ren, Nephros),

left. Ventral view; after vertical
Lobus renalis
A. arcuata dissection with exposed and
opened renal pelvis.

355
8 Pelvic viscera

Fusion fascia Fascia renalis, front sheet

(TOLDT) (GEROTA’s fascia)
M. obliquus Peritoneum parietale Ren [Nephros] dexter
externus abdominis V. cava inferior
M. obliquus
internus abdominis
Pars abdominalis aortae
M. transversus abdominis

Vertebra lumbalis
Flexura coli dextra

Fascia renalis, M. psoas major

rear sheet

Ren [Nephros],
Capsula fibrosa
Autochthonous back muscles
Ren [Nephros],
Capsula adiposa

M. latissimus dorsi Fig. 8.8 Fascial systems of the

kidneys; horizontal incision at
M. quadratus lumborum the level of the III lumbar verte-
bra. Caudal view. [L238]

8.1.6 Topography Various nerves of the Plexus lumbalis are located directly at the
renal fascia between the kidney and abdominal wall in the area of
The kidneys are located in the retroperitoneal space of the upper the inferior renal pole. (› Fig. 8.9):
abdomen and both adrenal glands sit above them (› Fig. 8.5). • N. iliohypogastricus and N. ilioinguinalis which, among other
To the anterior they are separated from other organs by their things, provide sensory innervation to the inguinal region
3-fold fascial system but nevertheless have a close topographical • N. genitofemoralis, which courses further to caudal and there-
relationship on both sides to various viscera. fore has no contact with the kidneys but only with the ureter.
• The right kidney has broad surface contact with the Facies vis- • 11th and 12th intercostal nerves (12th intercostal nerve = N.
ceralis of the liver as well as contact to medial with the Pars de- subcostalis), which are located slightly further to cranial and
scendens of the duodenum, and at its inferior pole to the jeju- therefore below both of the two lowest ribs.
num and right colic flexure (› Fig. 7.19a).
• At its upper pole, the left kidney has contact with the posterior
side of the stomach and at its lateral border it has contact with
Clinical remarks
the Facies visceralis of the spleen. In front at the level of the hi- The close proximity of the kidneys to the N. iliohypogastricus
lum is the tail part of the pancreas. At the inferior pole there is and N. ilioinguinalis explains why diseases of the kidneys,
contact with the Ileum and Colon descendens (› Fig. 7.19b, c). such as inflammation of the renal pelvis (pyelonephritis) or
Kidneys and adrenal glands are located dorsally in the retroperito- trapped kidney stones in the pelvis (nephrolithiasis) can
cause radiating pain up into the inguinal region.
neal space directly against the posterior abdominal wall and thus
ventrally of the M. psoas major and the M. quadratus lumborum.

Pars abdominalis aortae V. cava inferior

Ren [Nephros]

N. iliohypogastricus

N. ilioinguinalis

N. subcostalis

N. iliohypogastricus

Sensory innervated skin area, N. ilioinguinalis

in which during nerve stimulation
pain is perceived N. genitofemoralis Ureter
a b

Fig. 8.9 Proximity of the kidneys to nerves of the Plexus lumbalis. a Radiating pain into the inguinal region. b Course of the nerves of the Plex-
us lumbalis in relation to the kidneys. a[L126 ]; b[L238]

356
 8.1 Kidneys

8.1.7 Vessels and nerves of the kidney the pyramids, and then run at the cortex-medulla border as the A.
and V. arcuata in an arch shape around the pyramids and leave
Arterial and venous supply them at their bases as the A. and V. corticalis radiata, which as-
The Aa. renales (› Fig. 8.10a) originate in pairs from the abdomi- cend to the capsule. From these, the fine vessels go to the capillary
nal section of the aorta and run dorsal to the veins to the hilum of loops in the nephrons (› Fig. 8.12).
the kidney, whereby the right A. renalis runs along behind the V.
cava inferior. With 3–5 cm, the right A. renalis is considerably long­er
than the left (2–3 cm). In front of the hilum the A. suprarenalis
Clinical remarks
­inferior goes to the adrenal gland as well as thin branches to the In contrast to the veins, the intrarenal arteries do not form
ureter. The branches of the A. renalis divide the kidneys with their closed vessel arches, i.e. they are terminal arteries. Thus, in
supply areas into 5 segments, whereby the A. renalis branches at the case of arterial occlusion, e.g. due to a transported blood
the hilum firstly into an R. anterior, which with various branches clot (embolism), renal infarction occurs. Its extent corre-
sponds to the segmental borders; however, the branching pat-
supplies the inferior, both anterior and the inferior segment of the
terns are highly variable.
kidney, and a R. posterior for the posterior segment (› Fig. 8.11, Accessory renal arteries (30%) are evolutionary relics and
also › Fig. 8.6). Alternatively, the lower segment can also receive must be protected during operations in order to avoid haemor-
an independent branch. rhages. Up to 5 arteries can occur. Aberrant arteries enter into
The renal capsule is reached by small branches from the A. renalis the parenchyma outside of the hilum. Capsular vessels can
or the A. testicularis/ovarica or the Aa. lumbales. also cause haemorrhages during operations.
The Vv. renales correspond with their branches to the arteries; they Because kidney carcinoma often grows into the Vv. renales, a
tumour on the left hand side in men can cause backflow into
run ventrally of these and flow on both sides into the V. cava inferi-
the V. testicularis with a tangled ball-like expansion of the
or (› Fig. 8.10b). Since the inferior vena cava lies to the right of veins in the scrotum (varicocele). Therefore, in the case of a
the Aorta, the left V. renalis is, at 7.5 cm long, three times as long as left-sided varicocele, a kidney tumour must always also be ex-
the vessel on the right side (1–2.5 cm). cluded (› Fig. 8.43)!
On the left side, the V. renalis takes up 3 veins; the corresponding
veins flow to the right independently into the V. cava inferior:
• V. suprarenalis sinistra
• V. testicularis/ovarica sinistra Lymphatic pathways
• V. phrenica inferior sinistra The regional lymph nodes of the kidneys are the Nodi lymphoidei
lumbales around the Aorta and V. cava inferior (› Fig. 8.63).
Intrarenal blood vessels From there, the lymph on both sides goes into the Trunci lum-
The segmental branches of the A. renalis and V. renalis divide with- bales.
in the hilum and ascend as the A. and V. interlobaris at the edge of

V. suprarenalis dextra V. suprarenalis sinistra

Aa. suprarenales superiores

A. phrenica inferior

Aa. suprarenales mediae

A. suprarenalis inferior

A. renalis

Pars abdominalis aortae

a b
V. renalis sinistra
V. renalis dextra V. cava inferior

Fig. 8.10 Vascular supply of kidneys and adrenal glands. Ventral view. a Arteries. b Veins.

Segmentum Segmentum
anterius superius superius

A. renalis
V. renalis Segmentum
Segmentum posterius
anterius inferius

Segmentum
Ureter Fig. 8.11 Renal segments, Seg-
inferius Segmentum
a b inferius menta renalia, right. a Ventral
view. b Dorsal view.

357
8 Pelvic viscera

8.2 Adrenal gland
A. corticalis radiata
Arterial Vasa recta
Skills
A. arcuata
After working through this chapter, you should be able to:
• explain the vital function of the adrenal glands and the di-
A. inter- verse evolutionary origins of their parts
lobaris • show on a specimen the location of the adrenal glands with
V. arcuata attachment to the different vessels and nerves on both
Renal goblet sides of the body
V. stellata

Vv. corticales
radiatae V. interlobaris

Venous Vasa recta 8.2.1 Overview

The adrenal gland, Glandula suprarenalis, is an endocrine organ of

gold-yellow colour, which rests on the upper pole of the kidney
within the retroperitoneal space. In both diagnosis as well as in
medical and surgical treatment, it is particularly important for spe-
cialists such as endocrinologists and highly experienced visceral
Collecting tube
surgeons.
Nephron with
long loop

Nephron with
8.2.2 Functions of the adrenal gland and develop-
cortical loop Nephron with ment
short loop
The adrenal glands are an absolutely essential endocrine gland.
Cortex and medulla have different evolutionary origins and form
Fig. 8.12 Course of arteries, veins and nephrons in the renal paren- hormones, which are particularly necessary for managing stress
chyma; schematic illustration. (according to [S010-1-16]) and in emergency situations and they have a regulating effect on
metabolism and the circulation (› Table 8.1).
Innervation
The autonomic innervation of the kidneys is overwhelmingly
sympathetic (› Fig. 8.13) and effects vasoconstriction and thus a Table 8.1 Hormones of the adrenal glands.
reduction of blood flow as well as the secretion of renin. The post-
Hormones of the cortex Hormones of the medulla
ganglionic sympathetic nerve fibres from the Ganglion aorticore- (steroid hormones)
nale form the Plexus renalis around the A. renalis.
• Glucocorticoids (cortisol) • Catecholamines (adrenaline, nor-
For the general organisation of the autonomic nervous system in
• Mineralocorticoids (aldosterone) adrenaline)
the abdomen see › Chap. 7.8.5 and on the autonomic ganglia in • Androgens (DHEA)
the retroperitoneum see › Chap. 8.8.5.

Aa. suprarenales Truncus vagalis anterior

superiores
Oesophagus N. phrenicus sinister,
V. cava inferior
R. phrenicoabdominalis
N. phrenicus dexter, Truncus vagalis posterior
R. phrenicoabdominalis
N. splanchnicus major
with direct branches to
A. phrenica inferior
the adrenal glands

Glandula suprarenalis Ganglia

coeliaca
A. suprarenalis media
N. splanchnicus
Truncus coeliacus minor

Ganglia
A. suprarenalis aorticorenalia
inferior
Ganglion mesentericum
superius
Truncus sympathicus

Ren [Nephros]

A. renalis Ureter
A. mesenterica Pars abdominalis
superior aortae Fig. 8.13 Innervation of kidney
and adrenal gland. [L238]

358
 8.3 Efferent urinary tracts

The cortex develops in the 6th week from the mesoderm in the Innervation
wall of the abdominal cavity (coelomic epithelium); the medulla, Autonomic innervation is carried out by preganglionic (!) sympa-
however, originates from the neural crest (neuroectoderm) and thetic nerve fibres from the Nn. splanchnici from the Plexus su-
thus corresponds to a ‘modified’ sympathetic ganglion. Until birth, prarenalis medially of the gland. In the adrenal medulla they effect
the adrenal glands are 10–20 times larger than in adults relative to the release of catecholamines (the adrenal medulla corresponds to
body weight and then shrink in the first 2 years of life. a modified sympathetic ganglion) (› Fig. 8.13).
For general organisation of the autonomic nervous system in the
abdomen, see › Chap. 7.8.5.
Clinical remarks
If both adrenal glands are removed due to disease, mineralo-
corticoids and glucocorticoids must be replaced by medica- 8.3 Efferent urinary tracts
tion because otherwise life-threatening shock conditions can
ensue due to low blood sugar (hypoglycaemia) and low blood
pressure (hypotension). This can also be the case with adrenal Skills
gland insufficiency (ADDISON's disease).
After working through this chapter, you should be able to:
• explain the structure of the efferent urinary tracts with their
development
• show sections and the precise course of the ureter on a
specimen and pinpoint its constriction
8.2.3 Structure, projection and topography of the • know the position and closure mechanisms of the urinary
adrenal glands bladder as well as basic processes during micturition
• understand sections and differences of the urethra in both
The adrenal glands are 5 cm long and 2–3 cm wide with a weight of sexes and their clinical significance
4 g. A distinction is made between anterior, posterior and inferior • demonstrate the vessels and nerves of the efferent urinary
surfaces (Facies anterior, posterior and renalis) as well as a medial tracts
(Margo medialis) and a superior border (Margo superior)
(› Fig. 8.6). At the medial border is the hilum, where the vascular,
lymphatic and nervous systems enter and exit. The adrenal glands
project onto the neck of the XIth and XIIth ribs. In the retroperito- 8.3.1 Overview and function
neum they lie directly below the diaphragm and in the process rest
upon the upper pole of the kidneys (› Fig. 8.6) and are embedded The efferent urinary tracts include:
with these in a common fat capsule (Capsula adiposa), which are • Renal pelvis (Pelvis renalis)
encased by the renal fascia (Fascia renalis, GEROTA's fascia). Here- • Ureter
by, they have the following topographical relationships: • Urinary bladder (Vesica urinaria)
• Facies anterior: Facies visceralis of the liver and Pars descend­ • Urethra
ens of the duodenum as well as the V. cava inferior (right), pos- The efferent urinary tracts together with the kidneys (› Chap. 8.1)
terior surface of the stomach (left, separated by the Bursa omen- form the urinary system (› Fig. 8.1). They range from the renal
talis) pelvis in the retroperitoneal space of the upper abdomen via the
• Facies posterior: diaphragm ureters to the urinary bladder in the subperitoneal space of the
• Facies renalis: rests on the superior renal pole pelvis and there facilitate the excretion of urine via the urethra
(micturition).
With the exception of the urethra, the urinary system is identically
8.2.4 Vessels and nerves of the adrenal glands formed in both sexes. In men, the urethra in the penis is a
urine-semen duct, as it is also used to transport the ejaculate and
Arterial and venous supply thus is also part of the external male genitalia.
Usually there are 3 adrenal arteries (› Fig. 8.10a):
• A. suprarenalis superior: usually several small vessels, origina­
ting from the A. phrenica inferior 8.3.2 Development of the efferent urinary tracts
• A. suprarenalis media: directly from the Aorta
• A. suprarenalis inferior: branch of the A. renalis The efferent urinary tracts originate from 2 parts (› Fig. 8.14):
This ‘luxury perfusion’ prevents the occurrence of organ infarction • Ureteric bud: forms ureters, renal pelvis and the collection duct
that could jeopardise the vital organ; however, all 3 adrenal arteries of the kidney parenchyma
are formed only in one third of cases, otherwise usually the middle • Sinus urogenitalis: becomes the urinary bladder and urethra
or inferior artery is missing.
In contrast, for each adrenal gland there is only one adrenal vein, Ureteric bud
which collects blood and conducts it right into the V. cava inferior The ureteric bud develops in the 5th week as a protrusion from the
or left into the V. renalis (› Fig. 8.10b). primitive ureters of the mesonephros (Ductus mesonephricus,
WOLFFIAN duct) and therefore emerges from the mesoderm. The
Lymphatic pathways ureter later includes attachment to the caudal part of the hindgut
The regional lymph nodes of the adrenal gland are the Nodi lym- (cloaca), which differentiates from the ectoderm (› Chap. 8.1.3 ).
phoidei lumbales around the Aorta and V. cava inferior (› Fig. The cloaca is then divided by the urorectal septum in the 7th week
8.63). From there, the lymph on both sides goes in the Trunci lum- into the anterior Sinus urogenitalis and the posterior rectum
bales. (› Chap 7.2.3) (› Fig. 8.14a–c).

359
8 Pelvic viscera

Sinus urogenitalis groove and form the Pars membranacea and Pars spongiosa of the
The upper part of the sinus urogenitalis develops into the epitheli- urethra, which are surrounded by the Pars spongiosa of the penis
um of the urinary bladder, in that the inferior sections of the me- (Corpus spongiosum) (› Fig. 8.31). Only the distal part in the area
sonephric ducts up to and including the ureteric buds are incorpo- of the glans of the penis originates from a depression of the ecto-
rated so that the ureters are now connected directly to the urinary derm. In a female embryo the urethral groove does not close, but be-
bladder (› Fig. 8.14b, c). Connective tissue and smooth muscles comes the vestibule of the vagina (Vestibulum vaginae) (› Fig. 8.49).
emerge from the surrounding mesoderm. The apex of the urinary
bladder continues into the allantoic duct, which ends as a blind
sac within the body stalk . The allantoic duct degenerates into a
Clinical remarks
connective tissue cord (Urachus) (› Fig. 8.14e, f), which after Various double formations of the ureter can occur. The ureter
birth runs as the Lig. umbilicale medianum on the inside of the fissus is usually an incidental finding and has no clinical rele-
abdominal wall up to the navel. vance; however, where there is ureteral duplication, it often
The Urethra also originates from the Sinus urogenitalis (› Fig. causes incorrect confluence into the urinary bladder, which
can lead to vesicoureteral reflux or incontinence. Both ureters
8.14e, f), whereby the middle section in a female embryo forms the
usually cross each other (MEYER-WEIGERT rule): the ureter
epithelium of the whole of the urethra; however, in a male embryo it originating from the more cranially located renal pelvis enters
only forms the Pars intramuralis and prostate gland. In the inferior more into the urinary bladder or distally into the urethra,
section of the Sinus urogenitalis its boundary invaginates into the am- which can result in urinary incontinence; however, the ureter
niotic cavity (urogenital membrane) between 2 folds (urethral with a more cranially located urinary opening which usually
folds) and tears in the 7th week (› Fig. 8.31, › Fig. 8.49). In this originates from the lower renal pelvis, has a shorter Pars intra-
opening the entoderm of the Sinus urogenitalis forms the urethral muralis in the urinary bladder wall, so that in this case it can
lead to vesicoureteral reflux.
groove. In a male embryo the urethral folds close over the urethral

Sinus urogenitalis Allantoic duct

Mesonephros Pars vesicalis

Genital
Mesonephric duct tubercle Sinus
urogenitalis
Pars pelvina
Ureteric bud
Pars phallica
Septum urorectale
Site of the rectum
a Cloacal membrane b

Allantoic duct Mesonephric duct

Gonad

Mesonephros Mesonephros

Metanephros Metanephros

Site of the Ureter

urinary bladder
Ureter
Mesonephric duct

Site of the rectum Pars pelvina of the

Sinus urogenitalis
c d
Ventral section
of the Septum urorectale

Tuba uterina

Kidney
Urachus
Kidney

Urinary bladder
Testis
Urethra Ovar
Pars spongiosa
Ureter
of the urethra
Clitoris Uterus Ductus deferens
Penis
Vagina

e f

Fig. 8.14 Development of the efferent urinary ducts between the 5th (a) and 12th (e, f) weeks of development; view from left. [E347-09]

360
 8.3 Efferent urinary tracts

Reflux favours ascending infections, which can lead to perma- • The Pars abdominalis firstly crosses over the N. genitofemoralis
nent damage of the kidneys. and crosses below the A./V. testicularis/ovarica. On the right
If the Urachus does not completely obliterate, then urachus side it is covered by the duodenum, the A. colica dextra and the
cysts can remain and become infected. In the case of urachus mesenteric root, and on the left by the A./V. mesenterica inferior
fistulas a duct remains, which can still be connected to the
or the A. colica sinistra. When entering the lesser pelvis the ure-
urinary bladder, so that in newborns urine drains out of the
naval. ter crosses over the A./V. iliaca communis.
• The Pars pelvica in men passes under the Ductus deferens, and
in women behind the ovary and in the vicinity of the uterus un-
der the A. uterina.
• The Pars intramuralis runs 1.5–2 cm through the musculature
8.3.3 Renal pelvis and ureter of the urinary bladder wall and confluences with its two slot-
shaped apertures (Ostia uteris) into the Trigonum vesicae of the
The renal pelvis (Pelvis renalis) is surrounded by adipose tissue in urinary bladder. The valve-like openings are closed when no
the Sinus renalis of the kidneys (› Fig. 8.7). On the papillae of the urine passes through the ureter in order to avoid a reflux of
medullary pyramids the renal pelvis is extended to the renal caly- urine, which can damage the kidneys by ascending infections.
ces (Calices renales) whereby the protrusions that emerge directly
from the renal pelvis are referred to as the major calyces (Calices NOTE
majores). These then divide into the minor calyces (Calices mi- The over-under-over-under rule for the course of the ureter: the
nores) that surround the papillae of the medullary pyramids. Ac- ureter first runs over the N. genitofemoralis, crosses under the A.
cording to the width and length of the calyx, a distinction is made and V. testicularis/ovarica, crosses over the A. and V. iliaca and
between dendritic and ampullary types of renal pelvis. then crosses under the Ductus deferens in men and under the A.
uterina in women.
The ureter is 25–30 cm long and has a diameter of approximately 5
mm (› Fig. 8.15). It transports urine by regularly occurring peri-
staltic waves and is divided into 3 sections: The ureter has 3 constrictions (› Fig. 8.15):
• Pars abdominalis: in the retroperitoneal space • at the outflow of the renal pelvis
• Pars pelvica: in the lesser pelvis • at the intersection of the A. iliaca communis or externa
• Pars intramuralis: traverses the urinary bladder wall • at the passageway through the wall of the urinary bladder (most
The ureter leaves the renal pelvis in an inferior medial direction narrow part)
and firstly crosses the inferior renal pole.

Pelvis renalis

Ren
1st ureter constriction
in the area of the inferior
renal pole

Crossed over
N. genitofemoralis

A.; V. iliaca Ureter, pars

communis abdominalis
A.; V. ovarica

N. genito- 2nd constriction of

femoralis ureter to the
intersection
of the Vasa iliaca

Crossed under A.; V. iliaca

A.; V. ovarica interna
A.; V. iliaca
externa

Crossed Ureter, Pars

Vasa iliaca pelvica

Rectum

Crossed under A. uterina

the A. uterina
Uterus

3rd ureter constriction when it passes through Vesica urinaria

the urinary bladder wall (Pars intramuralis) Fig. 8.15 Sections of the ureter
with constrictions. [L238]

361
8 Pelvic viscera

Clinical remarks The bladder is surrounded by paravesical adipose tissue and is se-
cured by various ligaments:
Kidney stones coming loose can remain stuck at the constric-
• Lig. umbilicale medianum (contains the urachus = relic of the
tions and then cause very strong wave-like radiating pain (re-
nal colic). The proximity of the ureter to the A. uterina must be allantoic duct): runs from the apex of the urinary bladder to the
taken into consideration in removal of the uterus (hysterecto- navel
my) so that the ureter is not ligated with the artery. A urine • Lig. pubovesicale (› Fig. 8.58), traverses the Spatium retropu-
blockage may lead to irreversible damage to the kidneys. bicum and in women is anchored on both sides of the neck of
the bladder on the posterior side of the pubic bone
• Lig. puboprostaticum (› Fig. 8.57), corresponding ligament in
men
8.3.4 Urinary bladder Behind the urinary bladder the peritoneal cavity in both sexes is
extended caudally to a recess: the Excavatio vesicouterina and the
The urinary bladder (Vesica urinaria) lies subperitoneally and is Excavatio rectovesicalis separate the urinary bladder from the
covered on its superior side by the Peritoneum parietale of the pel- uterus and rectum in both women and men.
vic cavity. It is divided into a body (Corpus vesicae), which tapers
off above to the apex (Apex vesicae) and in a posterior inferior di-
rection has a bladder base (Fundus vesicae) (› Fig. 8.16). In an
Clinical remarks
anterior inferior direction the urinary bladder narrows into the When full the urinary bladder protrudes over the pubic bone
neck of bladder (Cervix vesicae), which merges into the urethra. and can be punctured in the case of urinary retention, without
The wall of the urinary bladder has a thick layer of muscle, which is opening the peritoneal cavity (suprapubic catheter).
activated parasympathetically and is referred to as the M. detru-
sor vesicae.
At the fundus the exit of the urethra (Ostium urethrae internum)
forms, together with the confluence found on both sides of the ure- 8.3.5 Urethra
ter (Ostium ureteris), the trigone of the bladder (Trigonum vesi-
cae). The urinary bladder has a capacity of 500–1500 ml. The urethra is formed very variably in both sexes.
In men the prostate gland, which is crossed by the urethra, is locat- • The female urethra is 6 mm wide and, at 3–5 cm, very short and
ed directly under the fundus of the bladder and there gives rise to enters directly ventral of the vagina into the vestibule of the va-
the Uvula vesicae. gina (Vestibulum vaginae) (› Fig. 8.46).
In pairs abutting the urinary bladder on the posterior side from • The male urethra, however, is relatively long at 20 cm and is di-
medial to lateral are: vided into different sections (› Fig. 8.16):
• Extended section of the Ductus deferens (Ampulla ductus defer- – Pars intramuralis (1 cm): in the urinary bladder wall, its be-
entis) gins at the Ostium urethrae internum
• Seminal glands (Glandula vesiculosa) – Pars prostatica (3.5 cm): traverses the prostate; here, the
• Ureter Ductus ejaculatorii (common exit duct of Ductus deferens

Pars Ostium urethrae internum

intramuralis
Colliculus seminalis
Pars Ductus ejaculatorii Ductuli prostatici
prostatica
Crista urethralis
Glandula bulbourethralis,
Pars
Ductus glandulae
membranacea
bulbourethralis
Ductus glandulae
bulbourethralis
Corpus cavernosum
penis

Urethra
masculina Corpus spongiosum
penis

Pars
spongiosa
Lacunae urethrales

Fossa navicularis urethrae Fig. 8.16 Urinary bladder and

Glans penis
urethra. Ventral view; urinary
Ostium urethrae externum bladder and urethra opened
ventrally.

362
 8.3 Efferent urinary tracts

and seminal vesicle) confluences with the Colliculus seminalis Vesica urinaria
and the prostate glands bilaterally
– Pars membranacea (1–2 cm): at the passage through the pel-
vic floor
*
– Pars spongiosa (15 cm): runs within the Corpus spongiosum
of the penis up to the external orifice (Ostium urethrae exter- Urethra
num). Here COWPER's glands (Glandulae bulbourethrales)
M. sphincter
and the LITTRÉ's glands (Glandulae urethrales) flow into urethrae externus
each other. The proximal section is extended to the Fossa na-
M. transversus
vicularis. The proximal section is also somewhat wider and is, perinei profundus
a
therefore, sometimes referred to as the ‘Ampulla urethrae’.
In this course, the male urethra has 2 curvatures (› Fig. 8.57) – at Vesica urinaria
the transition from the Pars membranacea to the Pars spongiosa
and in the middle section of the Pars spongiosa – and the following
constrictions (› Fig. 8.16):
*
• Ostium urethrae internum
Urethra
• Pars membranacea
• Ostium urethrae externum (narrowest point, diameter: 6 mm)
M. sphincter
In contrast, the Pars spongiosa (especially proximally = ‘Ampulla
urethrae externus
urethrae’) and the Fossa navicularis are particularly wide.
b

Clinical remarks Fig. 8.17 Closure mechanisms of the urinary bladder and the ure-
Because the female urethra is much shorter than the male thra; median incision; view from left; * smooth muscles of the ure-
one, ascending infections of the urinary bladder (cystitis) are thra. a Male view. b Female view.
more common in women than in men.
Due to the stretched course of the female urethra the placing Although the urinary bladder has a capacity of 500–1500 ml, the
of a urinary catheter is much easier in women; however, care
urge to urinate already starts from 250 ml. Via stretching receptors,
must be taken that the urethral orifice in the vestibule is locat-
ed in front of the opening to the vagina. In men, however, the an autonomic reflex arc in the sacral portion of the parasympa-
curvatures of the urethra must be offset by aligning the penis thetic nervous system (S2–4) in the spinal cord is activated, which
in order to prevent perforations especially in the tissue of the increases the tone of the smooth muscles of the urinary bladder
prostate, which are painful and can bleed severely. Firstly, the wall (M. detrusor vesicae). Micturition is set in motion via a mic-
urethra is inserted with the catheter after stretching the penis turition centre in the Pons of the brain stem: firstly, the pelvic
in order to compensate for the bend in the Pars spongiosa. floor weakens so that the urinary bladder descends and then the
Resistance means the second curvature before the construc-
tone of the smooth and striated closure muscles relaxes:
tion of the Pars membranacea has been reached. To compen-
sate more easily for this second curvature, the penis is placed • via parasympathetic reflex arcs (S2–4):
downwards between the legs of the patient. – reflex contraction of the M. detrusor vesicae (parasympathet-
ic, S2–4)
• regulates via micturition centre in the brain stem (Pons):
– atony of the pelvic floor → descent of the bladder
– atony of the circular muscles of the urethra (inhibition of the
8.3.6 Closure mechanisms of the urinary bladder sympathetic nervous system)
and the urethra – atony of the M. sphincter urethrae externus

Contributing to the closure mechanisms are both muscle tension

from smooth muscles in the wall of the urethra and striated mus-
Clinical remarks
cles in the perineal area (› Fig. 8.17): If the closure mechanisms fail, incontinence ensues, which in
• Smooth muscles of the annular muscle layer of the urethra older age is especially common in women, if the pelvic floor is
­(‘M. sphincter urethrae internus’). This muscle layer is activated weakened after pregnancy (pelvic floor weakness). Treatment
­sympathetically. A true sphincter is not morphologically defin- consists of training the pelvic floor muscles and, if necessary,
surgical tightening of the pelvic floor. In men, surgical removal
able. In men, the muscles prevent retrograde ejaculation into the
of the prostate often leads to incontinence caused by damage
urinary bladder; however, their contribution to urinary conti- to the smooth muscles of the proximal urethra.
nence is unclear.
• M. sphincter urethrae externus: in men this muscle is a divi-
sion of the M. transversus perinei profundus, which does not
form an independent muscle in women. This striated muscle,
which is U-shaped and incomplete to the back towards the rec- 8.3.7 Vessels and nerves of the efferent urinary
tum, is innervated by the N. pudendus and facilitates arbitrary tracts
closure of the urinary tract.
In addition, the shape and function of the pelvic floor (Diaphrag- Arterial blood supply
ma pelvis) are also crucial for continence because the pelvic floor Only the urinary bladder has its own arteries; all other sections of
supports the urinary bladder. the efferent urinary tracts are supplied from vessels in the sur-
rounding.

363
8 Pelvic viscera

• Renal pelvis: is concomitantly supplied by the A. renalis stones). The Pars spongiosa of the male urethra, like the penis, re-
• Ureter: due to its long course various arteries are involved ceives sensory innervation via the N. pudendus and is thus highly
(› Fig. 8.15) sensitive to pain.
– Pars abdominalis: A. renalis, A. testicularis/ovarica, Pars ab- For the general organisation of the autonomic nervous system in
dominalis of the aorta, A. iliaca communis the abdomen, see › Chap. 7.8.5 and on the autonomic ganglia in
– Pars pelvica and intramuralis: A. iliaca interna with Aa. vesi- the retroperitoneum, see › Chap. 8.8.5.
cales superior and inferior as well as the A. uterina
• Urinary bladder:
– upper main part (around two thirds): A. vesicalis superior 8.4 Rectum and anal canal
(from the A. umbilicalis of the A. iliaca interna) Jens Waschke, Friedrich Paulsen
– fundus and neck of the bladder (approximately one third): A.
vesicalis inferior; in women, the A. vaginalis often replaces the
A. vesicalis inferior Skills
• Urethra: A. vesicalis inferior or A. vaginalis; in men the Pars
spongiosa is supplied by its own A. urethralis, which is the ter- After working through this chapter, you should be able to:
minal branch of the A. bulbi penis (from the A. pudenda inter- • show the sections of the rectum and anal canal on a speci-
men and explain their evolutionary origins
na)
• describe the topographical relationships of the rectum and
anal canal and understand the mesorectum in its expansion
Venous drainage and delineation
The veins correspond to the respective arteries. In the pelvis the • explain the continence organ with the functions of its differ-
veins form extended plexi around the individual organs, which ex- ent parts and describe the key processes in defecation
tensively communicate with each other. The Plexus venosus vesi- • show on a specimen the boundaries of supply areas of the
calis drains via the Vv. vesicales into the V. iliaca interna. vascular, lymphatic and nervous systems of the rectum and
anal canal and know their clinical relevance
Lymphatic pathways
The regional lymph nodes for the proximal ureter are the Nodi
lymphoidei lumbales around the aorta and V. cava inferior
(› Fig. 8.63). In the pelvis, corresponding to various lymph nodes 8.4.1 Overview and function
in the immediate surroundings of the urinary bladder, the Nodi
lymphoidei iliaci interni and externi are the central lymph node Rectum and anal canal (Canalis analis) are the last segments of
stations for the distal ureter, urinary bladder and urethra. From the large intestine (› Chap. 7.2 ) and serve the purpose of tempo-
both groups, the lymph on both sides goes into the Trunci lum- rary storage and the controlled excretion of the faeces. They form a
bales. Only the lymphatic pathways from the Pars spongiosa of the functional unit.
male urethra, like those of the penis, have a connection to the in- Due to various idiosyncrasies in topography, structure and vascu-
guinal lymph nodes (Nodi lymphoidei inguinales). lar, lymphatic and nervous systems, both these sections are dealt
with in the pelvic organs. For development, see › Chap. 7.2.3.
Innervation
The efferent urinary tracts are both sympathetically and parasym-
pathetically innervated: 8.4.2 Classification, projection and structure of
• The sympathetic nervous system inhibits peristalsis of the M. rectum and anal canal
detrusor vesicae and the smooth muscle of the ureter, but acti-
vates the smooth muscles of the urethra at the exit of the blad- The rectum is joined to the Colon sigmoideum and begins at the
der. level of the II or III sacral vertebra (› Fig. 8.5). It is located in the
• The parasympathetic nervous system in contrast, facilitates pelvic cavity and has a length of 12 cm. In passing through the pel-
peristalsis and activates the micturition reflex. vic floor the rectum continues into the anal canal, which is sur-
Preganglionic sympathetic nerve fibres from the sympathetic rounded along its length of 3–4 cm by the two sphincters and ends
chain (T11–L2) reach the Plexus aorticus abdominalis via the Nn. at the anus. The anal canal is shorter in women. The anorectal tran-
splanchnici lumbales and sacrales. The neurons for the proximal sition projects onto the apex of the coccyx.
ureter are switched in the Ganglia aorticorenalia and reach the ure- In the sagittal plane, the rectum exhibits 2 curvatures:
ter via the Plexus renalis and Plexus testicularis along the respec- • the dorsally directed convex Flexura sacralis and
tive arteries. The sympathetic neurons for the distal ureter, urinary • the ventrally directed convex Flexura perinealis
bladder and urethra descend via the Plexus hypogastricus superior Below the Flexura perinealis, which is induced by the pull of a
to the Plexus hypogastricus inferior in the pelvis, where they are muscle sling (M. puborectalis) of the M. levator ani, (› Fig. 8.22),
connected to postganglionic neurons and reach the target organs is where the anal canal begins. The superior, proximal part of the
via the Plexus vesicalis. rectum (⅔) up to the Flexura sacralis lies in a secondary retroper-
Preganglionic parasympathetic nerve fibres pass from the sacral itoneal position, the inferior, distal part (⅓) and the anal canal are
spinal cord (S2–4) via the Nn. pelvici splanchnici to the Plexus located in the subperitoneal space.
hypogastricus inferior, where they are also switched and reach the The rectum and anal canal just as the vermiform appendix differ
Plexus vesicalis. from the other sections of the large intestine (› Fig. 8.18), so that
In the ureter and in the urinary bladder there can also be afferent the transition of the Colon sigmoideum into the rectum, e.g.
nerve fibres that trigger the micturition reflex, but as nociceptors during operations, can be seen with the naked eye:
also detect hyperextension (e.g. in the case of descending kidney

364
 8.4 Rectum and anal canal

• no taenia but a closed longitudinal muscle layer. On the anterior NOTE

The rectum has 2 distinct curvatures in the sagittal plane (Flexurae
and posterior sides, the taenia first form 2 wide muscle strands, sacralis and perinealis) and 3 less distinct curvatures in the frontal
which then fuse into a continuous layer that surrounds the entire plane (Flexurae laterales). The Flexura sacralis develops passively
rectum by the rectum joining the Os sacrum; the Flexura perinealis devel-
• no haustra ops actively through the pull of the puborectal sling (M. puborecta-
• Folds: the rectum has 3 (only visible from the inside) irregular lis). The lateral curvatures correspond to the Plicae transversae rec-
transverse folds (Plicae transversae recti, › Fig. 8.21); in con- ti on the inside.
trast, in the anal canal there are longitudinal folds (Columnae
anales) The anal canal is divided into 3 sections (› Fig. 8.18, › Fig.
• no Appendices epiploicae. 8.20):
The transverse folds of the rectum cause in addition to the two cur- • Zona columnaris: it extends from the Linea anorectalis to the
vatures in the sagittal plane, up to three curvatures (Flexurae late- Linea pectinata and contains 6–10 longitudinal folds (Colum-
rales) in the frontal plane, which, however, are very irregular and nae anales = MORGAGNI's columns), which are elevated by a
usually difficult to discern. One of the folds is relatively consistent- cavernous body (‘Corpus cavernosum ani’). The longitudinal
ly palpable 6–9 cm above the Linea anocutanea (Plica transversa folds are delineated to the inferior by the Valvulae anales, which
recti = KOHLRAUSCH's folds). Under this fold the rectum is ex- continue caudally into short pockets (Sinus anales), in whose
tended to the Ampulla recti (› Fig. 8.18). The Linea anorectalis depths the anal glands (Glandulae anales, Proctodeal glands,
forms the transition area to the anal canal, which is recognisable • Zona alba (anoderm enter) or Pecten analis (HILTON's zone):
due to the change from the transverse folds of the rectum to the the approximately 1 cm long section ranges from the Linea
longitudinal folds of the anal canal. pectinata (clinical term: Linea dentata), runs jaggedly because
here the Valvulae anales from above and the whitish squamous
epithelium that tapers off on the longitudinal folds from below.
Clinical remarks Due to the multi-layered non-keratinised squamous epithelium,
From a clinical perspective, the anal canal usually begins in the mucosa has a whitish colour and is referred to synonymously
the area of the radiating in of the M. puborectalis (‘rectally as the ‘Zona alba’. The epithelium is firmly bound to the lower
palpable anorectal ring’) at the level of the Linea pectinata third of the M. spincter ani internus; a shift up or down is not
(› Fig. 8.18). Anatomically this boundary runs along the Lin- possible, but there is a strong elasticity in the horizontal plane, as
ea anorectalis. Due to its position between the two lines (Lin-
it is important for the passage of the faecal column.
ea anorectalis and Linea pectinata), the cavernous body in the
anal canal is assigned either to the rectum (‘Corpus caverno- • Zona cutanea: this starts at the blurred Linea anocutanea (HIL­
sum recti’) or to the anal canal (‘Corpus cavernosum ani’). In TON's line) and forms the transitional zone to the outer skin.
the following section, the Corpus cavernosum ani is dis- The skin is highly puckered, pigmented and hairless. Finally,
cussed. somewhat distant from the anus, is the perianal region with hair,
sebaceous glands and sweat glands (› Fig. 8.21). Located at the
border between the Zona cutanea and perianal region is the sub-
epithelial Plexus venosus subcutaneus.

Clinical remarks
As the rectum has transverse folds (Plicae transversae recti),
Tunica muscularis, whilst the anal canal, in contrast has longitudinal folds (Co-
Stratum longitudinale
lumnae anales), if there is a protrusion of intestinal sections
Plica transversa
recti
out of the anus (prolapse) it can be seen with the naked eye,
whether it is a case of rectal prolapse or anal prolapse. In the
case of an anal prolapse there are longitudinally running mu-
Plica trans-
cosal folds and in a rectal prolapse the mucosal folds run cir-
versa recti
cularly. Both can be associated with incontinence.
Because the supply areas of the vessels and nerves change
here, the Linea pectinata is an important orientation line in
Ampulla recti the diagnosis and treatment of cancer of the anal canal (see
below).
The proctodeal glands can penetrate the sphincter and in the
Junctio (Linea)
anorectalis
case of inflammation can lead to the formation of fistulas and
abscesses, which can spread into the Fossa ischioanalis.
Sinus anales M. levator ani
M. sphincter ani
Columnae anales internus
*
Linea pectinata Valvulae anales
Pecten analis M. sphincter ani 8.4.3 Mesorectum
externus
The topography of the rectum is of great clinical significance
Cutis Linea
anocutanea
(› Fig. 8.19). The bony pelvis is covered on its inner side by a pa-
rietal fascia (Fascia pelvis parietalis). The section on the anterior
Fig. 8.18 Rectum and anal canal. Ventral view; * Haemorrhoidal side of the Os sacrum is referred to as the Fascia presacralis (clini-
nodes. cally: WALDEYER's fascia). In addition, every single organ is sur-

365
8 Pelvic viscera

rounded by connective tissue that in its entirety constitutes the vis- (prostatic hyperplasia) and malignant prostate carcinoma,
ceral fascia (Fascia pelvis visceralis). Because these fascia are not digital rectal examination forms part of a complete physical
disectable on a fixed specimen they were neglected for a long time examination in men over 50 years old.
in anatomy. The section of the visceral fascia around the rectum
(clinically: mesorectal fascia) is of particular importance. It sur-
rounds a space filled with fat and connective tissue, which contains
the vascular, lymphatic and nervous systems of the rectum and the 8.4.4 Continence organ
regional lymph nodes. This space within the ‘mesorectal fascia’ is,
therefore, referred to clinically as the ‘mesorectum’. Continence is the ability to hold back intestinal contents/faeces re-
Embedded in the ‘mesorectum’, in men the anterior wall of the flexively at will and to induce its emptying reflexively and at a de-
­rectum is firstly positioned from behind the urinary bladder (Vesi- sired point in time at will. For this, the anal canal has a locally and
ca urinaria) and the seminal vesicles (Glandulae vesiculosae) and central nervous system-controlled continence organ (› Fig. 8.20,
then further caudally the prostate gland. In the process, the rectum › Fig. 8.21).
is separated from the prostate only by the thin Fascia rectoprostat-
ica (clinically: DENONVILLIER’s fascia) (› Fig. 8.19), which con- Components
tinues cranially into the Septum rectovesicale. In women, the rec- The continence organ is composed of:
tum has a close topographical relationship to the posterior side of • Ampulla recti: the expansion of the ampulla on filling is regis-
the vagina and is divided by this only by the Fascia rectovaginalis tered by autonomous afferents (Nn. splanchnici pelvici) and per-
(= Septum rectovaginale) (› Fig. 8.58). ceived by central pathways as an impulse to defecate. Via spinal
The mesorectal fascia thus separates the rectum with its vascular, reflex arches it causes short-term atony of the M. sphincter ani
lymphatic and nervous systems from the Plexus hypogastricus in- internus (see below, anorectal relaxation reflex) with resulting
ferior, which represents the large autonomic nerve plexus of the contraction of all sphincters.
pelvis and thus is responsible for the innervation of all pelvic vis- • M. levator ani (striated muscle, innervated arbitrarily by the N.
cera (› Chap. 8.8.5). pudendus and directly by the Plexus sacralis): the puborectal
section of the M. levator ani (levator sling = M. puborectalis,
› Fig. 8.22) encompasses the distal section of the rectum at the
Clinical remarks transition to the anal canal (M. sphincter recti). The muscle is in
The mesorectal fascia is an important boundary structure in a state of permanent contraction, which is only countermanded
coloproctological surgery. In the case of rectal cancer it en- temporarily during defecation. The pubococcygeal section (M.
ables a bloodless removal of the rectum with its regional pubococcygeus) of the M. levator ani is also involved in conti-
lymph nodes (total mesorectal excision, TME). In the case of a nence activity.
TME, the Plexus hypogastricus inferior can be preserved,
• M. sphincter ani externus (striated muscle, arbitrarily innervat-
which is important for urinary and faecal continence, as well
as erection and ejaculation in men, and among others the ed by the N. pudendus): the muscle has 3 sections: Pars profun-
function of the cavernous body and BARTHOLIN's glands in da, Pars superficialis and Pars subcutanea (› Fig. 8.20). The
women. In this way, incontinence and disorders of sexual Pars profunda is functionally closely linked with the M. pu-
functions can mostly be avoided. borectalis, M. pubococcygeus and the retrorectal connective tis-
Since in men the rectum is separated by just the thin Fascia sue. Via short-term atony of the M. sphincter ani internus (see
rectoprostatica (DENONVILLIER's fascia) from the prostate, below), an expansion of the ampulla causes the contents of the
the prostate is diagnostically accessible in a rectal examina-
rectum to come into contact with the intermediate zone (Ano-
tion. Due to the high incidence of benign prostatic adenomata
derm). This results in a reflexive contraction of the M. sphincter

Rectum Vesica urinaria

Plexus vesicalis Fascia rectoprostatica
Prostata (DENONVILLIER’s fascia)
Plexus prostaticus Ductus deferens
Nodi lymphoidei pararectales Nn. cavernosi penis

Glandula vesiculosa

Fascia pelvis visceralis Plexus rectalis

(mesorectal fascia)
“Mesorectum”

A. rectalis media

Plexus hypogastricus
inferior

Plexus venosus rectalis

Branches of the A. rectalis superior Fascia pelvis parietalis

Os sacrum
Fascia presacralis
Fig. 8.19 Mesorectum; sche-
(WALDEYER’s fascia) Canalis sacralis matic diagram of a transversal
incision, cranial view. [L238]

366
 8.4 Rectum and anal canal

ani externus. If the muscle is now voluntarily contracted further, ically activated): the muscle forms the centre of the continence
the M. sphincter ani internus also contracts again and excretion organ. It continues the circular layer of the intestinal wall and is,
is suppressed. If the ‘externus’ is not voluntarily contracted, then to a certain extent ‘inserted’ into the M. sphincter ani externus
excretion ensues. (› Fig. 8.21). Thus, with respect to defecation, (between which is only connective tissue › Fig. 8.21). Cranially
the M. sphincter ani externus performs a regulating function. it is connected to the M. puborectalis. The longitudinal layer runs
• M. sphincter ani internus (70% of continence function at rest, on the outside of the circular layer as the so-called M. corrugator
protracted contraction, smooth muscles, involuntary, sympathet- ani and terminates later with elastic tendons in the perianal skin.

Rectum Sinus anales

Columnae anales Stratum circulare recti

(Zona columnaris)
Stratum longi-
Vesica urinaria Corpus caver- tudinale recti
nosum recti M. pubococcygeus
Prostata (M. levator ani)
M. sphincter
Corpus ani internus
cavernosum ani
M. puborectalis
(M. levator ani)
M. transversus
perinei profundus Pars
profunda
M. canalis analis Pars
M. sphincter
super-
ani externus
ficialis
Corpus Pars sub-
spongiosum penis cutanea

M. bulbo-
Linea pectinata
spongiosus

Linea anocutanea Fig. 8.20 Rectum and anal

canal in men with presentation
of the continence organ; medi-
M. corrugator Glandula Valvula Valvulae Pecten Zona
ani analis analis anales analis cutanea an incision; view from left
(according to [S010-1-16])

Peritoneum viscerale
(= peritoneum recti)

Plica transversa recti superior

Stratum longitudinale

Stratum circulare

Plica transversa recti media

(KOHLRAUSCH’s fold)

M. canalis analis

Corpus caver- Plica transversa recti inferior

nosum ani

Peritoneum parietale Ampulla recti

Columnae anales
Linea anorectalis
M. levator ani,
pars puborectalis
M. sphincter Anorectum
Glandulae anales ani internus
Zona columnalis
Pars
profunda Canalis analis

Linea pectinata
M. sphincter Pars
(dentata)
ani externus superficialis
Pecten analis
Pars
subcutanea Linea anocutanea

Valvulae anales Zona cutanea

M. corru- Plexus venosus subcutaneus Fig. 8.21 Frontal incision
gator ani (= subanodermal venous plexus) through the pelvis with Ampulla
recti and Canalis analis. [L238]

367
8 Pelvic viscera

Rectum sebaceous glands. At approximately 1 cm wide, it is inseparably

Os pubis fixed with the M. sphincter ani internus at the latter's posterior
Flexura edge: Pecten analis (HILTON's zone). The highly sensitive skin
perinealis is of critical importance for the anorectal reflex. It controls vol-
ume, consistency (liquid, solid, gaseous) and position. This sen-
sory detection is also the stimulus for voluntary termination of
defecation. Here, the M. sphincter ani externus and M. puborec-
talis contract. After a slight delay, the M. sphincter ani internus
Os coccygis also contracts again.

Canalis analis
Clinical remarks
M. pubo- M. pubo-
rectalis coccygeus Haemorrhoids are pathologic extensions of the Corpus cav-
ernosum ani and are a common occurrence. The causes are
M. levator ani unclear, but appear to be associated with dietary habits in in-
dustrialised nations (too much fat, too little dietary fibre). The
Fig. 8.22 Course of the M. puborectalis; schematic diagram. [L126] location of the haemorrhoidal nodes is given in terms of a
clock face (in a ‘lithotomy position’. Due to the branching pat-
tern of the main branches of the A. rectalis superior on enter-
A contraction of the M. corrugator ani causes a puckering of the ing the Corpus cavernosum ani, the so-called main nodes typi-
anal skin and a ‘drawing in’ of the perianal skin into the outer cally form at 3, 7 and 11 o'clock. In addition, ‘accessory
anal canal with sealing of the anal edge. In defecation the M. cor- nodes’ may occur (corresponding to the accessory branches
rugator ani contracts and leads to shortening of the anal canal. that emerge from the main branches), e.g. at 1 o'clock in
The circular layer increases in diameter caudally in the area of the › Fig. 8.23.
Haemorrhoids can be divided into different stages:
M. sphincter ani internus (in comparison to the rest of the intes-
• Stage I: only visible endoscopically
tinal tract) = true sphincter. The smooth muscles of the ‘internus’ • Stage II: when pressed, they will emerge through the anal
differ in their physiological behaviour from the rest of the intesti- canal to the outside, but will return spontaneously back into
nal muscles as there is no peristalsis and they are continually con- the anal canal
tracted. Only in defecation does a short-term, reflexively induced • Stage III: emerge spontaneously, but can be repositioned
atony of the muscles occur. with the finger
• M. canalis analis (smooth musculature) and Corpus caverno- • Stage IV: emerge from the anal canal and cannot be reposi-
sum ani: The sphincters alone are not in a position to seal the tioned
From stage II onwards treatment should be undertaken ac-
anal canal. Even at maximum contraction an opening of several cording to the stage and form: either using sclerotherapy or
millimetres remains. It is sealed by the M. canalis analis and the rubber band ligation (stage II) or surgery: fixation or removal
Corpus cavernosum ani that sits upon it. (stages III and IV).
– The muscle originates from the M. sphincter internus ani and
the longitudinal muscle layer of the rectum and radiates in a
fan shape into the epithelium above the Corpus cavernosum,
which it penetrates in the process. In this way, it creates a con- Defaecation (bowel movement)
nection between the muscular, contractile part of the sealing Via stretching receptors in the Ampulla recti, an autonomic reflex
mechanism with the vessels (angiomuscular sealing mecha- arc in the sacral portion of the parasympathetic nervous system
nism). Due to the fan-shaped course, variably long muscle fi- (S2–4) is activated in the spinal cord (defaecation reflex) (› Fig.
bres develop; the shortest terminate at the level of the Linea 8.26), which increases the peristaltic activity of the muscles of the
dentata. Due to radiation into the mucosa, the Linea dentata Colon sigmoideum and rectum and reduces the tone of the M.
is kept taut and the Corpus cavernosum is fixed into its posi- sphincter ani internus (› Table 8.2). Through voluntarily induced
tion above this line (› Fig. 8.21). relaxation of the puborectal sling and the M. sphincter ani externus
– The Corpus cavernosum ani (approx. 10% of continence func- the anorectal angle is counteracted and the anal canal is widened.
tion) is fed arterially and consists of arteriovenous anastomo- The blood-filled Corpus cavernosum ani is slowly ‘squeezed’ by the
ses with specialised vessels. It enables gas-tight, water-tight column of stool passing through. The flatly-oriented portions of
and faecal-tight sealing (finely tuned continence) of the anal
canal. If the M. sphincter ani internus is contracted (during
perpetuation of continence at rest), venous outflow is restrict- Accessory nodes
at 1 o'clock
ed, whilst arterial inflow is maintained. The cavernous body
tissue fills with blood, becomes enlarged and effectively seals
the lumen of the anal canal. In the process the vessel cushions 11 o'clock
interlock in a star shape. The A. rectalis superior divides at the Main
nodes 7 o'clock
level of the IIIrd sacral vertebra (corresponds to the KOHL­
3 o'clock
RAUSCH’s fold) into 2 main branches; the right branch di-
vides again (› Fig. 8.24). In this way, 3 main arteries at 3, 7
and 11 o'clock reach the intestinal wall at the level of the Linea
anorectalis and feed, among other things, the Corpus cav-
ernosum ani (› Fig. 8.21). Fig. 8.23 Haemorrhoids stage IV; caudal view in the ‘lithotomy posi-
• Anal skin (Anoderm): above the Linea anocutanea (HILTON's tion’, when the patient is lying on his back and the examiner is look-
line) the skin has very good sensory innervation and contains ing at the bowel. [R234]

368
 8.4 Rectum and anal canal

Table 8.2 Processes during bowel movement (defaecation). and the upper part of the anal canal originates from the hind gut,
but the lower sections of the anal canal from the proctodeum, it is
Via parasympathetic reflex arc Arbitrary (thalamus and
(S2–4, brain stem) ­cerebrum) understandable why anastomoses of vessels are located in the area
of the Linea pectinata (clinically ‘Linea dentata’). The arteries of the
• Reflex muscle contraction of the • Weakness of the M. puborectalis and
rectum and anal canal are (› Fig. 8.24):
Colon sigmoideum and rectum of the pelvic floor → spreading of the
(parasympathetic, S2–4) Flexura perinealis and raising of the
• A. rectalis superior (unpaired): from the A. mesenterica inferi-
• Atony of the M. spincter ani internus rectum or, supplies the majority of the rectum and the M. sphincter ani
(inhibition of the sympathetic • Atony of the M. sphincter ani internus as well as the mucosa of the anal canal above the Linea
­nervous system) ­externus pectinata and thus also the cavernous body (‘Corpus caverno-
sum ani’). Its branches anastomose with the A. rectalis inferior.
the M. levator ani tense and thereby counteract the rising intra-ab- • A. rectalis media (paired): outflow from the A. iliaca interna
dominal pressure. The increase in pressure is based on the simulta- above the pelvic floor (M. levator ani); however, this artery is rare-
neous contraction of the muscles of the diaphragm and abdominal ly formed on both sides and can even be missing on both sides. If
wall and closure of the glottis. A squatting position facilitates de- present, it supports blood flow in the lower third of the rectum.
faecation. The column of stool passing along the anoderm is regis- • A. rectalis inferior (paired): outflow from the A. pudenda interna
tered via somatic afferents of the N. pudendus. After the stool has beneath the pelvic floor. From the outside it supplies the anal canal
passed through, defaecation is completed by contraction of both and its sphincters up to the bottom third of the rectum as well as
anal sphincters and the puborectal sling. the mucosa of the anal canal underneath the Linea pectinata.
Between the various arteries numerous anastomoses are formed.
The A. rectalis superior is the last branch of the A. mesenterica in-
Clinical remarks ferior. It gives off one branch, which anostomoses with the Aa. sig-
For a smooth course of defaecation several factors must work moideae. From this point on (clinically: SUDECK’s point [∗] ) it is
together: stool consistency must be such that a terminal artery.
• intrarectal pressure is increased, so that the M. sphincter
ani internus slackens;
• the Corpus cavernosum ani is compressed and emptied Clinical remarks
during the passage;
• the stool can be clearly perceived in the area of the anoderm The cavernous body of the anal canal (‘Corpus cavernosum
in order to finish defaecation in a targeted manner. ani’) is fed predominantly by the A. rectalis superior. There-
If the stool is too soft (diarrhoea) or too hard (constipation), fore, bleeding from haemorrhoids, which constitute the ex-
then this is not the case. panded caverns of the cavernous body, is arterial bleeding
that is conspicuous due to its bright red colour.

8.4.5 Arteries of the rectum and anal canal

8.4.6 Veins of the rectum and anal canal
The rectum and anal canal are supplied by 3 arteries (Aa. rectales
superior, media and inferior). The innervation areas of the arter- As with all pelvic organs the veins of the rectum form an extensive
ies correspond to their evolutionary origin. Since the whole rectum plexus in the mesorectum (Plexus venosus rectalis). The blood

A. mesenterica inferior
Pars abdominalis aortae
A. rectalis superior*

A. iliaca
communis

Aa. sigmoideae

Colon sigmoideum

A. glutea superior

A. iliaca interna Canalis

obturatorius
A. iliaca externa
Rectum
A. glutea inferior

A. pudenda interna
M. obturatorius
A. obturatoria internus
Fig. 8.24 Arteries of the rec-
A. rectalis media M. levator ani tum, Aa. rectales. Dorsal view.
After the SUDECK's point ( ∗) the
A. rectalis inferior M. sphincter
Anus
A. rectalis superior is a terminal
ani externus
artery.

369
8 Pelvic viscera

V. cava inferior A. rectalis superior

8.4.7 Lymphatic vessels of the rectum and anal
­canal
V. iliaca communis V. sigmoidea

V. sacralis mediana Lymph drainage follows the course of the arterial blood vessels.
V. iliaca
The regional lymph nodes are the Nodi lymphoidei anorectales/
V. rectalis superior
externa pararectales, which lie directly on the intestine, and the Nodi lym-
phoidei rectales superiores, which are also located in the me-
V. iliaca sorectum (› Fig. 8.19).
interna From the proximal rectum, the lymph passes into the Nodi lym-
phoidei mesenterici inferiores at the outflow of the A. mesenteri-
Ampulla recti ca inferior and from there into the para-aortic lymph nodes (Nodi
lymphoidei lumbales) located in the retroperitoneum and into the
Plexus venosus Vv. rectales Trunci lumbales (› Fig. 7.23).
rectalis mediae The distal rectum and the anal canal including the M. sphincter
M. levator ani A. pudenda
ani internus also have a connection to the drainage area of the
Columnae anales interna Trunci lumbales. The first lymph node stations are the Nodi lym-
phoidei iliaci interni (or for the end section of the anal canal be-
M. sphincter Vv. rectales
ani internus inferiores low the Linea pectinata and for the M. sphincter ani externus, the
M. sphincter
Nodi lymphoidei inguinales superficiales) in the groin (› Fig.
ani externus Anus 7.23).

Fig. 8.25 Venous supply of rectum and anal canal, Canalis analis.
Ventral view. Tributaries to the V. portae hepatis (purple) and to the V.
Clinical remarks
cava inferior (blue). As long as a malignant tumour remains confined to the intesti-
nal wall, local lymph node metastasis usually only occurs in
flows out of this plexus according to the arteries of the rectum and the mesorectum, so that a cure is possible via total mesorectal
anal canal via 3 veins (› Fig. 8.25): excision (TME, see above); however, if the tumour has an out-
flow below the Linea pectinata, then inguinal lymph node me-
• V. rectalis superior (unpaired): connection via the V. mesenteri-
tastasis is also possible, which requires a modified therapeu-
ca inferior to the portal vein (V. portae hepatis) tic strategy.
• V. rectalis media (paired, but very variable): connection via the
V. iliaca interna to the V. cava inferior
• V. rectalis inferior (paired): connection via the V. pudenda in-
terna and the V. iliaca interna to the V. cava inferior
The boundary between the drainage area of the V. portae hepatis 8.4.8 Innervation of the rectum and anal canal
and the V. cava inferior is located in the area of the Linea pectinata;
however, here there are numerous links. The Plexus rectalis is a part of the Plexus hypogastricus inferior
and correspondingly contains sympathetic and parasympathetic
nerve fibres (› Table 8.3, › Fig. 8.26):
Clinical remarks • The sympathetic fibres activate the M. sphincter ani internus
When giving suppositories one can make targeted use of the ve- and thereby ensure continence.
nous drainage conditions: the aim is to avoid conveying the sub- • The parasympathetic nerve fibres facilitate peristalsis and in-
stance to the body via the portal circulation of the liver, which hibit the sphincter.
would immediately remove a significant part. Therefore, suppos- The preganglionic sympathetic nerve fibres (T10–L3) reach the
itories should not be inserted into the anal canal too far cranial-
rectum via the Plexus mesentericus inferior or descend from the
ly, otherwise the active substance will be drained through the
V. rectalis superior via the V. portae hepatis directly to the liver. Plexus aorticus abdominalis via the Plexus hypogastricus superior
Anal and perianal venous thrombosis is a common cause for and out of the sacral ganglia of the sympathetic trunk (Truncus
acute presentation to a proctologist or in surgical outpatient sympathicus) via the Nn. splanchnici sacrales. They are predomi-
clinics, because it is extremely painful. Within a short time, nantly converted in the Plexus hypogastricus inferior into post-
one or more bluish-red painful nodes form at the edge of the ganglionic neurons (Ganglia pelvica). These reach the rectum with
anus, which materialise via a blood clot in the veins of the the branches of the Aa. rectales superior and media.
Plexus venosus subcutaneus. A node can contain several
Preganglionic parasympathetic nerve fibres pass out of the sacral
thrombi and reach the size of a cherry or in rare cases, even the
size of a plum. Causes are often unusual strain and strong parasympathetic nervous system (S2–S4) via the Nn. splanchnici
physical activity associated with intra-abdominal pressure in-
creases, such as those which occur, e.g. when sitting for long
Table 8.3 Innervation of the rectum and anal canal.
periods during long haul flights or when giving birth. A perianal
venous thrombosis must be distinguished from haemorrhoids. Innervation of the rectum and Innervation of the anal canal
During an increase in pressure in the portal circulation (portal anal canal above the Linea below the Linea pectinata
hypertension), e.g. in cirrhosis of the liver, blood can pass ­pectinata
through the connection between the V. rectalis superior, Plex-
us venosus rectalis, Vv. rectales mediae and inferiores (porto- • Sympathetically (T10–L3) via the • Somatically via the N. pudendus
caval anastomoses) to the inferior vena cava (› Fig. 7.32). Plexus mesenterius inferior and the
This can lead to the formation of varices but haemorrhoids do Plexus hypogastricus inferior
not occur in the process. • Parasympathetically (S2–4) via the
Plexus hypogastricus inferior

370
 8.5 Male genitalia

Plexus coeliacus;
Ganglia coeliaca Truncus coeliacus

Pars abdominalis aortae

Ganglia trunci sympathici with Plexus aorticus abdominalis

Ganglion mesentericum inferius

A. mesenterica inferior
Nn. splanchnici lumbales

Plexus hypo-
gastricus superior

A. iliaca communis
Radices anteriores (S2–S4)

N. hypogastricus dexter
Plexus hypogastricus inferior

S1
Plexus rectalis Ganglia pelvica,
S2 Radix parasympathica
S3 [Nn. splanchnici pelvici]
S4
Plexus sacralis
S5
M. levator ani
Fig. 8.26 Innervation of the rec-
Rectum
N. pudendus tum and anal canal. Ventral
Nn. anales view; schematic diagram. The
Plexus rectalis contains sympa-
Anus M. sphincter ani externus thetic (green) and parasympa-
thetic (purple) nerve fibres.

pelvici into the ganglia of the Plexus hypogastricus inferior. They NOTE
Evolutionarily, (such as at the left colic flexure) at the Linea pecti-
are converted either here or in the vicinity of the intestine into
nata there occurs a change of the innervation areas of all vascular,
postganglionic fibres (Ganglia pelvica), which enter the mesorec- lymphatic and nervous systems:
tum and there ascend, either independently or along the A. rectalis • Arteries: A. mesenterica inferior ↔ A. iliaca interna
superior. • Veins: V. portae hepatis ↔ V. iliaca interna
The autonomic innervation ends roughly in the area of the Linea • Lymph nodes: Nodi lymphoidei iliaci interni ↔ Nodi lymphoidei
pectinata. The inferior section of the anal canal has somatic inner- inguinales
vation from the N. pudendus with sensory fibres. In addition, the • Innervation: autonomic innervation (Plexus mesentericus inferior
and Plexus hypogastricus inferior) ↔ somatic innervation (N. pu-
N. pudendus activates the M. sphincter ani externus and the M.
dendus)
puborectalis with motor fibres and thus makes voluntary closure of
the anus possible.
For general organisation of the autonomic nervous system in the
pelvis, see › Chap. 8.8.5. 8.5 Male genitalia

Clinical remarks Skills

Since the innervation areas of the vascular, lymphatic and After working through this chapter, you should be able to:
nervous systems change there, the Linea pectinata is an im- • explain the sections of the internal and external male geni-
portant orientation line regarding clinical and surgical treat- talia and their function
ment of carcinoma of the rectum and the anal canal: • explain the development of the male genitalia, describe dif-
• Tumours situated proximally of the Linea pectinata metasta- ferences from the development of female genitalia, and un-
sise into the pelvic lymph nodes and via venous blood to the derstand possible deformities
liver. Proximal tumours are usually painless. • explain the structure and organisation of the penis and scro-
• Distal tumours metastasise firstly into the pelvic lymph tum on a specimen
nodes of the groin and into the lungs. Particularly because • show on a specimen the position, structure and fascia of the
of their somatic innervation by the N. pudendus, distal tu- testes and epididymis, as well as the sections and course of
mours can be extremely painful. the Vas deferens
Nevertheless, classification of rectal cancer tumours currently • retrace fascia and content of the spermatic cord on a speci-
depends on the distance between the tumours and the Linea men
anocutanea. • explain the function and efferent ducts of the accessory sex
glands

371
8 Pelvic viscera

• explain the zonal classification of the prostate and topo- The urethra is described with the efferent urinary tracts (› Chap.
graphical relationship to the rectum with its clinical rele- 8.3).
vance The internal male genitalia include:
• show arteries of the individual sexual organs and deduce • Testis
their different origins from the development
• characterise drainage areas of veins and lymphatic path-
• Epididymis
ways with their clinical importance • Vas deferens (Ductus deferens)
• understand the exact course of the arteries and veins of the • Spermatic cord (Funiculus spermaticus)
penis with their importance for erection • Accessory sex glands:
• explain the autonomic and somatic innervation of the geni- – Prostate gland
tal organs with their importance for the sexual functions – Seminal gland (Glandula vesiculosa), paired
– COWPER's gland (Glandula bulbourethralis) paired

8.5.1 Overview 8.5.2 Function of the male genitalia

The male genitalia are divided into the internal and the external The external genitalia are sexual organs. The penis is used for sex-
male genitalia (› Fig. 8.27). Whilst the external genitalia are lo- ual intercourse. The scrotum encases testis, epididymis, the first
cated outside the body in the perineal region (› Chapter 8.9.3), section of the Vas deferens as well as their vessels and nerves, and
the internal genitalia are found in the pelvic cavity or have been due to the storage of the testis outside the body, enables lowering of
shifted according to their development from the abdominal cavity the surrounding temperature, which is necessary for the formation
into the scrotum. Male genitalia are treated in medicine by the spe- of sperm (spermatogenesis).
cialist field of urology. The internal genitalia are reproductive organs with different func-
The external genitalia include: tions:
• Penis • Testis: formation of sperm cells and sex hormones (testosterone)
• Urethra (Urethra masculina) • Epididymis and spermatic duct: storage and transport of sperm
• Scrotum cells
• Spermatic cord: guidance of spermatic duct and vessels and
nerves of the testis
• Accessory sex glands: secretion of the ejaculate and lubricants
Ren
The sperm cells (spermatozoa) are formed in the testis and con-
veyed to the epididymis, where they are stored. During orgasm
spermatozoa are transported via the spermatic duct into the ure-
Pelvis renalis
thra (emission), where they are mixed with secretions from the
prostate and seminal glands into an ejaculate (volume: 3ml), before
Ureter it is then released via the penis (ejaculation). The secretions of the
ejaculate are important for the nourishment of spermatozoa and
support fertilisation. COWPER’s gland already issues secretion
during the arousal phase, which moistens the woman's vagina as a
lubricant. The testis, in addition to forming sperm cells, also has
the important task of forming the male sex hormone testosterone.
Because testis and epididymis have been shifted into the scrotum,
the vessels and nerves arise according to their site of origin in the
retroperitoneal space at the level of the kidneys and run in the in-
guinal canal together with the spermatic duct in the spermatic
cord.
Ureter

Ductus deferens
Vesica
Glandula vesiculosa
8.5.3 Development of the male genitalia
urinaria

Ductus ejaculatorius The internal and external genitalia in both sexes develop equally up
Prostata to the 7th week (sexually indifferent stage). Only afterwards do the
Glandula bulbourethralis
genitalia differentiate specifically according to the genetic sex of
Ductus glandulae the embryo.
Penis
bulbourethralis
Development of the internal genitalia (sexually indifferent
(Paradidymis) stage)
The genitalia develop out of the intermediate mesoderm, which in
Epididymis
the 4th week forms the urogenital ridge. The medial section ap-
Appendix testis pears in the 5th week as the gonadal ridge and thus a week later
Cauda epididymidis than the laterally located renal unit, which at this point in time is
Testis
[Orchis] found at the stage of the mesonephros (› Fig. 8.28, › Fig. 8.29).
The connective tissue of the gonadal ridge is covered by a serous
Fig. 8.27 Male urinary and reproductive organs. View from right membrane (Tunica serosa), which emerges from the coelomic epi-

372
 8.5 Male genitalia

in the area of the primitive ridge, in the 4th week they pass firstly
with the yolk sac into the epithelium of the hindgut, which they
Ren [Nephros]
leave again in order to migrate via its mesenterium into the gonad-
al ridge.
Laterally from these sexually indifferent gonads 2 pairs of ducts
Ureter
running in parallel develop one after the other: initially, in the 5th
week on both sides the mesonephric duct (Ductus mesonephricus)
or WOLFFIAN duct, a primitive ureter of the mesonephros, is pres-
Ovary system Rete testis ent, which enters the caudal part of the hindgut, from which the
Testicular system
WOLFFIAN duct Sinus urogenitalis later emerges as a precursor of the urinary blad-
MÜLLERIAN der (› Fig. 8.28). The sinus induces in the 7th week the formation
duct of the similarly paired MÜLLERIAN duct (Ductus paramesone-
phricus), which, therefore, sinks out of the coelomic epithelium of
Mesonephros the gonadal ridge and remains in open connection with the ab-
dominal cavity (› Fig. 8.28, › Fig. 8.29). In contrast to the
Sinus urogenitalis
WOLFFIAN duct, the distal ends of the MÜLLERIAN duct fuse
prior to entering the Sinus urogenitalis and form the uterovaginal
Ureteral confluence canal.
Caudal
Gubernaculum testis Development of the internal male genitalia
Opening of the WOLFFIAN duct At the end of the 7th week in men, the gonad system develops into
the testis. Responsible for the formation of the testis is a certain
Genital tubercle transcription factor (TDF, ‘testis-determining factor’), which is ex-
pressed by a gene on the Y chromosome (SRY, ‘Sex determining
Opening of the
Sinus urogenitalis Region of the Y chromosome’) of male embryos. The germinal
cords now form the testicular cords, which become the seminifer-
Anus
ous tubules (Tubuli seminiferi) (› Fig. 8.29). In their walls are the
SERTOLI cells, the spermatogonia, which are incorporated into
the epithelium as descendants of the primordial germ cells. Be-
Fig. 8.28 Development of the urinary organs and early development
of the internal genitalia in both sexes in the 8th week of develop- tween the seminiferous tubules connective tissue cells differentiate
ment. (according to [S010-1-16]) into the LEYDIG cells. The testis has thus formed as the male go-
nad. If the TDF is missing, then an ovary forms.
thelium of the abdominal cavity. In the 6th week the primary germ The testis was generated in the lumbar region at the level of the me-
cords form when the primordial germ cells migrate into the go- sonephros, which also prepares several ductules (Ductuli efferentes)
nadal ridges (› Fig. 8.29). In the process, these take a complicated as a connection to the later epididymis. In the process, the testis
route: after they have already become differentiated in the 2nd week bulges out into the peritoneal cavity and is anchored dorsally by a

Posterior cardinal vein

Mesonephric Mesonephric tubules

glomerulus

Mesonephric
streak
WOLFFIAN duct

MÜLLERIAN duct
Coelomic
epithelium ♀ Stroma of the mesonephric cells
a Germ cords b
Germ cords
Germ cells
♂ + Testes determining
factor (TDF)

Coelomic
epithelium

LEYDIG cell
Ovarian medulla Fig. 8.29 Development of the
Ovarian cortex gonads from the sexually indif-
ferent gonad from the 6th week
c d Testis Primary Tunica (a, b) into ovary (c) and testis
cords albuginea (d). (according to [S010-1-16])
[L126]

373
8 Pelvic viscera

peritoneal duplicature (Mesorchium), in which the coelomic epi- NOTE

The internal male genitalia originate from three sources:
thelium runs over the surface of the testis. This peritoneal fold • Gonadal ridge with migrated germ cells → testis
forms the upper and lower gonadal ligaments (› Fig. 8.28) crani- • WOLFFIAN duct → Epididymis, Vas deferens, seminal glands
ally and caudally of the testis. In the course of the body's growth the • Sinus urogenitalis → prostate, COWPER’s glands
testis is then shifted to caudal (Descensus testis), whereby it brings The development of the testis is determined by the male genetic
along its vascular and nerval supply as the spermatic cord. In the sex; the differentiation of the remaining internal and external geni-
process, along the inferior gonad ligament, which becomes the Gu- talia in their turn are differentiated by the sex hormone formed by
bernaculum testis, a peritoneal protrusion first forms (Proc. vagi- the testis, testosterone.
nalis peritonei) up to the area of the later scrotum, where the testis
descends until birth (› Fig. 8.30). As the Proc. vagi­nalis peritonei
pushes the layers of the ventral wall apart from each other in front
Clinical remarks
of it, these form the walls of the inguinal canal. Around birth the The testes descend into the scrotum in 97% of all neonates,
Proc. vaginalis peritonei closes in the area of the spermatic cord. but only in 70% of premature babies. In the remaining cases
The distal part of the Proc. vaginalis remains and forms the Tunica cryptorchidism is present, whereby one or both testes are usu-
vaginalis testis as part of the testicular coatings. ally located in the inguinal canal (inguinal testis). Most of
these testes spontaneously descend into the scrotum in the
The formation of the genital ducts depends on hormones, both of
first half year of life but then no further so that surgical an-
which are formed only in the testis: choring in the scrotum must be carried out due to the threat of
• Testosterone (from the LEYDIG cells): promotes the differentia- infertility and because of an increased risk of testicular cancer.
tion of the WOLFFIAN ducts Small processes are present on the testes and epididymis as
• AMH (anti-MÜLLERIAN hormone, from the SERTOLI cells): evolutionary relics (› Fig. 8.35), which are morbidly relevant
inhibits the development of the MÜLLERIAN ducts in spite of their small size (see below). The Appendix testis at
Testosterone causes the differentiation of the WOLFFIAN duct into: the upper testicular pole is a remnant of the MÜLLERIAN duct;
• Epididymis in contrast the Appendix epididymidis at the head of the epi-
didymis originates from the WOLFFIAN duct.
• Vas deferens (Ductus deferens) If the Proc. vaginalis peritonei fails to close completely, then
• Seminal glands (Glandulae vesiculosae) fluid from the peritoneal cavity can cause a swelling of the
as well as the formation of the other accessory sex glands (prostate, scrotum (hydrocele). If the opening remains so wide that in-
COWPER’s glands) from the entoderm of the Sinus urogenitalis, testinal loops can shift into the inguinal canal, then a congeni-
which has developed in this section into the urethra. In the pro- tal inguinal hernia ensues.
cess, only the epithelial parts of the organs are formed by the
WOLFFIAN duct or the Sinus urogenitalis. Connective tissue, and
smooth muscles emerge from the surrounding mesoderm.
Development of the external male genitalia
The external genitalia develop from the caudal part of the Sinus
urogenitalis. In addition, the ectoderm with its inferiorly located
connective tissue is also involved. In both sexes the external genita-
Ren [Nephros] lia develop identically between the 4th and 7th week (sexually in-

Ureter Urethral groove

Genital tubercle

Genital fold

Ductuli efferentes
Labioscrotal swellings
Testis testis

Epididymis

Gubernaculum testis MÜLLERIAN duct

Ductus deferens

Vesica Glandula
urinaria vesiculosa

Prostata Glans penis

Glandula
bulbourethralis
Penis
Corpora caver- Corpus spongiosum
nosa penis penis

Scrotum

Fig. 8.30 Development of the internal male genitalia, Organa genita- Fig. 8.31 Development of the external male genitalia, Organa genita-
lia masculina interna. (according to [S010-1-16]) lia masculina externa.

374
 8.5 Male genitalia

Glans penis

Ostium urethrae
orifice in epispadias
Fig. 8.32 Hypospadias and
epispadias. The outer opening
Ostium urethrae of the urethra is not located at
externum in
hypospadias the end of the glans penis, but,
in the case of hypospadias, on
the under side of the penis (a)
and in epispadias (b) it is found
Glans penis
a b dorsally at the penile shaft.
[L266]

different stage). At the same time, the anterior wall of the Sinus well as from the cavernous body of the urethra (Corpus spongio-
urogenitalis sinks firstly to the urethral groove which is delineated sum penis), which surrounds the urethra. The Corpora cavernosa
on both sides by the urethral folds. Lateral to them are the labio- are fixed with the proximal ends (Crura penis) to the inferior pubic
scrotal swellings and at the anterior edge of the groove is the geni- bones and are stabilised by the Mm. ischiocavernosi. The Corpus
tal tubercle (› Fig. 8.31). spongiosum is extended proximally to the Bulbus penis, which is
Afterwards in the male embryo under the influence of testosterone covered by the M. bulbospongiosus, and forms the Glans penis dis-
produced by the testis: tally. Externally, all the cavernous bodies are encased together by
• the genital tubercle develops into the penis (Corpora caverno- penile fascia (Fascia penis), which has superficial and deep fibres.
sa)
• the urethral folds develop into the Corpus spongiosum and into
the glans penis
Clinical remarks
• the labioscrotal swellings develop into the scrotum If the foreskin is too tight (phimosis) and cannot be retracted,
Due to the closure of the urethral folds over the urethral ridge the problems with urination and infections can occur. Then the
Pars spongiosa of the urethra is created at the same time. foreskin must be removed by circumcision.
Injuries to the suspensory ligaments can lead to curved de-
formities of the penis.
Clinical remarks
When the closure of the urethral ridge is incomplete, the
opening of the urethra is not located at the glans penis, but
lies further proximally (› Fig. 8.32). In hypospadias (most
common deformity of the penis) the urethra exits on the inferi-
or side of the penis between the scrotum and the glans. In
epispadias (rare) the urethra exits in a groove on the dorsal
side of the penis. In addition to problems with urination, this
condition can also cause a distorted curvature of the penis
requiring surgical correction within the first years of life.
Ostium urethrae
internum

Glandula
8.5.4 Penis and scrotum bulbourethralis Bulbus penis
Crus penis

The penis, in a flaccid state, is usually about 10 cm long and is di-

vided into the shaft (Corpus penis) and the root (Radix penis) Corpus caver-
(› Fig. 8.33). The vascular, lymphatic and nervous systems of the nosum penis

penis lie on the dorsal side (Dorsum penis). The root of the penis is Corpus spongiosum Tunica albuginea
corporum
attached to the anterior abdominal wall by 2 ligaments: penis
cavernosorum
• The superficial Lig. fundiforme penis emerges from the Linea A. profunda penis
alba and encompasses the penis on both sides as its fibre bundles Aa. helicinae Cavernae corporum
form a loop. cavernosorum
• Lying underneath, the Lig. suspensorium penis is attached to
the symphysis (› Fig. 8.34).
The distal end of the penis is thickened into the glans penis, which
has a ridge (Corona glandis) at the base. When the penis is flaccid, Corona glandis
the glans is covered by the foreskin (Preputium penis), which is se- Preputium penis
cured to the inferior side of the penis by a ridge (Frenulum pre-
Glans penis Ostium urethrae
putii). externum
The penis is constructed from the paired cavernous bodies of penis
(Corpora cavernosa penis), which are surrounded by a tough Fig. 8.33 Male member, penis, with exposed spongy tissue. Ventral
sheath (Tunica albuginea) and are separated by a Septum penis, as view; urinary bladder and urethra opened, penile fascia removed.

375
8 Pelvic viscera

Anulus inguinalis
superficialis

Canalis inguinalis

Fascia spermatica externa

Lig. suspensorium
Fascia cremasterica;
penis
M. cremaster
Plexus pampiniformis
Ductus deferens

A. testicularis

Epididymis
Fascia cremasterica;
Tunica vaginalis testis, M. cremaster
Lamina visceralis
Fascia spermatica
Tunica vaginalis testis, externa
Lamina parietalis
Tunica dartos, M. dartos
Fascia spermatica interna
M. cremaster Fig. 8.34 Scrotum and spermat-
Fascia spermatica externa Cutis ic cord (Funiculus spermaticus).
Septum scroti Raphe scroti Ventral view; scrotum opened
and penis frontally severed.

The scrotum is divided into two halves: externally in the median superior and Extremitas inferior). The anterior and posterior bor-
plane by a membranous raphe (Raphe scroti), and internally by a ders (Margines anterior and posterior) are not clearly set and there-
connective tissue separation layer (Septum scroti) (› Fig. 8.34). The fore indistinctly subdivide a medial and a lateral surface (Facies
wall of the scrotum consists of relatively strongly pigmented skin (Cu- medialis and lateralis).
tis), under which is a fat-free subcutis with much smooth muscula- The epididymis sits above and distally to the testis and is secured
ture (Tunica dartos), which contributes to temperature regulation by by a superior and an inferior ligament (Ligg. epididymidis superius
its involuntary movement. Underneath, following as further layers, as and inferius) (› Fig. 8.35). The epididymis is divided into the
with the spermatic cord, are the Fascia spermatica externa, the Fascia head (Caput), body (Corpus) and tail (Cauda).
cremasterica and the Fascia spermatica interna (› Chap. 8.5.5). The testis contains delicate ductules, which transport the sperma-
tozoa formed in their walls to the epididymis. The epididymis con-
sists of a single 6 m long coiled duct (Ductus epididymidis), which
8.5.5 Testis and epididymis continues into the spermatic duct.
Between the wall of the scrotum and the testis is a further sheath,
The testis (Orchis) is egg-shaped (› Fig. 8.35) and 4 × 3 cm in the Tunica vaginalis testis (› Fig. 8.34). It consists of an outer
size (10–15 g). It has a superior and an inferior pole (Extremitas Lamina parietalis (Periorchium) on the inner side of the scrotum
and an inner Lamina visceralis (Epiorchium) on the surface of the
testis, which are connected to one another by the Mesorchium. Be-
tween these two layers is the ‘Cavitas serosa scroti’, which corre-
Fascia cremasterica; sponds to one of protrusions of the peritoneal cavity that arises in
M. cremaster the course of the descent of the testes.
Fascia spermatica interna

Clinical remarks
Tunica vaginalis testis,
Lamina parietalis Caput epididymidis
Diseases of the testis, which often occur during childhood and
Appendix testis adolescence, can to some extent be fulminant and associated
Lig. epididymidis superius
(Appendix epididymidis) with acute pain (acute scrotum). The most common is testicu-
Sinus epididymidis lar torsion, where the testis revolves around its longitudinal
Extremitas superior
axis and, due to torsion of the spermatic cord and of the A.
Corpus epididymidis
testicularis lying within, restricts blood flow, which can result
Facies lateralis in irreversible damage after just a few hours. Torsion usually
Margo posterior occurs spontaneously or during exercise. After the blood flow
Testis
disturbance has been established by a duplex ultrasonogram,
Lig. epididymidis inferius Margo anterior surgery must take place immediately: the affected testis is
turned back and both testes are fixed in the scrotum.
Cauda epididymidis From a differential diagnostic point of view, there are torsions
of the Appendix testis and the Appendix epididymis (torsion
Extremitas inferior of the hydatids), which, however, are treated conservatively

Fig. 8.35 Testis (Orchis) and epididymis. View from right

376
 8.5 Male genitalia

with painkillers (› Chap. 8.5.3); there are also bacterial and side of the urinary bladder, where it expands (Ampulla ductus def-
viral (mumps) infections, where the testes or epididymis be- erens) and, together with the efferent duct of the seminal gland,
come inflamed and swollen. connects to the Ductus ejaculatorius (› Fig. 8.27), which finally
In adults, asymptomatic testicular enlargements are always to flows into the Pars prostatica › Fig. 8.16). In the spermatic cord,
be evaluated as an indication of a possible testicular tumour,
the Ductus deferens can clearly be felt due to its strong muscle
which if necessary, should be excluded by a biopsy (see be-
low). wall!
The spermatic cord (Funiculus spermaticus) forms a fascia sys-
tem in the scrotum and in the inguinal canal around the spermatic
cord and the vascular, lymphatic and nervous systems of the testis.
The coverings of the spermatic cord are connected to the abdomi-
8.5.6 Vas deferens and spermatic cord nal wall and therefore, like the latter, also form multiple layers
(› Fig. 8.34, › Fig. 8.37):
The Vas deferens (Ductus deferens) is 35–40 cm long and 3 mm • Scrotal skin (Cutis)
thick and runs with a scrotal, funicular, inguinal and pelvic section • Tunica dartos: subcutis of scrotum with smooth musculature
(› Fig. 8.36) via the spermatic cord and the inguinal canal. In the • Fascia spermatica externa: continuation of the superficial ab-
pelvis it crosses over the ureter, before it is attached to the dorsal dominal fascia (Fascia abdominis superficialis)

Glandula suprarenalis
Ren [Nephros]

Ureter

A.; V.
testicularis

A. vesicalis
superior
A. epigastrica
A. ductus inferior
deferentis

A.; V. cre-
masterica

Fig. 8.36 Sections and course

Ductus deferens
A.; V. testicularis with A. ductus deferentis of the Ductus deferens. Ventral
view. [L238]

A.; V. cremasterica
Ductus deferens
N. ilioinguinalis

Fascia spermatica externa

Plexus deferentialis

A. ductus deferentis

Fascia cremasterica;
M. cremaster Vasa lymphatica

Plexus pampiniformis
Plexus testicularis
Fascia spermatica interna
Fig. 8.37 Fascia and content of
A. testicularis the spermatic cord, left. Frontal
incision; ventral view. [S010-17]

377
8 Pelvic viscera

• M. cremaster with Fascia cremasterica 8.5.7 Accessory sex glands

• Fascia spermatica interna: continuation of the Fascia transversa-
lis The accessory sex glands include the unpaired prostate as well as
• Tunica vaginalis testis the two seminal glands (Glandulae vesiculosae) and the two COW­
The content of the spermatic cord consist of the vas deferens and PER’s glands (Glandulae bulbourethrales).
the different vessels and nerves of the testis as well as of the cover-
ings (› Fig. 8.37): Prostate gland
• Vas deferens (Ductus deferens) with the A. ductus deferentis The unpaired gland is 4 × 3 × 2 cm in size (20 g) and is located be-
(from the A. umbilicalis) low the fundus of the bladder. The prostate has a superior base and
• A. testicularis from the abdominal aorta and as venous accessory an inferior apex as well as an anterior and a posterior surface (Fa-
vessels of the Plexus pampiniformis cies anterior and Facies posterior). It is divided into a right lobe
• N. genitofemoralis, R. genitalis (innervation of the M. cremas- and left lobe (Lobus dexter and Lobus sinister), which are sepa-
ter) rated by a flat groove and also divided into a Lobus medius
• Lymph vessels (Vasa lymphatica) to the lumbar lymph nodes (› Fig. 8.38). Internally, the prostate is traversed by the urethra
• Autonomic nerve fibres (Plexus testicularis) from the plexus (Pars prostatica), into which its 30–50 individual glands each issue
around the aorta secretions via their own efferent ducts on both sides of the Collicu-
Attached externally to the spermatic cord are: lus seminalis. It forms 15–30% of the liquid volume of the ejacu-
• N. ilioinguinalis late.
• A. and V. cremasterica (from A./V. epigastrica inferior) Internally, the prostate is divided into different zones, which are of
the highest clinical relevance (› Fig. 8.39):
• Central zone or internal zone (25% of the glandular tissue):
Clinical remarks wedge-shaped segment between the Ductus ejaculatorii up to its
During surgery on an inguinal hernia in men, care must be tak- confluence and the urethra
en so that the inguinal canal is not narrowed too much, be- • Peripheral zone or outer zone (70% of the glandular tissue):
cause otherwise the A. testicularis is compressed and infertili- surrounds the inner zone on the dorsal side like a mantle
ty can ensue. • Anterior zone: gland-free area ventral of the urethra
Since the spermatic cord is easily accessible before its entry
• Periurethral zone: narrow strip of tissue immediately around
into the inguinal canal, it can be cut on both sides for sterilisa-
tion (vasectomy). the proximal urethra
• Transition zone (5% of the glandular tissue): both sides lateral
of the periurethral zone

Ductus deferens

Glandula
Glandula vesiculosa
vesiculosa
Ampulla ductus deferentis

Lobus prostatae Lobus prostatae medius

dexter
Lobus prostatae sinister
Basis prostatae
Urethra masculina Fig. 8.38 Prostate and seminal
vesicles. Cranial view.

Ductus deferens
Glandula vesiculosa
Vesica urinaria

Periurethral zone Central zone

(internal zone)
Urethra, Pars prostatica Transition zone
Peripheral zone Prostata
(outer zone)
M. transversus Anterior zone
perinei profundus (gland free)

Glandula
bulbourethralis
Fig. 8.39 Zones of the prostate.
View from left; median incision.

378
 8.5 Male genitalia

Clinical remarks Clinical remarks

Prostate tumours (› Fig. 8.40c) are one of the three most The topographical relationships of the prostate make it clear
common malignant tumours in men. They mostly originate which complications in surgical removal of the prostate are
from the peripheral zone of the gland and therefore only cause common. Injury to the smooth muscles of the Urethra at the
symptoms quite late. Because the prostate is only separated exit from the bladder can cause retrograde ejaculation. Dam-
from the rectum by the thin Fascia rectoprostatica (DENON­ age to the M. sphincter urethrae externus leads to inconti-
VILLIER's fascia) (› Fig. 8.19, › Fig. 8.57), the tumours are nence. Lesion of the Nn. cavernosi penis causes erectile dys-
palpable in a clinical rectal examination (› Fig. 8.41). The function.
digital rectal examination (DRE) is, therefore, part of a com-
plete physical examination in men over 50 years of age.
Prostate adenoma (› Fig. 8.40b) are benign enlargements
(prostatic hyperplasia) of the prostate gland up to a weight of
100 g, and occur in various forms in almost all men over the 8.5.8 Vessels and nerves of the external and
age of 70 years. Since adenoma emanate from the transition ­internal male genitalia
zone, which has been differentiated from the inner zone for
several years, problems with urination occur at an early stage. Arterial blood supply and venous drainage
External genitalia
The blood vessels of the penis are complicated. Their position in
relation to the penile fascia is of great functional importance for
Seminal gland (Glandula vesiculosa) erection of the penis (› Fig. 8.42).
The paired gland rests on the dorsal side of the urinary bladder The penis is supplied by 3 paired arteries from the A. pudenda in-
(› Fig. 8.38). The seminal glands are elongated oval glands (5 × 1 terna:
× 1 cm) and each consist of an individual raised gland of 15 cm in • A. dorsalis penis: runs subfascially between the V. dorsalis pro-
length. Its efferent duct combines with the Vas deferens to the Duc- funda penis (medial) and the N. dorsalis penis (lateral), supplies
tus ejaculatorius and ends in the Pars prostatica of the Urethra on the skin and glans of the penis
the Colliculus seminalis (› Fig. 8.16). It secretions form 50–80 % • A. profunda penis: lies in the Corpora cavernosa, and is respon-
of the ejaculate. sible for their filling via their Aa. helicinae
• A. bulbi penis: penetrates into the Bulbus penis, supplies the
COWPER’s glands (Glandulae bulbourethrales) Glandula bulbourethralis and, as the A. urethralis, supplies the
Embedded into the perineal muscles (M. transversus perinei pro- urethra and Corpus spongiosum
fundus) are the COWPER’s glands on both sides (› Fig. 8.16). The Blood is taken up by 3 venous systems:
individual glands have a diameter of approximately 1 cm and flow • V. dorsalis superficialis penis: paired or unpaired; lies epifascially
on both sides with their 3 cm long efferent ducts proximally into in the subcutis and conducts blood from the penile skin to the V.
the Pars spongiosa of the urethra (2.5 cm below the Membrana pudenda externa
perinei). • V. dorsalis profunda penis: unpaired; runs subfascially and
drains the cavernous bodies via the Cv. cavernosae to the Plexus
Topography venosus prostaticus
The prostate sits in a subperitoneal position directly below the • V. bulbi penis: paired; it brings blood from the Bulbus penis to
fundus of the urinary bladder. Its base, therefore, borders above the V. dorsalis profunda penis
onto the smooth muscles at the exit of the urethra (‘M. sphincter During penile erection a dilation of the A. profunda penis occurs,
urethrae internus’). The apex sits inferior of the perineal muscles activated parasympathetically, which causes filling of the Corpora
and has contact with the external urethral sphincter (› Fig. 8.57). cavernosa. These compress the V. dorsalis profunda penis under
To the anterior the prostate is connected via the Ligg. puboprostat- the stiff penile fascia so that blood cannot flow away. Erection oc-
ica to the posterior surface of the superior pubic bone branch; to curs under additional contraction of the Mm. ischiocavernosi (in-
the posterior it is separated from the rectum only by the Fascia rec- nervated by the N. pudendus).
toprostatica (DENONVILLIER’s fascia). Laterally the parasympa-
thetic Nn. cavernosi penis run from the Plexus hypogastricus infe-
rior along the gland and reach the cavernous body of the penis via
Clinical remarks
the perineal muscles (› Fig. 8.19). The parasympathetic nerve fibres release nitric oxide (NO),
The seminal glands lie in a directly subperitoneal position be- which causes an increase of the secondary messenger cGMP
tween the dorsal side of the urinary bladder and the anterior side in the smooth muscle cells of the blood vessels and inhibits
of the Rectum. contraction of the cells. Inhibitors of phosphodiesterase (e.g.
Viagra®) delay the breakdown of cGMP and thereby improve
The COWPER’s glands are embedded below the pelvic floor (ex-
the erection.
trapelvic) into the perineal muscles of the deep perineal space.

NOTE The scrotum is supplied by the A. pudenda interna (Rr. scrotales

All accessory sex glands are important for the formation of ejacu- posteriores) and the Aa. pudendae externae (Rr. scrotales anteri-
late secretions or for moistening of the female genitalia. In con- ores) as well as the A. cremasterica. The veins correspond to the
trast, the prostate with its different zones is of the greatest clinical arteries.
importance! A malignant prostate tumour usually originates in the
outer zone; a benign prostate adenoma in contrast, arises from the
transition zone laterally of the central zone.
Internal genitalia
Testis and epididymis, Vas deferens and spermatic cord have their
own respective arteries (› Fig. 8.36, › Table 8.4). In contrast, the

379
8 Pelvic viscera

Rectum

Vesica urinaria

Prostata

a Urethra, Pars prostatica

Prostate cancer with breakouts

in the rectum and bladder

Prostate adenoma with

compression of the urethra

b c

Congested
renal pelvis
Hydronephrosis of the kidney with
reduced renal parenchyma

Dilated ureters

Bladder with hypertrophy of the

musculature (“Trabeculated bladder”)

d Prostate adenoma

Fig. 8.40 Tumours of the prostate with clinical presentation. a–c Sagittal incision through a male pelvis. a Normal prostate. b Prostate adeno-
ma. The adenoma emanates from the transition zone inside the gland and compresses the urethra, so that micturition is affected at an early
stage. Enlargement of the prostate is palpable during a rectal examination. c Prostate cancer. In contrast to the adenoma, the carcinoma ema-
nates from the peripheral zone of the prostate, so discomfort when urinating is rare. A rectal palpation finding of a hard nodular mass can,
therefore, be the first clinical sign. d Due to backing-up of urine in the case of a prolonged narrowing of the urethra caused by a prostate ade-
noma, the muscles of the urinary bladder (trabeculated bladder) hypertrophy, the ureters and renal pelvis dilate and hydronephrosis ensues.
[L266]

380
 8.5 Male genitalia

Table 8.4 Blood vessels of the internal genitalia.

Organ Blood vessels

Arteries Testis and epididymis A. testicularis (from the Pars abdominalis of

the Aorta)
Ductus deferens A. ductus deferentis (mostly from the
A. umbilicalis)
Prostata Vesica Spermatic cord A. cremasterica (from the A. epigastrica
urinaria
(M. cremaster) ­inferior)
Accessory sex A. vesicalis inferior, A. rectalis medialis and
glands: A. pudenda interna (all from the A. iliaca
interna)

Veins Testes, epididymis, Plexus pampiniformis: venous plexus, the

Rectum Ductus deferens and branches of which join to the V. testicularis,
spermatic cord which flows to the right into the V. cava infe-
rior and to the left into the V. renalis sinistra
Canalis analis
Accessory sex Plexus venosi vesicalis and prostaticus with
Glandula glands: connection to the V. iliaca interna
vesiculosa

Fig. 8.41 Palpation of the prostate. [L126] The blood from the testes, epididymis and Vas deferens accumu-
lates firstly in a venous plexus, the Plexus pampiniformis, the
branches of which unite proximally in the spermatic cord into the
Corpus cavernosum penis V. testicularis (› Fig. 8.36). The vein runs through the inguinal
V. dorsalis profunda penis canal, ascends under the peritoneum of the pelvic cavity into the
A. dorsalis Aa. helicinae retroperitoneal space and flows to the right into the V. cava inferi-
penis
V. dorsalis superficialis Fascia or, but to the left into the left V. renalis.
penis penis From the accessory sex glands, blood in the pelvis runs into the ve-
nous plexi in the vicinity of the prostate and urinary bladder (Plex-
us venosi prostaticus and vesicalis) and then drains via the Vv. vesi-
cales into the V. iliaca interna (› Fig. 8.61).
The V. cremasterica accompanies the eponymous artery and flows
into the V. epigastrica inferior.
A. urethralis Fascia
Clinical remarks
A. profunda
penis
penis Vv. cavernosae

A. bulbi penis Corpus Glans penis, An extension of the veins of the Plexus pampiniformis (varico-
spongiosum penis Corpus spongiosum
cele) (› Fig. 8.43) can cause infertility due to backflow of
blood.
Fig. 8.42 Arteries and veins of the penis. [L126]

accessory glands are supplied by the visceral branches of the A. ili-

aca interna (› Fig. 8.61, › Table 8.4). Lymphatic pathways of the external and internal genitalia
The A. testicularis supplies the testis and epididymis. It originates The external and internal genitalia in men have completely sepa-
from the abdominal section of the Aorta just below the renal arter- rated lymphatic drainage pathways (› Fig. 8.44)!
ies, and then descends in the retroperitoneal space, whereupon it • For the external genitalia (penis and scrotum) the lymph nodes
crosses over the N. genitofemoralis, the ureter and the A. iliaca ex- of the groin (Nodi lymphoidei inguinales superficiales) repre-
terna running, before entering into the inguinal canal, within the sent the first lymph node stations.
spermatic cord into the scrotum. • The regional lymph nodes of the testis and epididymis are the
The A. ductus deferentis is a thin vessel that usually originates Nodi lymphoidei lumbales at the level of the kidneys, from
from the A. vesicalis superior or the A. vesicalis inferior and is at- which the lymph runs into the Trunci lumbales.
tached to the pelvic section of the Vas deferens and accompanies it • In contrast, lymph from the Vas deferens, spermatic cord and
until its transition into the epididymis. accessory sex glands drains firstly into the lymph nodes of the
The fascia of the spermatic cord are supplied by the A. cremasteri- pelvic cavity (Nodi lymphoidei iliaci interni/externi and nodi
ca, which originates shortly after its exit from the A. epigastrica in- lymphoidei sacrales).
ferior and is attached externally to the spermatic cord.
The accessory sex glands are supplied by the visceral branches of NOTE
the A. iliaca interna in their vicinity. The prostate and seminal The external and internal genitalia in men have completely sepa-
glands receive blood from the A. vesicalis inferior and A. rectalis rate lymphatic drainage pathways! Due to the descent of the testis
media (› Fig. 8.61); the Glandulae bulbourethrales are supplied during its development, the lymphatic pathways of the testis and
by the A. pudenda interna during its course in the deep perineal epididymis ascend up to the Nodi lymphoidei lumbales at the level
of the kidneys. In contrast, the regional lymph nodes of the exter-
space. nal genitalia are the inguinal lymph nodes.

381
8 Pelvic viscera

Through the scrotal skin

Plexus
Fascia spermatica visible extensions
pampiniformis
interna of the Plexus pampiniformis
with varicocele

Fig. 8.43 Varicocele. Due to

Tunica vaginalis testis, Epididymis backing-up of blood in the
Lamina parietalis V. renalis sinistra, dilation of the
Testis
Plexus pampiniformis can occur
a b
Scrotum (a), which is visible through the
skin of the scrotum (b). [L266]

Nodi lymphoidei
lumbales

Nodi lymphoidei Nodi lymphoidei

iliaci communes sacrales

Nodi lymphoidei Nodi lymphoidei

iliaci externi iliaci interni

Nodi lymphoidei
inguinales profundi

Nodi lymphoidei Fig. 8.44 Lymphatic drainage

inguinales superficiales pathways of the external and
internal male genitalia. Ventral
view.

Clinical remarks the smooth muscles of the Vas deferens, produces emission of
sperm into the urethra and issue of secretions by the accessory
Due to the different lymphatic drainage pathways the first glands. At the same time, the circular muscles of the urethra at
lymph node metastases in penile cancer are found in the the exit of the bladder prevent retrograde ejaculation into the
groin; however, in the case of testicular cancer, they are found
urinary bladder.
in the retroperitoneal space. Since the lymphatic drainage
pathways of the internal and external genitalia do not commu- • Individual parasympathetic fibres promote the formation of se-
nicate with each other, if a testicular tumour is suspected, a cretions during arousal.
transscrotal biopsy must not be carried out, because tumour The preganglionic sympathetic nerve fibres (T10–L2) descend
cells could be displaced into the lymphatic pathways to the from the Plexus aorticus abdominalis via the Plexus hypogastricus
inguinal lymph nodes. In this case, the biopsy must always be superior and from the sacral ganglia of the sympathetic chain
made via the inguinal canal. (Truncus sympathicus) via the Nn. splanchnici sacrales and are
synaptically converted mainly in the Plexus hypogastricus inferior
into postganglionic neurons (› Fig. 8.45). These postganglionic
Innervation of the external and internal genitalia fibres reach the pelvic organs and thus also the accessory sex
The external male genitalia have both autonomic as well as somat- glands and the Ductus deferens (Plexus deferentialis). Some fibres
ic innervation (› Fig. 8.45): also join the Nn. cavernosi penis, which penetrate the pelvic floor
• The predominantly parasympathetic innervation increases and supply the cavernous bodies of the penis. The (mostly) post-
blood flow to the cavernous body of the penis and thereby in- ganglionic sympathetic fibres for the testis and epididymis run
duces penile erection. within the Plexus testicularis along the A. testicularis, after they
• The somatic innervation is sensory and for the purpose of sexu- have already been converted within either the Ganglia aorticorena-
al arousal. lia or the Plexus hypogastricus superior (› Table 8.5).
• The motor innervation of the perineal muscles (M. bulbospon- The preganglionic parasympathetic nerve fibres pass from the
giosus and M. ischiocavernosus) supports ejaculation of the sacral parasympathetic nervous system (S2–S4) via the Nn.
sperm out of the urethra. splanchnici pelvici into the ganglia of the Plexus hypogastricus in-
In contrast, innervation of the internal genitalia is purely autonomic: ferior (› Fig. 8.45). They are converted either here or in the vicini-
• The predominantly sympathetic innervation reduces the blood ty of the organs into postganglionic fibres, which then reach the
flow of the testis and epididymis and by means of contraction of accessory sex glands. The Nn. cavernosi penis penetrate the pelvic

382
 8.6 Female genitalia

Medulla spinalis

T10
T11
T12
L1 Rr. communicantes
L2
L3 Truncus sympathicus
Ganglia trunci
L4
L5
sympathici
S1
S2 Plexus hypogastricus superior
S3
S4
Plexus testicularis
S5 A. testicularis
Ureter
Ductus deferens

Glandula vesiculosa

Ganglia pelvica, Vesica urinaria

Radix parasympathica
[Nn. splanchnici pelvici] Prostata

N. hypogastricus sinister Nn. cavernosi

Plexus Fig. 8.45 Innervation of the

Plexus hypogastricus inferior deferentialis Penis male reproductive organs. Ven-
Plexus prostaticus tral and lateral views; schematic
Ganglia pelvica, Radix diagram. The Plexus hypogastri-
parasympathica cus inferior contains sympathet-
Plexus testicularis Epididymis ic (green) and parasympathetic
Plexus deferentialis Testis (purple) nerve fibres.

Table 8.5 Innervation of the male genitalia.

In surgical removal of the Rectum or prostate, e.g. due to rec-
Innervation Target structures tal cancer or prostate cancer or pronounced prostatic hyper-
plasia of the prostate, the parasympathetic fibres to the penis
Sympathetic • Ductus deferens and accessory sex glands (Plexus can be separated so that an erection is no longer possible (Im-
­innervation hypogastricus inferior) potentia coeundi).
(T10–L2) • Testis and epididymis (Plexus testicularis)
Parasympathetic • Accessory sex glands (Plexus hypogastricus inferior)
innervation (S2–4) • Cavernous bodies of the penis (Nn. cavernosi penis)
Somatic innervation • Sensory: mainly N. pudendus to penis and scrotum
For general organisation of the autonomic nervous system in the
• Motor: N. pudendus to the perineal muscles abdomen, see › Chap. 7.8.5 and on the autonomic ganglia in the
retroperitoneum, see › Chap. 8.5.5 .

floor and run (partly below the attachment to the N. dorsalis penis)
into the cavernous bodies, where they trigger erection (› Fig. 8.6 Female genitalia
8.65, › Table 8.5).
The somatic innervation via the N. pudendus sensorily innervates
the penis via the N. dorsalis penis (› Fig. 8.45). The scrotum is
Skills
also mostly sensorily innervated by the N. pudendus (Rr. scrotales After working through this chapter, you should be able to:
posteriores) and only to a small extent by the N. cutaneus femoris • explain the sections of the internal and external female gen-
posterior (Rr. perineales), N. ilioinguinalis (Rr. scrotales anteri- italia and their function
ores) and N. genitofemoralis (R. genitalis). Motor fibres run to the • explain the development of the female genitalia and demon-
strate differences from the development of the male genita-
perineal muscles (M. bulbospongiosus and M. ischiocavernosus,
lia
› Table 8.5). • identify parts of the vulva on a specimen
• know the structure, sections and topographical relation-
NOTE ships of the internal female genitalia
The parasympathetic nervous system induces the erection; the • understand changes of the uterus in overview with structure
sympathetic nervous system effects emission and the N. puden- and function of the placenta
dus effects ejaculation. • explain all peritoneal duplicatures and ligaments of the in-
ternal genitalia with course and contents
• show arteries of the individual sexual organs and derive
Clinical remarks their different origins from the development
• characterise drainage areas of veins and lymphatic path-
In surgical removal of the para-aortic lymph nodes, e.g. in the ways with their clinical importance and demonstrate charac-
case of testicular cancer or cancer of the descending colon or terisation differences from the male genitalia
during surgery to the abdominal Aorta and the large pelvic ar- • explain the autonomic and somatic innervation of the geni-
teries, the sympathetic nervous system can be damaged. Dis- tal organs with their importance for the sexual functions
orders in emission and thereby ejaculation of sperm lead to
infertility (Impotentia generandi).

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8 Pelvic viscera

8.6.1 Overview • Vestibule of the vagina (Vestibulum vaginae)

• Greater vestibular glands (Glandulae vestibulares majores (BAR­
In the female sex organs a distinction is made between external THOLINI's and minores)
genitalia outside the pelvis in the perineal region and internal The vestibule of the vagina extends to the hymen, which delineates
genitalia within the pelvic cavity. As well as diagnostics, the spe- the entrance of the vagina (Ostium vaginae). The vagina itself is
cialist field of gynaecology also focuses on with both conservative part of the internal genitalia.
and surgical treatment of the female genitalia. The internal genitalia include (› Fig. 8.47):
The external genitalia are collectively called the vulva (› Fig. • Vagina
8.46). Parts include: • Uterus
• Mons pubis • Fallopian tube (Tuba uterina)
• Labia majora pudendi • Ovary (Ovar)
• Labia minora pudendi The fallopian tubes and ovaries are located as pairs and are collec-
• Clitoris tively known as adnexa (attachments).

Mons pubis

Preputium clitoridis
Commissura labiorum anterior
Frenulum clitoridis
Glans clitoridis

Labium majus pudendi

Ostium urethrae
Labium minus pudendi
externum
Glandula vestibularis Ostium vaginae
major, (Ostium)
Hymen
Vestibulum vaginae Frenulum labiorum pudendi

Commissura labiorum Perineum, Raphe perinei

posterior
Anus Fig. 8.46 External female geni-
talia. Caudal view.

Ren [Nephros]

Pelvis renalis

Ureter

Tuba uterina [Salpinx] Uterus

Infundibulum tubae
uterinae Vesica urinaria

Appendix vesiculosa
Ovarium
Lig. ovarii proprium
Ureter
Lig. teres uteri
Urethra feminina
Vagina

Ostium urethrae externum

Fig. 8.47 Internal female geni-
Ostium vaginae talia and urinary organs. Ventral
view.

384
 8.6 Female genitalia

8.6.2 Function of the female genitalia

The external genitalia are the sexual organs and serve the purpose
of intercourse. Also flowing into the vestibule of the vagina is the Ren [nephros]
external opening of the urethra (Ostium urethrae externum),
Ureter
which is located ventrally to the entrance into the vagina. Female
internal genitalia are both reproductive as well as sexual organs: Lig. suspensorium
• Ovaries: formation of oocytes and sex hormones (oestrogen) Ovar
ovarii
• Fallopian tubes: uptake of the ovum and the site of fertilisation
• Uterus: development of the child
• Vagina: cohabitation organ and birth canal WOLFFIAN duct

Tuba uterina
Lig. ovarii proprium
8.6.3 Development of the external and internal
­female genitalia
Uterus

Development of the internal female genitalia

The internal and external genitalia in both sexes develop ambigu-
ously (indifferent stage, › Chap. 8.5.3, › Fig. 8.28, › Fig. 8.29)
up to the 7th week. Only afterwards do the genitalia differentiate
specifically according to the genetic sex of the embryo. Lig. teres uteri
As no TDF is formed in the female sex (‘testis-determining fac-
tor’), which is expressed by a gene onto the Y chromosome, from Vesica urinaria
Vagina
the 10th week an ovary develops on each side out of the ambiguous
gonadal units (› Fig. 8.28, › Fig. 8.29). The primary germ cords Urethral opening
now form the cortex of the ovary, in which the ova that emerge
from the primordial germ cells are surrounded by epithelial cells Ostium vaginale
and in the process up to the 17th week they form follicles. Similar
to the testes, the ovary protrudes into the abdominal cavity and re- Fig. 8.48 Development of the internal female genitalia, Organa geni-
ceives the Mesovarium as a peritoneal duplicature for the purpose talia feminina interna. (according to [S010-1-16])
of attachment to the dorsal abdominal wall with a superior and an
inferior enveloping fold (superior and inferior gonadal liga- peritoneal duplicatures of the MÜLLERIAN ducts, which protrude
ments); however, in the case of the ovary the coelomic epithelium into the peritoneal cavity, later form the peritoneal folds of the fal-
remains on the surface (superficial epithelium) so that it maintains lopian tube (Mesosalpinx) and of the Uterus (Lig. latum uteri),
its intraperitoneal location. which divide the caudal part of the peritoneal cavity into the dor-
Similar to the testes, the ovary is also located in the lumbar region sally located Excavatio rectouterina (DOUGLAS pouch) and the
at the level of the Mesonephros. (› Fig. 8.28, › Fig. 8.29). As the ventral Excavatio vesicouterina.
body grows, the ovary is shifted, but only to the level of the lesser There, where the uterovaginal canal flows into the Sinus urogeni-
pelvis (descent) and does not leave the peritoneal cavity (› Fig. talis, it bulges out as the sinus mount. Developing in this area from
8.48). The upper gonadal ligament becomes the Lig. suspensorium the ectoderm of the Sinus urogenitalis is the vaginal plate, the lu-
ovarii, in which the vessels and nerves run, which the ovary has men of which only forms subsequently. The sinus mount remains
taken with it in its descensus. The superior part of the inferior go- preserved as the hymen and demarcates the vagina downwards
nadal ligament, which originates directly at the ovary, becomes the from the vestibule of the vagina (Vestibulum vaginae). The hymen
Lig. ovarii proprium and later connects the ovary with the uterus. usually ruptures after birth and remains as a remnant at the dorsal
From there the inferior section, which corresponds to the Guber- edge of the vaginal orifice.
naculum testis, runs into the inguinal canal and becomes the Lig.
ovarii proprium, which later anchors the uterus within the con- NOTE
nective tissue of the Labia majora. Without the suppressing effect If hormones formed in the testis (testosterone, anti-MÜLLERIAN
of the anti-MÜLLERIAN hormone from the testes the MÜLLERI­ hormone) are missing, an ovary is formed and the MÜLLERIAN
AN ducts develop into female genital tracts. ducts differentiate into the Tuba uterina, uterus and vagina. Simi-
• Fallopian tube (Tuba uterina) larly to the male embryo, the internal female genitalia originates
from 3 sources:
• Uterus • Gonadal ridge with migrated germ cells → ovary
• Vagina • MÜLLERIAN duct → Tuba uterina, uterus, vagina (superior sec-
The WOLFFIAN ducts, however, degenerate as there is no testos- tion)
terone. The cranial, un-fused sections of the MÜLLERIAN ducts • Sinus urogenitalis → vagina (inferior section)
develop from the 12th week into the fallopian tubes, while the
­uterus and the distal part of the vagina emerge from the distally
fused parts to the uterovaginal canal (› Fig. 8.28, › Fig. 8.48). Clinical remarks
The inferior part of the vagina, the majority of its epithelium and
If the MÜLLERIAN ducts do not fuse with each other, septation
also the BARTHOLIN's glands originate from the Sinus urogeni- of the uterine lumen (Uterus septus or subseptus) or even
talis. Here, the MÜLLERIAN ducts and the Sinus urogenitalis only double formation (Uterus duplex) can ensue. In the case of a
form the epithelium of various organs, whilst connective tissue and Uterus bicornis only the superior part is separated. If the
smooth muscles emerge from the surrounding mesoderm. The

385
8 Pelvic viscera

uterovaginal canal does not form a vaginal plate together with Clinical remarks
the Sinus urogentialis, then uterus and vagina are absent
(MAYER-ROKITANSKY-KÜSTER-HAUSER syndrome). If the vagi- The common features with the development of the external
nal plate does not form a lumen, the vagina remains closed in male genitalia explain why, in the case of disorders which in-
the superior part (vaginal atresia). In hymenal atresia the infe- volve excessive production of male sex hormones (adrenogen-
rior part of the vagina is not opened, so that the hymen does ital syndrome), penis-like hyperplasia of the clitoris can occur.
not tear after birth and impedes menstruation at puberty.
Relics of the various systems can be clinically remarkable in
rare cases if they form cysts, which can appear as tumours or
inflammation: remnants of the WOLFFIAN ducts can remain
extant as the Appendix vesiculosa in the vicinity of the ovary 8.6.4 Vulva
or as GARTNER’s duct in the Lig. latum uteri and in the vaginal
wall. The cranial end of the MÜLLERIAN duct can form a vesicle
The Mons pubis, which is covered by pubic hair after puberty, runs
at the fallopian tube (hydatid of MORGAGNI). Relics of the me-
sonephric tubercles can remain as the epoophoron within the down into the Labia majora pudendi, which unite ventrally and
Mesovarium or the paroophoron within the Lig. latum uteri. dorsally (Commissura labiorum anterior and posterior). The approxi-
mately 3 cm long cavernous bodies of the vestibule are embedded
on both sides into the Labia majora (Bulbus vestibuli) and behind
these into the vestibular glands (Glandulae vestibulares majores
Development of the external female genitalia BARTHOLINI and minores, clinical term: BARTHOLIN's glands).
The external genitalia in both sexes firstly develop ambiguously The BARTHOLIN's glands have a 2 cm long efferent duct corre-
(sexually ambiguous stage) between the 4th and 7th week. They are sponding to the COWPER’s glands in men and moisten the vesti-
formed from the caudal section of the Sinus urogenitalis. At the bule of the vagina during sexual arousal.
same time, the anterior wall of the Sinus urogenitalis descends Located between the Labia majora are the Labia minora (Labia
firstly to the urethral groove which is delineated on both sides by minora pudendi), which encompass the vestibule of the vagina
genital folds. Lateral to these are the labioscrotal swellings and at Vestibulum vaginae). In front the Labia minora run with a ridge of
the posterior edge of the groove is the genital tubercle (› Fig. tissue (Frenulum clitoridis) to the glans of the clitoris as well as its
8.49). Subsequently, in females, the following develop under the prepuce (› Fig. 8.50). Flowing into the vulvar vestibule are:
influence of the ovary and female sex hormones (oestrogen): • the vagina (dorsal)
• the genital tubercle develops into the clitoris (Corpora caverno- • the urethra (ventral), approximately 2.5 cm below the clitoris
sa) • the efferent ducts of the BARTHOLIN's glands (lateral)
• the genital folds develop into the Labia minora
• the labioscrotal swellings develop into the Labia majora and
into the Mons pubis
Clinical remarks
Unlike in men, the genital folds do not close and the labioscrotal Inflammation of BARTHOLIN'S glands can cause painful swell-
swelling only close anterior and posterior at the unification points ings of the Labia majora (BARTHOLIN's abscess). A cause is a
of the Labia majora (Commissura labiorum anterior and posteri- obstruction of the efferent ducts of the glands.
or). The BARTHOLIN’s glands develop from the Sinus urogenital- The topography of vaginal and urethral orifices in the vesti-
bule of the vagina is important when inserting a urinary cath-
is.
eter in order to prevent the catheter being placed in the vagina
(› Chap. 8.3.5).

The clitoris is the sensory organ for sexual arousal and 3–4 cm
Genital tubercle
Urethral groove
long. Evolutionarily there exist some common features between the
Labioscrotal swellings construction of the clitoris and the penis. Therefore, the mecha-
Genital fold nisms for filling the cavernous bodies and for erection are compa-
rable in both sexes. The clitoris consists of the two cavernous bod-
ies (Corpora cavernosa clitoridis), which are sheathed by a fascia
(Fascia clitoridis) and merge ventrally into a short body (Corpus
clitoridis), in which, however, they remain separated by the Sep-
tum corporum cavernosorum (› Fig. 8.50). Caudally adjoining is
the Glans clitoridis, which is covered by a prepuce (Preputium
clitoridis). The Corpora cavernosa gives way dorsally of the body
to the crus of the clitoris (Crura clitoridis), which are anchored to
the inferior branches of the pubic bone. The crura are surrounded
by the Mm. ischiocavernosi. The M. bulbospongiosus stabilises the
Bulbus vestibuli, which thus, as a cavernous body, corresponds to
Clitoris
the Corpus spongiosum of the penis. Similarly to the penis, the cli-
Urethra
toris is also anchored via 2 suspensory ligaments with the superfi-
Vagina
cial Lig. fundiforme clitoridis and the more deeply located Lig.
Large labium
fundiforme clitoridis, which is attached to the symphysis (› Fig.
Small labium 8.50).

Fig. 8.49 Development of the external female genitalia, Organa geni-

talia feminina externa.

386
 8.6 Female genitalia

Symphysis pubica
Tuberculum pubicum Lig. suspensorium clitoridis

Corpus cavernosum
clitoridis

Preputium clitoridis
Glans clitoridis
Frenulum clitoridis
Crus clitoridis Ostium urethrae externum
Labium minus pudendi Carunculae hymenales

Ostium vaginae M. ischiocavernosus

M. bulbospongiosus
Bulbus vestibuli
Membrana perinei
Glandula vestibularis
major*, (Ostium)
Vestibulum
vaginae Tuber ischiadicum
Fig. 8.50 External female geni-
M. sphincter ani externus, Frenulum labiorum
Pars subcutanea talia. Caudal view, after removal
pudendi
of the superficial fascia and the
Anus vascular, lymphatic and nervous
systems.

8.6.5 Ovary and fallopian tubes • Lig. suspensorium ovarii (clinically: Lig. infundibulopelvicum):
connects the ovary from the Extremitas tubaria outwards with
The ovary and fallopian tubes are referred to as adnexa. They are the lateral pelvic wall. It guides the A. and V. ovarica.
covered by the peritoneum and lie, therefore, in an intraperitoneal Dorsally, the ovary has contact with the ureter and the N. obtura-
position in the pelvic cavity (› Fig. 8.51). torius as well as on the right side with the vermiform appendix
(Appendix vermiformis) of the large intestine if it is suspended in
Ovary the lesser pelvis (descending type). To the left the Colon sigmoide-
In a female of child-bearing age, the ovary (Ovar) is 4 × 2 × 3 cm um traverses the superior pole of the ovary. Running caudally are
large, 7–14 g in weight and oval (› Fig. 8.51). In pregnancy it dou- the A. umbilicalis and the A. obturatoria (both branches of the
bles in size and after the menopause the ovary shrinks significantly. A. iliaca interna, › Fig. 8.62).
A distinction is made between a superior pole (Extremitas tubaria)
and an inferior pole (Extremitas uterina) as well as a medial and Fallopian tube
lateral surface (Facies medialis and lateralis). Secured to the anteri- The fallopian tube (Tuba uterina [Salpinx]) connects the ovary and
or border as a peritoneal duplication is the Mesovarium (Margo uterus (› Fig. 8.51). It is 10–14 cm long and has various sections:
mesovaricus); while the posterior border remains free (Margo • Infundibulum (Infundibulum tubae uterinae) : 1–2 cm long,
liber). The vessels and nerves enter and exit at the hilum of the ova- has an aperture to the abdominal cavity (Ostium abdominale
ry. tubae uterinae) and fringe-like processes (Fimbriae tubae uteri-
The ovary is secured by 2 suspensory ligaments: nae) for receiving the ovum during ovulation
• Lig. ovarii proprium: is attached to the Extremitas uterina and • Ampulla (Ampulla tubae uterinae): 7–8 cm, runs in an arch
connects the ovary and the uterus shape around the ovary

Mesovarium
Ampulla tubae uterinae
Ampulla tubae uterinae
Ostium abdominale tubae uterinae; Mesosalpinx
A.; Vv. ovarica(e)
Infundibulum tubae uterinae Isthmus tubae Fundus uteri
Fimbriae tubae uterinae uterinae
Tuba uterina
[Salpinx]
Lig. suspensorium ovarii

Ovarium
A.; Vv. ovarica(e)
Extremitas uterina
Ovarium Lig. ovarii proprium

Ureter
Lig. latum uteri
Ureter Corpus uteri

Lig. cardinale Isthmus uteri

[Lig. transversum cervicis] Cervix uteri
Lig. rectouterinum
Tunica serosa
Plica rectouterina [Perimetrium]

Fig. 8.51 Ovary, fallopian tubes and uterus with peritoneal duplicatures. Dorsal view.

387
8 Pelvic viscera

• Isthmus (Isthmus tubae uterinae): 3–6 cm, constriction at the Cavitas uteri
passageway to the uterus
• Intramural section (Pars uterina), 1 cm long, runs into the uter-
us (Ostium uterinum) Fundus uteri
Anteflexio

Comparable to the Mesovarium, the fallopian tube with the Me- Cervix uteri
sosalpinx has a peritoneal duplicature, which runs to the Lig. la-
tum uteri. Corpus uteri

NOTE Anteversio
The ovary and Tuba uterina, which are grouped as adnexa, are lo-
cated in the same way as the body of the Uterus intraperitoneal Vagina
and are, therefore, covered on their surface anatomy by peritone-
um. In contrast, there are no intraperitoneal genitalia in men.
Fig. 8.52 Location of the uterus and vagina. View from right.
Clinical remarks The space inside the uterus is divided into the Cavitas uteri in the
The intraperitoneal location of the adnexa is clinically signifi- body of the uterus and into the cervical canal (Canalis cervicis
cant: uteri) in the cervix. The cervix runs with its posterior section via
• A large proportion of malignant tumours of the ovary (ovari- the external uterine orifice (Ostium uteri) into the vagina, which
an cancer) do not arise from the organ itself, but from the is thus referred to as the Portio vaginalis cervicis. The superior
peritoneal epithelium on its surface.
section, which begins at the isthmus with the internal uterine ori-
• The open connection of the fallopian tube to the abdominal
cavity means that an ectopic pregnancy can occur, in which fice (Ostium anatomicum uteri internum) is the Portio supravagi-
the fertilised ovum does not implant in the uterus, but rath- nalis cervicis.
er in the peritoneum in the vicinity of the ovary. This can
cause life-threatening haemorrhaging due to erosion of
blood vessels.
Clinical remarks
After ascending bacterial infections of the fallopian tube (sal- Inspection and smear tests of the cervix are included in gynae-
pingitis) its walls can stick together, so the fallopian tube is no cology as part of routine diagnostics in Germany and are re-
longer accessible and fertilisation becomes impossible. In ster- munerated by health insurances for women from the 20th year
ilisation the tube is ligated or separated in a targeted manner. of age as a preventative screening. Screening should be car-
The close topographical relationship of the adnexa (ovary and ried out at least once a year for early recognition of any chang-
Tuba uterina) to the vermiform appendix (Appendix vermiform- es, such as precursors of a malignant tumour (cervical cancer)
is) of the large intestine explains why an inflammation of the so as to remove them. Cervical cancer is one of the most fre-
vermiform appendix (appendicitis) as well as an inflammation quent malignant cancers in women under the age of 40 years.
of the fallopian tubes (salpingitis) can be associated with
similar pain in the right lower abdomen.
The wall of the uterus consists internally of the endometrium,
which is followed by the strong muscular layer (myometrium)
made of smooth muscles as well as externally by the peritoneal lin-
8.6.6 Uterus ing (perimetrium).

Structure and location NOTE

The uterus (Metra) is 8 cm long, 5 cm wide and 2–3 cm thick. It Endometrium: mucosal membrane of the uterus
has a variable weight of between 30–120 g (on average 50 g), which Myometrium: smooth muscles of the uterus
reaches up to 1 kg in pregnancy, and greatly diminishes with age. Perimetrium: peritoneal lining of the uterus
The uterus is divided into an intraperitoneally located body (Cor- Parametrium (= Lig. cardinale): connective tissue anchoring of the
cervix in the pelvis
pus uteri) with an anteriorly directed base (Fundus uteri) and a Mesometrium (= Lig. latum): anteriorly placed peritoneal duplica-
subperitoneally anchored cervix (Cervix uteri) of approximately ture
2.5 cm in length, which are set apart from each other by a constric-
tion (Isthmus uteri) (› Fig. 8.51). The fallopian tubes (Tuba uteri-
na) are attached on both sides to the body of the uterus as a con- Suspensory ligaments
nection to the ovaries (Ovar). The two sections of the uterus have various suspensory ligaments,
The uterus has an anterior surface (Facies anterior or vesicalis), which have clinical relevance in gynaecological operations:
which points to the urinary bladder, and a posterior surface (Facies • Corpus uteri:
posterior or intestinalis) which has contact with the rectum. The – Lig. latum uteri (= Mesometrium): forms together with the
anterior of the peritoneal cavity sinks into the depths between peritoneal duplicatures of the adnexa (Mesosalpinx, Mesovar-
these as the Excavatio vesicouterina and posteriorly as the Exca- ium) an anteriorly positioned fold in the lesser pelvis, which
vatio rectouterina (DOUGLAS pouch). covers the body of the uterus (› Fig. 8.51) → uterus, fallopian
In the normal position the uterus is curved forwards towards the tube and ovary thus lie in an intraperitoneal position
vagina (anteversion) and the body is bent backwards towards the – Lig. teres uteri (clinical term: Lig. rotundum): connective tis-
cervix (anteflexion) (› Fig. 8.52). This position has a protective sue cord, which runs from the angle of the uterine tubes ante-
purpose and prevents the uterus from being everted out of the va- riorly to the lateral pelvic wall and through the inguinal canal
gina in the case of an increase in intra-abdominal pressure (sneez- to the Labia majora, where it inserts into the skin and adipose
ing, coughing). tissue; its purpose is to stabilise position of the uterus

388
 8.6 Female genitalia

Excavatio rectouterina
(DOUGLAS' pouch)
Os sacrum
Lig. transversum cervicis
[Lig. cardinale] Rectum Lig. rectouterinum

Os ilium
M. levator ani

Tuba uterina
Lig. teres uteri Fig. 8.53 Anchoring ligaments
Uterus of the uterus and connective tis-
Lig. ovarii proprium sue spaces of the pelvis. Trans-
Os pubis
verse incision at the level of the
Lig. pubovesicale Vesica urinaria Cervix uteri; cranial view; partial
schematic diagram. [L238]

• Cervix uteri (› Fig. 8.53): sels, which take up respiratory gases and nutrients and merge in
– Lig. cardinale (Lig. transversum cervicis): connective tissue the chorionic plate into the umbilical cord vessels.
strands from the cervix laterally to the pelvic wall (also re- Functions of the placenta are:
ferred to as the Parametrium) • Exchange of respiratory gases and nutrients between maternal
– Lig. rectouterinum (clinical term: Lig. sacrouterinum): con- and fetal blood
nective tissue strands from the cervix dorsally around the rec- • Hormone production (amongst others to maintain the placenta)
tum and up to the sacrum • Immune tolerance (to prevent rejection of the child)
– Lig. pubocervicale: secures the cervix ventrally at the pubic
bone
The Lig. rectouterinum is also delineated in gynaecological opera- 8.6.7 Vagina
tions in order to be able to protect the nerve fibres of the Plexus hy-
pogastricus inferior, which run inferiorly in this connective tissue. The vagina is a hollow muscular organ with a length of 10 cm and
Cranially, the connective tissue raises a peritoneal fold (Plica lies in a subperitoneal position. A distinction is made between the
rectouterina), which constitutes on both sides the lateral border of anterior and posterior walls (Paries anterior and Paries posterior),
the Excavatio rectouterina (DOUGLAS pouch). which both point towards the transverse folds on the inner surface
(Rugae vaginales). Bordering onto the Portio vaginalis of the cervix
Changes in the uterus during pregnancy is the vaginal vault (Fornix vaginae), which is divided into anteri-
The child develops in the uterus. After the ovum is fertilised by or, lateral and posterior sections (› Fig. 8.58).
spermatozoa in the fallopian tube, it is transported into the uterus, Because the uterus is tipped forwards (anteversion), the posterior
where it implants in the endometrium. The placenta develops in wall is longer than the anterior wall and the posterior vaginal fornix
the endometrium from maternal and neonatal tissue . The placenta is correspondingly higher than the anterior section (› Fig. 8.52).
is differentiated in the 4th month and at birth has a diameter of 20 Caudally, the vagina opens dorsal to the urethra into the vestibule
cm and a weight of 350–700 g. Simplified, the disc-shaped struc- of the vagina (Vestibulum vaginae), which is counted among the
ture of the placenta can be imagined as a shallow pot with a lid. external genitalia. Before the first occurrence of sexual intercourse,
The bottom of the pot corresponds to the basal plate, which is em- this connection is closed by the remnants of the hymen.
bedded into the endometrium of the uterus. The lid is the chorion- To the posterior, the vagina borders on the rectum and is only sep-
ic plate, from which the blood vessels originate and run via the arated from the latter by the Fascia rectovaginalis (= Septum rec-
umbilical cord to the child. In the umbilical cord, the two arteries tovaginale) (› Fig. 8.58). The connective tissue in front towards
(Aa. umbilicales) are twined in a spiral around a vein (V. umbilica- the urinary bladder is also referred to clinically as the Septum vesi-
lis). The V. umbilicalis brings blood, which has been oxygen-en- covaginale.
riched in the placenta to the child and connects to the inferior vena
cava whilst circumventing the liver (› Chap. 6.1.4). The two Aa.
umbilicales branch from the internal iliac arteries (Aa. iliacae in-
Clinical remarks
ternae) and conduct the deoxygenated blood to the placenta. Be- From the posterior vaginal vault outwards the Excavatio
tween the basal plate and chorionic plate is a cavity filled with ma- rectouterina (DOUGLAS pouch) can be aspirated in order to
ternal blood, which is referred to as the intervillous space, since investigate free fluid.
the placental villi hang into it from the chorionic plate for enlarge-
ment of the surface area. Located in the villi are the fetal blood ves-

389
8 Pelvic viscera

8.6.8 Vessels and nerves of the external and • R. ovaricus, in addition to the A. ovarica it is involved in blood
­internal female genitalia flow of the ovary
• Rr. vaginales, descend at the superior section of the vagina,
From a developmental point of view, the supply of the female geni- which they supply in addition to the A. vaginalis
talia has many common features with the vessels and nerves of the The vagina is predominantly supplied by the A. vaginalis from the
male genitalia (› Chap. 8.5.8). A. iliaca interna.
Blood from the ovary and Tuba uterina is drained via the V. ovari-
Arterial supply and venous drainage of the external genitalia ca. The vein ascends in the Lig. suspensorium ovarii to the pelvic
The external genitalia are supplied by the terminal branches of the wall and flows to the right into the V. cava inferior (› Fig. 8.62);
A. pudenda interna and the Aa. pudendae externae (› Table 8.6). but on the left side it flows into the left V. renalis. Blood from the
The blood vessels of the vulva thus correspond to those of the penis uterus, tube and vagina accumulates within the pelvis in the ve-
and scrotum. Accordingly, the mechanisms for filling the cavern- nous plexus in the vicinity of the organs (Plexus venosi uterinus
ous bodies, which are important for sexual sensation, are compara- and vaginalis) and then drains via the Vv. uterinae into the V. iliaca
ble (› Chap. 8.5.8). The Labia majora, which correspond develop- interna (› Fig. 8.62).
mentally to the scrotum, are supplied by the A. pudenda interna
(Rr. labiales posteriores) and the A. pudenda externa (Rr. labiales
anteriores). The veins correspond to the arteries.
Clinical remarks
In the case of endometrial cancer or benign tumors (fibroids)
Arterial supply and venous drainage of the internal genitalia of the Myometrium, which can bleed heavily, surgical removal
The internal female genitalia are supplied by three arteries, which of the uterus (hysterectomy) is necessary, which is often car-
originate from the abdominal section of the Aorta and the A. iliaca ried out transvaginally. Here, there is the danger that the ure-
ter can be accidentally ligated with the Aa. uterina. The result-
interna (› Fig. 8.54, › Fig. 8.62).
ing urinary backflow can lead to kidney loss and, therefore,
The A. ovarica supplies the ovary and adjacent sections of the Tuba requires surgical correction.
uterina. It originates from the abdominal section of the Aorta just
below the renal arteries and then descends into the retroperitoneal
space, whereupon it crosses over the N. genitofemoralis, the ureter
and A. iliaca externa, before approaching the ovary in the Lig. sus- Lymphatic pathways of the external and internal genitalia
pensorium ovarii. In contrast to men, the external and internal genitalia in women do
The A. uterina is a visceral branch of the A. illiaca interna. In the not have completely separated lymphatic drainage pathways, since
Lig. latum uteri the artery crosses over the ureter and branches into the female reproductive organs have a connection to the inguinal
its terminal branches, with which it is involved in blood supply to lymph nodes (› Fig. 8.55)!
all internal genitalia (› Fig. 8.54): For the external genitalia (vulva), just like in men, the lymph
• Rr. helicini, wind along the uterus, which they supply and can nodes of the groin (Nodi lymphoidei inguinales superficiales) are
adapt to the massive growth of the uterus during pregnancy the first lymph node station.
• R. tubarius, supplies the ampulla of the Tuba uterina The regional lymph nodes of the ovary, which correspond develop­
mentally to the testis, of the Tuba uterina and of the adjacent uter-
us (‘tube angle’) are the Nodi lymphoidei lumbales at the level of
Table 8.6 Vessels of the clitoris and Bulbus vestibuli.
the kidneys, from which the lymph runs into the Trunci lumbales.
Arteries Veins The lymphatic pathways ascend within the Lig. suspensorium ova-
rii.
• A. dorsalis clitoridis: supplies the • V. dorsalis superficialis clitoridis:
Glans clitoridis conducts blood from the Glans to
Lymph is drained from the uterus, Tuba uterina and vagina firstly
• A. profunda clitoridis: penetrates the V. pudenda externa into the lymph nodes of the pelvic cavity (Nodi lymphoidei iliaci
into the Crura clitoridis and supplies • V. dorsalis profunda clitoridis: interni/externi and Nodi lymphoidei sacrales).
the Corpora cavernosa clitoridis drains blood from the Corpora Specific to the lymphatic drainage of the internal female genitalia is
• A. bulbi vestibuli: supplies the ­cavernosa to the Plexus venosus that both the uterus, at the origin of the Lig. teres uteri (‘tube an-
B
­ ulbus vestibuli vesicalis
gle’) via the lymphatic pathways along this ligament, and the infe-
• V. bulbi vestibuli: paired, brings
blood from the Bulbus vestibuli to
rior sections of the vagina have a connection to the lymph nodes
the V. dorsalis profunda clitoridis of the groin (Nodi lymphoidei inguinales superficiales and pro-
fundi) (› Fig. 8.55).

Tuba uterina
Lig. suspensorium
ovarii
Clinical remarks
R. tubarius
Due to the different lymphatic drainage pathways, the first
A. ovarica
lymph node metastases in the case of vulval cancer are found
Ovarium in the groin; in the case of endometrial cancer of the uterus
and cervical cancer the metastases are found in the lesser pel-
R. ovaricus
vis, and in the retroperitoneal space in the case of ovarian tu-
Lig. ovarii proprium
mours.
Rr. helicini
A. uterina
R. vaginalis
Innervation of the external and internal genitalia
Fig. 8.54 Arterial blood supply of the internal female genitalia. Dor- The internal and external genitalia have both autonomic and so-
sal view. matic innervation (› Fig. 8.56, › Table 8.7).

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 8.6 Female genitalia

Nodi lymphoidei Nodi lymphoidei

lumbales sacrales

Nodi lymphoidei
Nodi lymphoidei iliaci interni
iliaci communes

Nodi lymphoidei
iliaci externi Nodi lymphoidei
inguinales profundi
Nodi lymphoidei
inguinales profundi

Nodi lymphoidei
inguinales superficiales Fig. 8.55 Lymphatic drainage
pathways of the external and
internal female genitalia. Ven-
tral view.

Medulla spinalis
T10
T11
T12
L1
L2
L3
L4
L5
Rr. communicantes S1
S2
S3
S4 Radices anteriores
S5
(S2–S5)
Plexus ovaricus

Ganglia trunci sympathici Plexus hypogastricus

superior
A. ovarica

N. hypogastricus Tuba uterina [Salpinx]

Ovarium

Plexus hypogastricus inferior

N. sacralis [S1]
Plexus uterovaginalis
Ganglia pelvica,
N. vaginalis
Radix parasympathica
Ganglia pelvica, Radix parasympathica [Nn. splanchnici pelvici]
[Nn. splanchnici pelvici]
Plexus sacralis
Clitoris
Labium minus pudendi N. pudendus
Nn. labiales posteriores

Fig. 8.56 Innervation of the female genitalia. Ventral view; schematic diagram. The Plexus hypogastricus inferior and the Plexus uterovaginalis
contain sympathetic (green) and parasympathetic (purple) nerve fibres.

The mostly parasympathetic innervation of the vulva increases rior and out of the sacral ganglia of the sympathetic chain (Truncus
blood flow in the cavernous bodies and thus supports sexual arous- sympathicus) via the Nn. splanchnici sacrales and are mostly in the
al, which is perceived by somatic innervation. Plexus hypogastricus inferior converted synaptically into postgan-
Depending on hormone status, the autonomic innervation of the in- glionic neurons (› Fig. 8.56). Their axons reach the pelvic organs
ternal genitalia modulates the tone of the uterine muscles, tubal
motility and the secretion of the glands. The sympathetic innerva-
tion reduces the blood flow of the organs and causes a contraction of Table 8.7 Innervation of the female genitalia.
the muscles of the uterus. In contrast, the parasympathetic nervous Autonomic innervation Somatic innervation
system has a dilating effect on the vessels of the uterus and reduces
Sympathetic (T10–L2) and parasympa- • Sensory: mainly N. pudendus to the
the tone of the uterine muscles. It fosters secretion formation of the
thetic (S2–4): clitoris, labia and vagina (lower sec-
vagina (transudate from the blood vessels as there are no glands!) as • Uterus, Tuba uterina, vagina (Plexus tion)
well as secretions of the BARTHOLIN's glands during arousal. hypogastricus inferior) • Motor: N. pudendus to the perineal
The inferior sections of the vagina have somatic innervation, which • Ovary (Plexus ovaricus) muscles
promotes sexual arousal. • Cavernous bodies of the clitoris and
Preganglionic sympathetic nerve fibres (T10–L2) descend from BARTHOLIN's glands (Nn. cavernosi
clitoridis)
the Plexus aorticus abdominalis via the Plexus hypogastricus supe-

391
8 Pelvic viscera

and continue into the Plexus uterovaginalis (FRANKENHÄUS­ – Colon descendens

ER's plexus), which innervates the uterus, Tuba uterina and vagina. – Proximal rectum (up to the Flexura sacralis)
The predominantly postganglionic sympathetic nerve fibres for the – Pancreas
ovary run in the Plexus ovaricus along the A. ovarica, after they On a specimen, the secondary retroperitoneal organs can be de-
have already been converted in the Ganglia aorticorenalia or in the tached bluntly from the primary retroperitoneal organs in the
Plexus hypogastricus superior. plane of the tolot-fascia (› Fig. 8.8).
The preganglionic parasympathetic nerve fibres pass from the Some organs in the subperitoneal space, such as the urinary blad-
sacral parasympathetic nervous system (S2–S4) via the Nn. der, are covered on a part of their superior side with parietal peri-
splanchnici pelvici into the ganglia of the Plexus hypogastricus in- toneum, whereas other organs of the pelvis (distal rectum from the
ferior (› Fig. 8.56). They are converted either here or in the vicini- Flexura sacralis, anal canal, Cervix uteri, vagina, prostata, Glandula
ty of the organs into postganglionic neurons, which innervate the vesiculosa) have no contact with peritoneum (› Fig. 8.57, › Fig.
uterus, Tuba uterina and vagina. The Nn. cavernosi clitoridis pen- 8.58).
etrate the pelvic floor and run (partly below the attachment to the
N. dorsalis clitoridis) into the cavernous bodies, where they induce
filling (erection), and to the BARTHOLIN's glands.
Clinical remarks
Somatic innervation by the N. pudendus provides sensory inner- Retroperitoneal organs, such as the kidneys are also accessi-
vation to the inferior part of the vagina as well as to the posterior ble from the dorsal side during operations without needing to
two thirds of the labia via the Rr. labiales posteriores nerves and to open the peritoneal cavity. This reduces the risk of infections
the clitoris via the N. dorsalis clitoridis (› Fig. 8.56). The anterior of the abdominal cavity (peritonitis) or postoperative adhe-
sions.
third of the labia receives sensory innervation from the N. ilioin-
guinalis (Rr. labiales anteriores) and the lateral sections receive ad-
ditional innervation from the N. cutaneus femoris posterior (Rr.
perineales) and the N. genitofemoralis (R. genitalis). NOTE
For the general organisation of the autonomic nervous system in Extraperitoneal organs:
the abdomen, see › Chap. 7.8.5 and on the autonomic ganglia in • Located outside of the peritoneal cavity in the retroperitoneal

the retroperitoneum, see › Chap. 8.8.5 . space of the abdominal cavity (Spatium retroperitoneale) or in
the subperitoneal space of the pelvis (Spatium extraperitoneale
pelvis)
• Not or only partially covered by Peritoneum parietale
8.7 Retroperitoneal space and pelvic cavity

Skills 8.7.2 Retroperitoneal space

After working through this chapter, you should be able to:
• understand the structure of the retroperitoneum and pelvic The Retroperitoneum (Spatium retroperitoneale) is a slit-shaped
cavity space dorsal to the peritoneal cavity, which is delineated ventrally
• describe the topographical relationships of individual or- by the Peritoneum parietale and dorsally by the muscles of the pos-
gans on a specimen
terior abdominal wall (M. psoas major and M. quadratus lumbo-
rum). Located in this space are the kidneys, the adrenal glands and
the ureter, which together are surrounded by a fascia system
(› Chap. 8.1, › Chap. 8.2). Located between the two kidneys run
8.7.1 Overview the vessels and nerves of the retroperitoneal space (› Chap. 8.8).

The abdominal cavity (Cavitas abdominalis) and the pelvic cavity

(Cavitas pelvis) are predominantly lined with peritoneum and to- 8.7.3 Subperitoneal space
gether form the peritoneal cavity (Cavitas peritonealis) (› Chap.
7.7). Behind and below the peritoneal cavity is the extraperitoneal Caudal to the pelvic section of the peritoneal cavity (Cavitas peri-
space (Spatium extraperitoneale), which dorsally as the retroperi- tonealis pelvis) the extraperitoneal space is extended to the sub-
toneum (Spatium retroperitoneale), › Chap. 8.7.2) is lined pre- peritoneal space (Spatium extraperitoneale pelvis), in which con-
dominantly with adipose tissue between the organs and the vascu- nective tissue surrounds the individual organs with their vascular,
lar, lymphatic and nervous systems; this continues caudally into the lymphatic and nervous systems. The connective tissue is partially
pelvic cavity into the subperitoneal space (Spatium extraperitone- thickened to so-called fasciae, which surround the individual or-
ale pelvis, › Chap. 8.7.3). gans and subdivide individual compartments, such as the ‘Meso­
The organs of the retroperitoneal space are usually only covered rectum’, which constitutes a clinically very relevant space around
on their anterior side by Peritoneum parietale (› Fig. 7.47). These the rectum (› Chap. 8.4.3). The space behind the pubic symphysis
organs are either is referred to as the Spatium retropubicum (clinically: RETZIUS'
• already located outside the abdominal cavity (primary retroperi- space) (› Fig. 8.57, › Fig. 8.58).
toneal organs) The fasciae in the pelvis are divided into:
– Kidneys • Fascia pelvis parietalis: covers the bony pelvis on the inside; the
– Adrenal glands section ventrally of the sacrum is referred to as the Fascia presa-
• or have been shifted to the dorsal abdominal wall only during cralis (WALDEYER's fascia).
development (secondary retroperitoneal organs, › Chap. 7): • Fascia pelvis visceralis: encases the individual organs with their
– Duodenum (apart from the Pars superior) vascular, lymphatic and nervous systems, e.g. the ‘mesorectal
– Colon ascendens fascia’ around the rectum with its ‘Mesorectum’; in addition,

392
 8.7 Retroperitoneal space and pelvic cavity

Plica umbilicalis mediana

(Lig. umbilicale medianum)
Vesica urinaria
Spatium retropubicum*
Plica transversa recti
Linea alba Excavatio rectovesicalis

Symphysis pubica Ampulla recti

Fascia rectoprostatica**
Lig. fundiforme penis
Ostium urethrae internum
V. dorsalis profunda penis
Prostata
V. dorsalis superficialis penis
Fascia pelvis visceralis
Urethra, Pars spongiosa
Lig. anococcygeum
Ductus deferens
M. sphincter ani externus
Caput epididymidis
Tunica albuginea M. sphincter ani internus
corporum cavernosorum Plexus venosus prostaticus
Corpus cavernosum penis M. sphincter ani externus
Corpus spongiosum penis
M. transversus perinei profundus
Corona glandis
Corpus perineale
Glans penis
Fossa navicularis urethrae Urethra, Pars membranacea
Testis
Preputium penis Lig. puboprostaticum
Ostium urethrae externum Cauda epididymidis
Bulbus penis, Corpus
M. cremaster; Fascia cremasterica Scrotum, Tunica dartos spongiosum penis

Fig. 8.57 Male pelvis. Median incision; view from left; ∗RETZIUS' space ∗∗ clinically: DENONVILLIER's fascia.

Tuba uterina Uterus

Ureter

Lig. suspensorium ovarii; A.; V. ovarica

A.; V. iliaca externa

Ovarium

Isthmus tubae uterinae

Lig. teres uteri Plica rectouterina

Plica umbilicalis medialis

Ampulla recti
Peritoneum parietale
Excavatio rectouterina**

Plica umbilicalis mediana Fornix vaginae,

(Lig. umbilicale medianum) Pars posterior

Fascia pelvis parietalis Portio vaginalis cervicis

Spatium retropubicum Ostium uteri

Excavatio vesicouterina
Fascia rectovaginalis
Lig. pubovesicale
Ostium urethrae internum Vagina

Corpus clitoridis, *
Corpus cavernosum clitoridis
Vesica urinaria
V. dorsalis profunda clitoridis
Plexus venosus vesicalis
Labium minus pudendi
Ostium urethrae externum

Fig. 8.58 Female pelvis. Median incision; view from left; ∗ clinically: Septum vesicovaginale, ∗∗ clinically: DOUGLAS' pouch.

393
8 Pelvic viscera

there are sheets of connective tissue, which separate individual • identify lymph nodes and systems of lymphatic pathways
organs from each other, such as in men the Fascia rectoprostat- with formation of the Ductus thoracicus
ica (= Septum rectoprostaticum, clinically DENONVILLIER's • explain the organisation of the autonomic nervous system
fascia) and in women the Fascia rectovaginalis (= Septum rec- with plexi and ganglia in the retroperitoneum and pelvis
tovaginale).
Further thickenings of the connective tissue are referred to as liga-
ments (Ligamenta) and serve the purpose of securing the individu-
al organs to the bony pelvis. Even the remaining loose connective 8.8.1 Overview
tissue, which continuously merges into connective tissue fascia or
walls of the organs, have their own clinical terms: The major arterial, venous and lymphatic vascular branches of the
• Parametrium: fibre strands from the cervix to the lateral pelvic body in the Retroperitoneum continue caudally in the pelvic cavi-
wall (Lig. cardinale) ty into the subperitoneal space as well as from cranially into the
• Paraproctium: connective tissue around the rectum posterior mediastinum of the thoracic cavity (› Chap. 6.6 ). In
• Paracystium: connective tissue around the urinary bladder the process, the vessels supply both the dorsal abdominal wall (pa-
• Paracolpium: connective tissue around the vagina rietal vessels) as well as the viscera (visceral vessels) of the abdomi-
The pelvic cavity is thereby divided into a total of 3 levels. The pel- nal and pelvic cavities and continue as vessels of the lower extremi-
vic organs lie in the clinically designated as the ‘lesser pelvis’ cau- ties.
dal section below the Linea terminalis, which is composed of the The abdominal section of the Aorta (Pars abdominalis aortae) en-
anterior Pecten ossis pubis and the posterior Linea arcuata. The ters through the diaphragm from the thoracic cavity into the retro-
levels of the pelvic cavity (from cranial to caudal) are: peritoneal space. Their terminal branches are the iliac arteries (Aa.
• Pelvic section of the peritoneal cavity (Cavitas peritonealis pel- iliacae communes), which divide in the pelvis into the A. iliaca inter-
vis), caudally delineated by the Peritoneum parietale na (to supply the pelvic wall and organs) and the A. iliaca externa
• Subperitoneal space, which reaches caudally up to the pelvic (which merges under the inguinal ligament into the A. femoralis).
floor (› Chap. 8.9) The inferior vena cava (V. cava inferior) with its tributaries ex-
• Perineal region (Regio perinealis), which lies underneath the tensively corresponds to the Aorta. After its passage through the
pelvic floor and divides on both sides ventrally into the two peri- diaphragm it flows directly into the right atrium of the heart.
neal spaces and dorsally in the Fossa ischioanalis (› Chap. 8.9) In the Retroperitoneum, lymph trunks from the abdominal and pel-
The peritoneal cavity runs with various recesses (Recessus), which vic cavities merge into the thoracic duct (Ductus thoracicus), the
are lined with Peritoneum parietale, into the subperitoneal space. largest lymph trunk of the body, which continues on to the left ve-
In men the Excavatio rectovesicalis forms the deepest space of the nous angle though the diaphragm into the posterior mediastinum.
abdominal cavity; in women this is the Excavatio rectouterina The retroperitoneal and subperitoneal spaces also contain sections
(DOUGLAS' pouch), which runs still further caudally than the ven- of the somatic and autonomic nervous system. The Plexus lumbo-
trally lying Excavatio vesicouterina. sacralis is a somatic nerve plexus, which is formed by the anterior
branches of the spinal nerves and located between portions of the
M. psoas major. Its nerves largely serve the purpose of innervating
Clinical remarks the lower extremities (› Chap. 5.6.1), but also of innervating the
In an upright position, in the deepest recesses of the perito- anal canal and external genitalia.
neal cavity, the Excavatio rectovesicalis in men, and the Exca- On the aorta, the nerve fibres of the sympathetic and parasympa-
vatio vesicouterina (pouch of DOUGLAS) in women, may accu- thetic nervous systems form an autonomic nerve plexus (Plexus
mulate inflammatory exudate or pus if there is inflammation in aorticus abdominalis), the individual parts of which reach the in-
the hypogastrium, which can be detected by sonography as
dividual organs with their respective arterial vessels. The autonom-
free liquid. The pouch of DOUGLAS extends to the posterior
vaginal vault and can be aspirated from there in order to in- ic nerve plexus continues via the Plexus hypogastricus superior
vestigate the free fluid. into the pelvic cavity, where it innervates various organs as the
Plexus hypogastricus inferior.

8.8.2 Arteries of the retroperitoneum and pelvic

8.8 Vessels and nerves of the extraperitoneal cavity
space and pelvic cavity
The abdominal section of the Aorta (Pars abdominalis aortae)
passes at the level of the XIIth thoracic vertebra through the Hiatus
Skills aorticus of the diaphragm and afterwards descends to the left ven-
After working through this chapter, you should be able to: trally of the spinal column (› Fig. 8.59). On its way there parietal
• understand the basic structure of the vessels and nerves of branches emerge for the abdominal wall and visceral branches for
the retroperitoneum, so that you can retrace the origin of the the viscera of the peritoneal cavity and retroperitoneal and sub-
vascular and neural supply in the individual organs peritoneal spaces › Table. 8.8). While the paired visceral branches
• show on a specimen branches of the abdominal aorta and
supply organs in the retroperitoneum and pelvic cavity, the abdom-
tributaries of V. cava inferior
• explain on a specimen branches of the Aa. iliacae externa inal viscera receive blood from 3 unpaired arterial branches:
and interna with course and supply areas • Truncus coeliacus
• know the venous plexuses of the pelvis with their connec- • A. mesenterica superior
tions and understand their clinical relevance • A. mesenterica inferior
At the level of the IVth lumbar vertebra the Aorta divides into its ter-
minal branches. The Aa. iliacae communes pass over on both sides

394
 8.8 Vessels and nerves of the extraperitoneal space and pelvic cavity

Vv. hepaticae Oesophagus

A.; V. phrenica inferior
Diaphragma
Glandula suprarenalis
Truncus coeliacus
V. cava inferior A. mesenterica
superior
A. renalis V. suprarenalis

V. renalis V. renalis
Aorta
Ureter
A.; V. testicularis
A. renalis A. mesenterica
accessoria inferior

A.; V. testicularis Aa.; Vv. lumbales

A.; V. iliaca communis

A. sacralis mediana

A.; V. iliolumbalis,
R. iliacus A.; V. iliaca interna

N. femoralis
A.; V. iliaca
externa

A.; V. iliaca externa

Peritoneum over
Vesica urinaria
A. epigastrica inferior Plica umbilicalis medialis Fig. 8.59 Abdominal Aorta and
(in Plica umbilicalis lateralis) (obliterated A. umbilicalis) inferior vena cava. Retrositus.
[S010-2-16]

into the pelvic cavity, where they branch. The thin A. sacralis medi- The parietal branches are formed identically in both sexes › Fig.
ana continues its course on the sacrum (› Fig. 8.59). 8.60:
Before the sacroiliac joint the A. iliaca communis divides into the • A. iliolumbalis: it supplies the Fossa iliaca and lumbar region
A. iliaca externa, which continues under the inguinal ligament and also gives off a branch to the spinal canal.
into the A. femoralis (› Chap. 5.7.2), and into the A. iliaca inter- • Aa. sacrales laterales: these arteries enter into the sacral canal
na in order to supply the pelvis and its viscera (› Fig. 8.60). The and supply the spinal meninx.
A. iliaca interna usually splits (in 60% of cases) into an anterior and • A. obturatoria: it runs with the N. obturatorius through the Ca-
a posterior main branch. Since the branch sequence is relatively vari- nalis obturatorius to the thigh. The R. pubicus anastomoses with
able, it is worthwhile instead to group the branches according to an eponymous branch from the A. epigastrica inferior: in up to
their supply areas into parietal branches for the pelvic wall and the 20% of cases the entire A. obturatoria originates from this vessel.
external genitalia and into visceral branches for the pelvic viscera. In the Canalis obturatorius the A. obturatoria divides into the
R. anterior, which supplies the adductors of the thigh and anas-
tomoses there with the A. circumflexa femoris medialis. The
Table. 8.8 Branches of the Pars abdominalis aortae R. posterior runs to the gluteal muscles. The R. acetabularis runs
Parietal • A. phrenica inferior: on the underside of the diaphragm, via the Lig. capitis femoris to the head of the femur and is essen-
­branches to the gives off the A. suprarenalis superior to the adrenal gland tial in children for nutrition of the proximal femoral epiphysis.
thoracic wall • Aa. lumbales: 4 pairs directly from the Aorta, the 5th pair • A. glutea superior: it runs through the Foramen suprapiriforme
originates from the A. sacralis mediana
into the gluteal region and supplies the gluteal muscles.
Visceral • Truncus coeliacus: unpaired, originates directly beneath • A. glutea inferior: it passes through the Foramen infrapiriforme
­branches for the the Hiatus aorticus and supplies the organs of the upper and similarly supplies the gluteal muscles.
viscera abdomen (› Fig. 7.48)
• A. suprarenalis media supplies the adrenal glands
• A. renalis: to the kidneys, also gives off the A. suprarena- Clinical remarks
lis inferior to the adrenal glands
• A. mesenterica superior: unpaired, supplies parts of the If the anastomosis between the A. obturatoria and the A. epi-
pancreas, the entire small intestine and the colon up to gastrica inferior is broad, this is traditionally called the Corona
the left colonic flexure (› Fig. 7.49) mortis, because in past times during operations in the ingui-
• A. testicularis/ovarica: supplies the testis and epididy- nal region, e.g. due to inguinal hernias, there was a risk of
mis in men and the ovaries in women life-threatening haemorrhaging. Nowadays, this clinical refer-
• A. mesenterica inferior: unpaired, supplies the Colon ence plays a minor role due to improved operative techniques
descendens and upper rectum (› Fig. 7.50) and haemostatic capabilities.
Terminal • A. iliaca communis: for the pelvis and leg If the R. acetabularis in children, due to trauma (e.g. hip dislo-
branches • A. sacralis mediana: descends onto the sacrum cation) or because of unknown causes, such as in PERTHES

395
8 Pelvic viscera

A. iliaca communis
A. iliolumbalis
A. sacralis lateralis

A. glutea superior

A. iliaca interna M. piriformis

A. glutea inferior

A. iliaca externa Lig. sacrospinale

A. pudenda interna
A. obturatoria Lig. sacrotuberale
A. rectalis media
A. umbilicalis
A. uterina
A. vesicalis superior Fig. 8.60 Parietal branches of
the A. iliaca interna.

disease cannot ensure blood supply of the femoral head, then • A. vesicalis inferior: it runs to the urinary bladder in men to the
bone necrosis occurs, which can damage motion and stability prostate and seminal vesicle and sometimes gives off here the
of the hip joint. A. ductus deferentis. In women, it also supplies the vagina, but
can also be missing and is then replaced by the A. vaginalis.
• A. uterina (only in women): before its entrance into the Lig. la-
In contrast, the visceral branches are somewhat different in men tum uteri, the artery crosses over the ureter, before it branches
and women (› Fig. 8.61, › Fig. 8.62): and supplies the uterus, Tuba uterina, ovary and vagina with its
• A. umbilicalis: it gives off the A. vesicalis superior to the uri- respective branches.
nary bladder, which in men usually gives rise to the A. ductus • A. vaginalis (only in women): it supplies the majority of the vagi-
deferentis to the Vas deferens before it is closed ( = Lig. umbili- na and sometimes replaces the A. vesicalis inferior.
cale mediale) and gives rise to the Plica umbilicalis medialis.

Pars abdominalis aortae

A. umbilicalis

A. sacralis mediana
A.; V. vesicalis superior
A. iliaca interna

Ureter dexter A.; V. rectalis superior

A.; V. obturatoria
V. iliaca interna
V. iliaca externa
A.; V. vesicalis inferior
A. iliaca externa
A. ductus deferentis

M. piriformis
Ductus deferens
dexter
M. ischiococcygeus [coccygeus]

Vesica urinaria Plexus venosus rectalis

A.; V. rectalis media Ductus deferens sinister

Ureter sinister
Glandula vesiculosa
A. vesicalis superior
A.; V. rectalis media
V. dorsalis profunda penis
A. vesicalis inferior

M. levator ani
A. dorsalis penis
A.; V. rectalis inferior
Plexus venosus vesicalis A. profunda penis Prostata A.; V. pudenda interna
A.; V. pudenda interna,
Rr. scrotales posteriores

Fig. 8.61 Blood supply of the male pelvic viscera. View from left.

396
 8.8 Vessels and nerves of the extraperitoneal space and pelvic cavity

V. iliaca
interna A. sacralis mediana
A. iliaca interna
A.; V. rectalis superior

A. umbilicalis

A. uterina
A.; V. ovarica

A.; V. rectalis media

Ureter

Ovarium dextrum
Plexus venosus
rectalis
Tuba uterina

Lig. teres uteri;

A. ligamenti teretis uteri A.; V. uterina

A.; V. iliaca externa

Vagina

Uterus
A.; V. rectalis
media
Vesica urinaria A. vaginalis

A. vesicalis
inferior
Ovarium
sinistrum Plexus venosus
vesicalis

M. levator ani

Bulbus vestibuli A.; V. rectalis inferior

Plexus venosus vaginalis

Plexus venosus uterinus Ureter sinister A.; V. pudenda interna

Fig. 8.62 Blood supply of the female pelvic viscera. View from left.

• A. rectalis media: it runs above the pelvic floor to the rectum. from the pelvic viscera. A peculiarity in the pelvic cavity is that the
The vessel is rarely formed on both sides and can even be miss- veins in the vicinity of the individual organs form plexus (Plexus
ing completely. venosi), all of which communicate with each other and also estab-
• A. pudenda interna: it passes through the Foramen infrapiri- lish via the cavocaval anastomoses connections to the superior
forme and then through the Foramen ischiadicum minus into vena cava (V. cava superior). The inferior vena cava ascends to the
the lateral wall of the Fossa ischioanalis (Canalis pudendalis, right in front of the spinal column and passes in the Foramen v. ca-
ALCOCK's canal) Here, it gives off the A. rectalis inferior for the vae through the diaphragm. The vein plexus of the pelvis are
inferior anal canal and then divides gender-specifically into its (› Fig. 8.61, › Fig. 8.62):
superficial and deep terminal branches in order to supply the ex- • Plexus venosus rectalis: this plexus of the rectum is located
ternal genitalia: within the ‘Mesorectum’ and is in contact via the V. rectalis su-
– In men, the superficial A. rectalis inferior supplies the intes- perior with the portal artery circulation and via the Vv. rectales
tine and gives off the Rr. scrotales posteriores to the scrotum. media and inferior with the drainage area of the V. cava inferior
The deep branches supply the penis with its cavernous bodies (portocaval anastomosis).
(A. bulbi penis, A. dorsalis penis, A. profunda penis). • Plexus venosus vesicalis: the venous plexus at the fundus of the
– In women, the superficial A. perinealis runs to the intestine bladder collects blood from the urinary bladder and in men
and gives off the Rr. labiales posteriores to the labia. The deep from the accessory sex glands. In women it also collects blood
branches supply the clitoris with its cavernous bodies and the from the cavernous bodies (V. dorsalis profunda clitoridis).
vulval cavernous body in the Labia majora (A. bulbi vestibuli, • Plexus venosus prostaticus: in men, in addition to the blood of
A. dorsalis clitoridis, A. profunda clitoridis). the prostate, it also takes up blood from the cavernous bodies of
the penis (V. dorsalis profunda penis).
• Plexus venosi uterinus and vaginalis: the plexus around the
8.8.3 Veins of the retroperitoneum and pelvic cavity uterus and vagina collect the blood of both organs.
From these plexus the Vv. rectales mediae , Vv. vesicales and Vv.
The inferior vena cava (V. cava inferior) forms to the right of the uterinae flow outwards into the V. iliaca interna. Included among
aorta at the level of the lumbar vertebra vein through unification of them are the veins which correspond predominantly to the parietal
the two Vv. iliacae communes. Via the Vv. iliacae communes these branches of the A. iliaca interna (Vv. gluteae superiores and inferi-
conduct blood out of the lower limbs and via the V. iliaca interna ores, Vv. obturatoriae and Vv. sacrales laterales).

397
8 Pelvic viscera

Table 8.9 Tributaries from the V. renalis sinistra and the V. cava other. There are, however, bypass circulations (collaterals) that con-
­inferior. nect the two vessels indirectly (cavocaval anastomoses) and if
Tributaries of the Tributaries of the V. cava inferior there is occlusion or compression of one of the two venae cavae the
V. renalis sinistra blood can be redirected accordingly (› Chap. 6.6.3).
• V. phrenica inferi- • Vv. iliacae communes
or (sinistra) • V. sacralis mediana Clinical remarks
• V. testicularis/ • Vv. lumbales
ovarica (sinistra) • V. phrenica inferior dextra, entering left into the The asymmetrical confluence of the left V. testicularis into the
• V. suprarenalis V. renalis left V. renalis can, in the case of a malignant renal carcinoma,
(sinistra) • V. testicularis/ovarica dextra, entering left into the be diagnostically relevant in men. As renal carcinomas tend to
V. renalis spread from the kidneys outwards continuously within the ve-
• V. suprarenalis dextra, entering left into the V. renalis nous system, inflow congestion of the V. testicularis can occur
• Vv. renales dextra and sinistra with an extension of the Plexus pampiniformis in the scrotum,
• 3 Vv. hepaticae (Vv. hepaticae dextra, intermedia and which is referred to as a varicocele (› Fig. 8.43). Therefore, in
sinistra) the case of a left hand varicocele, steps should always be tak-
en to exclude cancer of the kidneys.
The connections of the Plexus prostaticus to the venous plex-
The V. cava inferior corresponds extensively in its tributaries to us of the spinal column (cavocaval anastomoses) explain to
the corresponding branches of the abdominal aorta (› Table 8.9); some extent why, in the case of prostate cancer, spinal metas-
tases often occur, which extend up into the neck area; via spi-
however, there are no veins which correspond to the three un-
nal fractures these can cause injuries to the spinal cord with
paired visceral arteries (Truncus coeliacus, A. mesenterica superi- paraplegia.
or, A. mesenterica inferior), since blood from the unpaired abdom-
inal organs is firstly siphoned via the portal vein (V. portae hepatis)
through the liver. Instead, therefore, the 3 Vv. hepaticae flow into
the inferior vena cava, which conducts all of the blood of the intra-
peritoneal abdominal organs. The second difference is found in an 8.8.4 Lymphatic vessels of the retroperitoneum
asymmetry in the outlet relationship of individual vessels. Whilst and pelvic cavity
on the right-hand side all tributaries flow directly into the inferior
vena cava, on the left 3 vessels merge with the V. renalis (› Ta- Located in the pelvis are the Nodi lymphoidei iliaci interni and
ble 8.9). externi along the respective blood vessels and the Nodi lym-
The superior and inferior vena cava flow directly into the right atri- phoidei sacrales on the anterior surface of the sacrum (› Fig.
um of the heart, so they do not communicate directly with each 8.63). Due to their close topographical relationships, it is not possi-

Nodi lymphoidei gastrici sinistri

V. cava inferior

Nodi lymphoidei
phrenici inferiores

Truncus
intestinalis
Nodi lymphoidei
Cisterna chyli lumbales dextri
Pars abdominalis aortae
Truncus lumbalis
dexter
Nodi lymphoidei Nodi lymphoidei
lumbales intermedii lumbales sinistri

V. cava inferior A. iliaca communis

Ureter
Nodi lymphoidei
V. iliaca communis
iliaci communes
Nodi lymphoidei
iliaci interni

Nodi lymphoidei
iliaci externi Colon sigmoideum

Nodi lymphoidei inguinales

superficiales, Nodi
superolaterales
Nodi lymphoidei inguinales, Nodi lymphoidei inguinales superficiales,
Fig. 8.63 Lymphatic vessels
(Nodi profundi) Nodi superomediales and inferiores and lymph nodes of the retro-
peritoneal space. Ventral view.

398
 8.8 Vessels and nerves of the extraperitoneal space and pelvic cavity

ble to strictly differentiate between parietal lymph nodes for the sides of the V. cava inferior, and as the Nodi lymphoidei lumbales
abdominal wall and visceral lymph nodes for the organs. Thus, the intermedi between both vessels. The lumbar lymph nodes are the
pelvic viscera (rectum, urinary bladder, internal genitalia) are con- collection lymph nodes for:
nected to all of the lymph node groups. • the lower extremities
Via the Nodi lymphoidei iliaci communes the lymph runs out of • the entire pelvic viscera
the pelvis into the parietal lymph nodes of the retroperitoneal • the left side of the large intestine (Colon descendens, Colon sig-
space, which are grouped as the Nodi lymphoidei lumbales. These moideum, rectum, anal canal)
are positioned in 3 chains as the Nodi lymphoidei lumbales sinistri • kidneys and adrenal glands
around the aorta, as the Nodi lymphoidei lumbales dextri to both • testicles/ovaries

N. phrenicus, R. phrenicoabdominalis
dexter and sinister
Truncus vagalis
anterior and posterior

A. phrenica inferior

Aa. suprarenalis superiores

N. splanchnicus major

Plexus coeliacus
with Ganglia coeliaca A. suprarenalis media

N. splanchnicus minor

A. suprarenalis inferior

Plexus renalis
with Ganglia aorticorenalia
A. renalis

Pars abdominalis aortae

Plexus mesentericus superior
with Ganglion mesentericum superius Truncus sympathicus

Plexus testicularis/ovaricus A. mesenterica superior

A. testicularis/ovarica

Plexus mesentericus inferior

with Ganglion mesentericum inferius
Nn. splanchnici
lumbales
A. mesenterica inferior

A. iliaca communis

N. splanchnicus
Plexus hypogastricus sacralis
superior
N. hypogastricus

S2
S3 Nn. splanchnici
S4 pelvici

Plexus hypogastricus inferior Fig. 8.64 Plexus aorticus

with Ganglia pelvica abdominalis with sympathetic
ganglia. [L238]

399
8 Pelvic viscera

The lymphatic pathways of the individual organs and their regional Clinical remarks
lymph nodes are explained together with the individual organs of
The systematics of major lymphatic trunks explain why malig-
the abdominal and pelvic cavities.
nant tumours of the abdominal organs (e.g. gastric cancer) or
Emerging on both sides from the efferent lymphatic pathways of the pelvic viscera (e.g. ovarian cancer) can also cause lymph node
lumbar lymph nodes are the Trunci lumbales, which merge to the metastasis in the area of the left venous angle. These lymph
right of the aorta within the retroperitoneum beneath the dia- node swellings in the left supraclavicular fossa are referred to
phragm with the Trunci intestinales (they collect the lymph of the as VIRCHOW's nodes after the first person to describe them
visceral lymph nodes from the abdominal cavity) into the Ductus and a doctor must always check for tumours in the abdominal
thoracicus. The merging point is often dilated to the Cisterna chyli and pelvic cavities.
(› Fig. 8.63), which, however, is formed very variably. Thus, the
Ductus thoracicus, as the main lymphatic trunk of the body be-
neath the diaphragm guides all of the lymph from the lower half of
the body. It runs dorsal to the aorta at the level of the XII thoracic 8.8.5 Nerves of the retroperitoneum and pelvic cavity
vertebra to the right, through the Hiatus aorticus of the diaphragm,
ascends in the posterior mediastinum and finally enters into the left For the basic structure of the autonomic nervous system, see
venous angle, which is located behind the sternoclavicular joint. › Chap. 7.8.5.
To the anterior in the retroperitoneal space on the abdominal sec-
tion of the aorta is a plexus of the autonomic nervous system
(Plexus aorticus abdominalis), which innervates the abdominal
viscera (› Fig. 8.64, › Fig. 8.65). The aortic plexus at the outlets

Truncus vagalis anterior Oesophagus

Diaphragma

Truncus vagalis N. splanchnicus

posterior major

N. splanchnicus
minor
Ganglia coeliaca
with Plexus coeliacus N. splanchnicus
imus
Truncus coeliacus
A. renalis
Ganglion aorticorenale
Aorta, Pars abdominalis
Ganglion mesentericum superius
with Plexus mesentericus superior
Truncus sympathicus
A. mesenterica superior
A. testicularis with
Ganglion mesentericum inferius
Plexus testicularis
with Plexus mesentericus inferior
A. mesenterica inferior
Ureter with
Plexus uretericus
A. iliaca communis

Plexus hypogastricus
A. iliaca interna
superior
N. obturatorius

Rectum Truncus lumbosacralis

A. epigastrica
inferior Nn. splanchnici
pelvici (S2–S4)
‘Corona mortis’

A. iliaca externa Plexus sacralis

A. obturatoria
N. hypogastricus
Vesica urinaria
Plexus hypogastricus
Prostata inferior
Nn. cavernosi penis N. pudendus

Plexus
rectalis
N. dorsalis penis
Plexus
vesicalis

Plexus
prostaticus Fig. 8.65 Plexus hypogastricus
inferior. [L238]

400
 8.9 Pelvic floor and perineal region

of the visceral vascular branches is further divided into eponymous 8.9 Pelvic floor and perineal region
sections:
• Plexus coeliacus
• Plexus mesentericus superior
Skills
• Plexus mesentericus inferior After working through this chapter, you should be able to:
• Plexus renalis • explain the construction, innervation and function of the
• Plexus testicularis/ovaricus pelvic floor and show its parts on a specimen
These autonomic plexus contain sympathetic and parasympathetic • distinguish between the perineum and perineal region
• explain the different development of perineal muscles and
nerve fibres. The sympathetic nerve fibres originate mainly from
perineal spaces in both sexes
the thoracic section of the sympathetic trunk (Truncus sympathicus) • describe the boundary and contents of the Fossa ischioana-
and as the Nn. splanchnici major and minor pass through the dia- lis on a specimen and understand their clinical relevance
phragm (› Fig. 8.64, › Fig. 8.65). In addition, from the abdominal
section of the sympathetic trunk neurons run as the Nn. splanchnici
lumbales up to the plexus on the Aorta. The parasympathetic neu-
rons run as the Trunci vagales together with the oesophagus through
the diaphragm and are the terminal branches of the Nn. vagi. 8.9.1 Overview
From the Plexus aorticus abdominalis outwards the nerve fibres in
the abdominal cavity reach their target organs mainly as periarterial The pelvic cavity (› Chap. 8.7) is delineated caudally by the mus-
plexus, which each form an organ-specific plexus at the respective cular pelvic floor (Diaphragma pelvis). Included in it is the peri-
organs. As in all sections of the autonomic nervous system, the viscer- neal region (Regio perinealis) in the posterior section of which on
al efferent to the effector organ consists of 2 neurons, whereby the both sides the Fossa ischioanalis is located, whilst the anterior sec-
preganglionic neuron originates in the central nervous system and is tion with the superficial (Spatium superficiale perinei) and the
converted synaptically within a ganglion into the so-called postgan- deep perineal spaces (Spatium profundum perinei) is divided
glionic neuron. Whilst the parasympathetic neurons are first convert- into 2 levels, which contain the perineal muscles to support the
ed in close vicinity to the organs and thus pervade the plexus of the pelvic floor. The anatomy of the pelvic floor is particularly relevant
Plexus aorticus abdominalis as preganglionic neurons, the sympa- in gynaecology, since the pelvic floor and muscles of the perineal
thetic neurons are converted into ganglia away from the organs and region can be damaged during pregnancy and childbirth. Since
are located at the eponymous vascular outlets of the abdominal aorta. these muscles are of central importance for faecal continence, their
The ganglia of the Plexus aorticus abdominalis are (› Fig. 8.64, topographical relationships are also important for visceral sur-
› Fig. 8.65): geons.
• Ganglia coeliaca
• Ganglion mesentericum superius
• Ganglion mesentericum inferius 8.9.2 Pelvic floor
• Ganglia aorticorenalia
In the pelvis, the Plexus aorticus abdominalis continues as the The pelvic floor (Diaphragma pelvis) is a plate of striated muscles,
Plexus iliacus on the A. iliaca communis and as the Plexus hypo- which complete the pelvic cavity caudally. The pelvic floor has the
gastrici superior and inferior to supply the pelvic organs (› Fig. same construction in both sexes.
8.65). Whilst the sympathetic neurons to some extent continue Function: the pelvic floor stabilises the position of the pelvic or-
from the abdomen and derive additionally as the Nn. splanchnici gans and thus ensures urinary and faecal continence.
sacrales from the pelvic section of the sympathetic trunk, all para- The muscles of the pelvic floor are (› Fig. 8.66, › Table 8.10):
sympathetic nervous originate as Nn. splanchnici pelvici from the • M. levator ani, which comprises the M. pubococcygeus, M. ilio-
sacral spinal cord (S2–4). coccygeus and M. puborectalis.
The sympathetic and parasympathetic neurons are converted • M. ischiococcygeus
(Ganglia pelvica) in the ganglia of the Plexus hypogastricus inferi- In contrast to the M. pubococcygeus and the M. ischiococcygeus,
or and reach the pelvic organs largely autonomously and thus inde- the M. iliococcygeus does not originate from the hip bone but from
pendently of the blood vessels. the Arcus tendineus musculi levatoris ani, which constitutes a re-
The Plexus hypogastricus inferior is embedded on both sides be- inforcement of the fascia of the M. obturator internus on its superi-
tween the Fascia pelvis visceralis, which surrounds the ‘Mesorec- or surface.
tum’, and the Fascia pelvis parietalis on the bony pelvis in the con- Individual muscle fibres of the M. pubococcygeus run to the anal
nective tissue of the subperitoneal space (› Fig. 8.65; also › Fig. canal and to the prostate or the vagina and are therefore corre-
8.19). In women, the plexus is thus located in the Lig. rectouteri- spondingly referred to as the M. puboanalis, M. prostaticus,
num between the Cervix uteri and rectum, which raises a peritone- M. vaginalis or collectively as the ‘M. pubovisceralis’.
al fold, which, as the Plica rectouterina marks the entrance to the On its anterior surface, the pelvic floor has contact with the uri-
Excavatio rectouterina (DOUGLAS' pouch). nary bladder, rectum, prostate or vagina.
The pelvic floor muscles of both sides leave a space (‘Hiatus
NOTE ­levatorius’) between them, which is divided by the connective
• The autonomous plexus on the abdominal aorta contain sympa- ­tissue of the Corpus perineale (Centrum perinei) into a Hiatus
thetic and parasympathetic nerve fibres. In contrast, only sympa- urogenitalis (anterior) as a passageway for the urethra and in
thetic fibres are located in the ganglia, which are converted syn- women for the vagina, as well as into a ‘Hiatus analis’ (posterior)
aptically from preganglionic to postganglionic neurons. for the rectum. The M. puborectalis forms a loop around the rec-
• The Plexus hypogastricus inferior in the pelvis, in contrast, has
both sympathetic and parasympathetic ganglia, in which the
tum and due its tone induces the development of the Flexura peri-
nerve fibres are converted close to the organs. nealis, which thus constitutes part of the continence organ
(› Chap. 8.4.4).

401
8 Pelvic viscera

Symphysis pubica Hiatus urogenitalis

Hiatus levatorius
Hiatus analis
Linea terminalis
Canalis obturatorius
Corpus ossis pubis M. levator ani,
M. pubococcygeus
M. obturatorius M. levator ani,
internus M. iliococcygeus
Arcus tendineus
musculi levatoris ani

M. ischiococcygeus
Os sacrum [coccygeus]

Foramen ischiadicum
majus

Lig. sacrotuberale

Os ilium
Fig. 8.66 Pelvic floor, diaphrag-
ma pelvis, female. Cranial view.

Table 8.10 Muscles of the pelvic floor (Diaphragma pelvis).

Innervation Origin Attachment Function

M. levator ani
Plexus sacralis (S3–S4) • M. pubococcygeus: inner surface of the • Centrum tendineum perinei, Stabilises the pelvic organs, hence facilitates
Os pubis near the symphysis Os coccygis, Os sacrum ­ rinary and faecal continence, encompasses the
u
• M. iliococcygeus: Arcus tendineus • Loop formation with fibres of the rectum from behind, hence distal rectal occlusion
musculi levatoris ani opposite side behind the anus (M. puborectalis)
(M. puborectalis)
M. ischiococcygeus
Plexus sacralis (S3–S4) Spina ischiadica, Lig. sacrospinale Os coccygis, Os sacrum Same as the M. levator ani

The pelvic floor is innervated by direct branches from the Plexus NOTE
• Perineal region (Regio perinalis): whole area between the pubic
sacralis (S3–S4). Only the M. puborectalis is also supplied by the symphysis and coccyx
N. pudendus. Blood comes from various branches of the A. iliaca • Perineum: narrow section between the posterior margin of the La-
interna (A. glutea inferior, A. vesicalis inferior and A. pudenda in- bia majora/root of penis and the anus
terna).

Clinical remarks Clinical remarks

During childbirth uncontrolled tearing of the skin and muscles
In women, weakness of the pelvic floor (pelvic floor insuffi-
of the perineum up to the sphincters of the anus (perineal fis-
ciency) is much more common than in men, because the pel-
sures) can occur, which in some cases can be prevented by
vic floor is strained during pregnancy and childbirth, during
targeted incisions laterally or in the median plane (perineal
which the levator is greatly stretched. As a result, there can
incision) (episiotomy).
ensue a drop (descent) or a prolapse of the uterus and vagina.
Since the uterus is connected to the posterior wall of the uri-
nary bladder and the vagina is connected to the anterior sur-
face of the rectum, this is often associated with a prolapse of The perineal region can be divided into an anterior Regio urogen-
the urinary bladder (cystocele) and the rectum (rectocele) and italis with sexual organs and urethra and a posterior Regio analis
thus urinary and faecal incontinence (› Fig. 8.67). around the anus (› Fig. 8.68, › Fig. 8.69). Both areas include
spaces:
• Regio analis:
– Fossa ischioanalis
8.9.3 Perineal region • Regio urogenitalis
– Superficial perineal space (Spatium superficiale perinei)
Located underneath the pelvic floor is the perineal region (Regio – Deep perineal space (Spatium profundum perinei)
perinealis), which stretches from the pubic symphysis (Symphysis
pubica) to posterior up to the apex of the coccyx , (› Fig. 8.68, Fossa ischioanalis
› Fig. 8.69). In contrast, the term perineum describes only the The Fossa ischioanalis is a pyramid-shaped space filled with fat on
narrow connective tissue bridge between the posterior margin of both sides of the anus, which is very similarly formed in both sexes
the Labia majora (in women) or the root of penis (in men) and the (› Fig. 8.68, › Fig. 8.69). Its boundaries are set out in › Ta-
anus. The taut connective tissue between the anus and coccyx is re- ble 8.11. Located in the lateral wall within a fascial duplicature on
ferred to as the Lig. anococcygeum.

402
 8.9 Pelvic floor and perineal region

a Cystocele b Cystocele

Fig. 8.67 Pelvic floor weakness.

When the stabilising function of
the pelvic floor fails, the posteri-
or wall of the urinary bladder or
the anterior wall of the rectum
can prolapse. a, b Prolapse of
the urinary bladder wall with
cystocele and incontinence. The
cystocele is visible vaginally, by
which the dorsal shadow should
indicate that it concerns the uri-
nary bladder wall. c, d Protru-
sion of the anterior wall of the
rectum with rectocele and faecal
incontinence. The rectocele is
c Rectocele d Rectocele
visible vaginally, the shadow is
shown here ventrally. [L266]

the inferior side of the M. obturatorius internus is the Canalis pu- The vessels and nerves run through the Foramen ischiadicum mi-
dendalis (ALCOCK’s canal). The Fossa ischioanalis contains: nus out of the Regio glutealis via ALCOCK's canal into the Fossa
• A. and V. pudenda interna ischioanalis.
• N. pudendus

Table 8.11 Delineation of the Fossa ischioanalis.

Clinical remarks
The Fossa ischioanalis has significant clinical relevance be-
Delineation Structures
cause of its expansion on both sides of the anus. Abscesses,
Medial and cranial M. sphincter ani externus and M. levator ani e.g. in the case of fistulas from the anal canal, can expand in
Lateral M. obturator internus
the whole Fossa ischioanalis right up to anterior to the pubic
symphysis. Besides non-specific symptoms of inflammation,
Dorsal M. gluteus maximus and Lig. sacrotuberale these kinds of abscesses are only detected due to intense
Ventral Posterior border of the superficial and the deep perineal pressure pain in the perineal region.
space, extensions stretch up to the symphysis
Caudal Fascia and skin of the perineum

403
8 Pelvic viscera

Corpus spongiosum penis

M. bulbospongiosus
Raphe perinei
M. ischiocavernosus
Glandula bulbourethralis
Membrana
perinei
M. transversus Regio
perinei profundus urogenitalis

Fascia
obturatoria
M. transversus
perinei superficialis Regio
perinealis

Fascia obturatoria
Regio
analis

Lig. sacrotuberale
Canalis
pudendalis
Anus Fossa ischioanalis

M. gluteus maximus Perineum

M. levator ani M. sphincter

Os coccygis Lig. anococcygeum ani externus

Fig. 8.68 Perineal region, Regio perinealis, male. Caudal view; after removal of all vascular, lymphatic and nervous systems.

Ostium urethrae externum

Labium Ostium vaginae;
minus pudendi Carunculae hymenales
Glandula vestibularis
major, (Ostium)
M. bulbospongiosus
Regio
M. ischiocavernosus
Raphe perinei urogenitalis

M. bulbospongiosus Membrana
perinei Regio
M. transversus perinealis
Perineum perinei
superficialis
Regio
Lig. sacrotuberale Fascia analis
obturatoria
Canalis
Fascia obturatoria pudendalis

M. sphincter
Fossa ischioanalis ani externus
M. levator ani
M. gluteus maximus Anus
Os coccygis
Lig. anococcygeum

Fig. 8.69 Perineal region, Regio perinealis, female. Caudal view; after removal of all vascular, lymphatic and nervous systems.

Deep and superficial perineal space Perineal spaces in men

Ventrally of the Fossa ischioanalis the perineal spaces form 2 lev- In men, the Hiatus urogenitalis between the two levator muscles on
els, which differ in structure and contents in both sexes (› Ta- bothsides, is closed largely by the underlying perineal muscles, so
ble 8.12): that only the passageway of the urethra remains free.
• The deep perineal space (Spatium profundum perinei) is delin- In men, the perineal muscles consist of a relatively strong M. trans-
eated caudally by the Membrana perinei (reinforced fascia of the versus perinei profundus, at the posterior edge of which is located
M. transversus perinei profundus) and contains the M. transver- the thin M. transversus perinei profundus (› Fig. 8.70, › Table
sus perinei profundus, which is distinctly formed in men, but 8.13). Since these muscles form a kind of muscle plate, they used
only weakly in women, and the M. sphincter urethrae externus. to be compared with the term ‘Diaphragma urogenitale’ to the
• Located in the superficial perineal space (Spatium superficiale ­Diaghragma pelvis of the pelvic floor; however, since there is no
perinei), which is delineated cranially by the Membrana perinei real diaphragm and a comparable muscle plate in women is not
and caudally by perineal fascia (Fascia perinei) are the M. trans- usually present, the term ceased to be used in anatomy; however, it
versus perinei superficialis, the M. bulbospongiosus and the continues to be used in clinical language.
M. ischiocavernosus, which in men stabilise the cavernous bodies On its superior and inferior surfaces the M. transversus perinei
of the root of the penis and support erection and ejaculation. In profundus is covered by a fascia. It is reinforced on the underside
women they cover the cavernous bodies of the vulva and clitoris. and is referred to here as the Membrana perinei.

404
 8.9 Pelvic floor and perineal region

Symphysis pubica

V. dorsalis profunda penis

A.; N. dorsalis penis Lig. pubicum inferius
Urethra masculina Lig. transversum perinei
Glandula bulbourethralis M. sphincter urethrae externus
M. transversus perinei profundus Ductus glandulae bulbourethralis
A.; V. bulbi penis M. transversus perinei profundus
A.; V. perinealis Membrana perinei
N. perinealis Ramus ossis ischii
A.; V. pudenda interna
N. pudendus

M. transversus Fig. 8.70 Perineal muscles,

perinei superficialis male. Caudal view; after removal
of all other muscles.

Os pubis,
Ramus superior Symphysis pubica

V. dorsalis profunda clitoridis

A.; N. dorsalis clitoridis Lig. pubicum inferius
Os pubis, Ramus inferior Lig. transversum perinei
M. sphincter urethrae externus
A. bulbi vestibuli
Urethra feminina
Ramus ossis ischii Membrana perinei

Vagina
Fig. 8.71 Perineal muscles,
female. Caudal view; after
removal of all other muscles.

Table 8.12 Content of the Perineum.

The space between the two fascia, which is almost completely filled
Shared content Content, male Content, female by the M. transversus perinei profundus, is the deep perineal
space. In men, in addition to the urethra, this contains COWPER’s
Spatium profundum perinei
glands (Glandulae bulbourethrales) and is traversed by the deep
• Deep terminal • M. transversus perinei • M. sphincter urethrovagi- branches of the N. pudenus and the A. and V. pudenda interna on
branches of the profundus and nalis (M. transversus
its way to the root of the penis (› Table 8.12). The Nn. cavernosi
A./V. pudenda M. sphincter urethrae perinei profundus)
interna and externus penis penetrate the deep perineal space and enter into the cavern-
N. pudendus ous bodies of the penis. The superficial perineal space attaches
• Urethra • Vagina with confluence
of the urethra
caudally to the Membrana perinei and contains the superficial
­perineal muscles (M. transversus perinei superficialis, M. ischio-
• Nn. cavernosi penis • Nn. cavernosi clitoridis
cavernosus, M. bulbospongiosus) as well as the superficial vessels
(parasympathetic fibres
to the erectile tissue) and nerves.
• Glandulae bulboure-
thrales (COWPER)
Perineal spaces in women
In women the deep perineal space is filled predominantly by con-
Spatium superficiale perinei
nective tissue and by individual muscle fibres of the M. transversus
• Superficial terminal • Crura penis • Crura clitoridis perinei profundus (› Fig. 8.71, › Table 8.13). Although the mus-
branches of the cle is usually not highly developed, the Membrana perinei is pres-
• Bulbus penis • Bulbus vestibuli
A./V. pudenda
interna and • Glandulae vestibulares ent as a dense connective tissue layer and allows demarcation of
N. pudendus majores (BARTHOLIN) the two perineal spaces. The deep perineal space contains the pas-
• M. transversus sageway of the vagina and urethra. As in men, it is pervaded by the
perinei superficial- N. pudendus and by the deep branches of the A. and V. pudenda
is, M. bulbospon- interna (› Table 8.12). The Nn. cavernosi clitoridis reach the cav-
giosus, M. ischio- ernous bodies of the clitoris.
cavernosus

405
8 Pelvic viscera

Table 8.13 Perineal muscles

Innervation Origin Attachment Function

M. transversus perinei profundus
N. pudendus Ramus inferior ossis pubis Centrum tendineum perinei Secures the levator hiatus
(plexus sacralis)
M. sphincter urethrae externus (part of the M. transversus perinei profundus)
N. pudendus Annular muscle, fibres from the M. trans- • Connective tissue around the urethra (Pars • Closure of the urethra
(Plexus sacralis) versus perinei profundus membranacea) • Closure of the urinary bladder during ejacu-
• Vaginal wall (M. sphincter urethrovaginalis) lation
M. transversus perinei superficialis (inconstant muscle)
N. pudendus Ramus ossis ischii Centrum tendineum perinei Supports the M. transversus perinei profun-
(Plexus sacralis) dus
M. ischiocavernosus
N. pudendus Ramus ossis ischii Crus penis/clitoridis Stabilisation of cavernous body, ejaculation
(Plexus sacralis)
M. bulbospongiosus
N. pudendus • Centrum tendineum perinei Encompasses the Bulbus penis and the Bul- Stabilisation of cavernous body, ejaculation
(Plexus sacralis) • In men, additionally at the Raphe penis bus vestibuli

The superficial perineal space stretches between the Membrana

Uterus perinei and the perineal fascia (Fascia perinei). In addition to the
M. transversus perinei superficialis, it also contains the flanks of
the cavernous bodies of the clitoris and the cavernous body of the
vestibule of the vagina (Bulbus vestibuli) with its enveloping mus-
cles (M. ischiocavernosus or M. bulbospongiosus) as well as the
Glandulae vestibulares majores (BARTHOLIN's glands).
Vesica In both sexes, the M. transversus perinei profundus also forms the
urinaria
M. sphincter urethrae externus, which constitutes the voluntary
sphincter of the urinary bladder (› Fig. 8.70, › Fig. 8.71, › Ta-
M. sphincter
Vagina ble 8.13). As the M. urethrovaginalis in women it also encompass-
urethrae externus es the vagina (› Fig. 8.72).
M. transversus
perinei profundus
Urethra

M. sphincter
urethrovaginalis

Fig. 8.72 Voluntary sphincters of the urinary bladder.

406
HEAD
AND
NECK
9 Head
10 Neck
9 Head
9.1 Skull 9.4 Eye
Lars Bräuer . . . . . . . . . . . . . . . . 411 Michael Scholz . . . . . . . . . . . . . 459
9.1.1 Neurocranium 9.4.1 Embryology . . . . . . . . . . . . . . . 460
and viscerocranium . . . . . . . . 411 9.4.2 Protective and auxiliary
9.1.2 Skull development – structures of the eye . . . . . . . . 461
Embryology . . . . . . . . . . . . . . . 411 9.4.3 Orbita . . . . . . . . . . . . . . . . . . . . 465
9.1.3 Calvaria . . . . . . . . . . . . . . . . . . 413 9.4.4 Bulbus oculi . . . . . . . . . . . . . . 472
9.1.4 Base of the skull . . . . . . . . . . . 414
9.1.5 Individual bones 9.5 Ear
of the viscerocranium . . . . . . 418 Friedrich Paulsen . . . . . . . . . . . 477

9.1.6 Individual bones 9.5.1 Embryology . . . . . . . . . . . . . . . 478

of the neurocranium . . . . . . . . 422 9.5.2 External ear . . . . . . . . . . . . . . . 478
9.5.3 Middle ear . . . . . . . . . . . . . . . . 481
9.2 Soft tissue covering
Lars Bräuer, Friedrich Paulsen . 424 9.5.4 Internal ear . . . . . . . . . . . . . . . 488

9.2.1 Overview 9.6 Nose

Friedrich Paulsen . . . . . . . . . . . 424 Friedrich Paulsen . . . . . . . . . . . 491
9.2.2 Scalp . . . . . . . . . . . . . . . . . . . . 425 9.6.1 Overview . . . . . . . . . . . . . . . . . 492
Friedrich Paulsen . . . . . . . . . . . 425
9.6.2 Development . . . . . . . . . . . . . . 492
9.2.3 Face and facial soft tissue
Lars Bräuer, Friedrich Paulsen . 428 9.6.3 External nose . . . . . . . . . . . . . 493

9.2.4 Superficial lateral facial region 9.6.4 Nasal cavities . . . . . . . . . . . . . 495

Friedrich Paulsen . . . . . . . . . . . 436 9.6.5 Paranasal sinuses . . . . . . . . . . 499
9.2.5 Deep lateral facial region . . . . 439 9.6.6 Vascular, lymphatic and
nervous systems . . . . . . . . . . . 500
9.3 Cranial nerves
Lars Bräuer . . . . . . . . . . . . . . . . 443 9.7 Oral cavity, masticatory
9.3.1 N. olfactorius [I] . . . . . . . . . . . 444 apparatus, tongue, palate, floor
of the mouth, salivary glands
9.3.2 N. opticus [II] . . . . . . . . . . . . . . 445 Wolfgang H. Arnold . . . . . . . . . 502
9.3.3 N. oculomotorius [III] . . . . . . . 445 9.7.1 Oral cavity . . . . . . . . . . . . . . . . 503
9.3.4 N. trochlearis [IV] . . . . . . . . . . 446 9.7.2 Masticatory apparatus – teeth . 506
9.3.5 N. trigeminus [V] . . . . . . . . . . 447 9.7.3 Masticatory apparatus –
9.3.6 N. abducens [VI] . . . . . . . . . . . 449 Masticatory muscles . . . . . . . 512
9.3.7 N. facialis [VII] . . . . . . . . . . . . . 449 9.7.4 Masticatory apparatus –
9.3.8 N. vestibulocochlearis [VIII] . . 453 temporomandibular joint . . . . 514

9.3.9 N. glossopharyngeus [IX] . . . 454 9.7.5 Tongue . . . . . . . . . . . . . . . . . . 516

9.3.10 N. vagus [X] . . . . . . . . . . . . . . 455 9.7.6 Palate . . . . . . . . . . . . . . . . . . . . 520

9.3.11 N. accessorius [XI] . . . . . . . . . 457 9.7.7 Floor of the mouth . . . . . . . . . 524

9.3.12 N. hypoglossus [XII] . . . . . . . . 457 9.7.8 Lymphatic pathways

of the oral cavity . . . . . . . . . . . 526
9.7.9 Salivary glands . . . . . . . . . . . . 526
 CLINICAL CASE

Epidural haematoma

Accident Pathogenesis
A 23-year-old male student is cycling to university without wearing a On impact with the front windscreen of the car the patient has
safety helmet. At an intersection, shortly before reaching the suffered a fracture in the area of the pterion, fracturing the inner hard
auditorium, he is hit by a car. He hits the front windscreen of the car bone layer of the calvaria (Lamina vitrea) creating sharp-edged
with the side of his head. After a brief loss of consciousness of less fracture elements: the outer skull bone, on the other hand, is not
than 20 seconds, he regains consciousness, reacts to speech and fractured. Through the jagged bone fragments, the A. meningea
has no impairments except for pain in his leg and a haematoma on media (between the dura mater and cranial bone) was injured, which
the left temple: he can stand up, does not want an ambulance and resulted in arterial bleeding. Due to the pressure of the bleeding the
opts for a short recovery pause on a bench in front of the auditorium dura mater has slowly become detached in a circumscribed area from
building; however, within the next half an hour he becomes extreme- the cranial bone, which in turn has led to an intracranial space-occu-
ly sleepy and is no longer responsive. Other students call an pying lesion. The symptom-free interval, which caused the patient to
ambulance which brings him as fast as possible to the nearby waive an ambulance, is typical for this type of injury.
emergency department of the university hospital.

Treatment
Diagnosis
The student is immediately brought into the operating room and the
In the emergency room the student's respiration suddenly severely skull is opened (trepanation). Then the treating trauma surgeon
deteriorates, necessitating an emergency intubation. The doctors (neurosurgeon) clears out the haematoma, seals off the source of
immediately arrange a head CT scan, on which the radiologist bleeding and reinserts the removed bone fragment. The patient
determines an intracranial lens-shaped (biconvex) area in the left remains in the ICU after surgery for 2 days, followed by 1 week in the
half of the head. Based on the findings, the radiologist diagnoses an hospital for observation. After 2 weeks all cerebral deficits, which
epidural haematoma, width approx. 3 cm, with midline shift. were caused by the lesion, have receded. He can continue studying,
but has decided to wear a helmet when riding his bicycle from now on.

You're in your 3rd year at university and as a fellow student, you have witnessed the accident.
In hindsight, you wonder if the bleeding could have been detected faster on the basis
of the symptoms. You are under the impression that it is not so easy to tell the characteristics
of a cerebral haemorrhage apart and therefore you draw an overview map of the topic.

Cerebral haemorrhages and how I recognise them

Epidural haematoma
Fracture of the skull bone → injury to vessels of the dura:
Often A. meningea media cha
r
epid acteris
Typical: (symptom-) free interval u
sub ral: a ics:
t
dur rter
In CT: hyperdense, (Bi)convex expansion al: v ial b
eno l
us b eeding
Subdural haematoma l eedi
ng
Acute: Chronic: after a mild trauma
usually tear of Bridging veins trauma, often can't remember,
Within 72 h after trauma even weeks after
Symptoms very variable, rapid promotion of anticoagulation
Vigilance reduction possible. Headache, change in character
CT: hyperdense, crescent-shaped, Memory impairment, etc.
Extra-cerebral expansion CT: sickle-shaped, hypodense
 9.1 Skull

The head (Caput) encloses organs with very different functions. – Inferior nasal concha (Concha nasalis inferior), paired
The bony basis is the skull, which surrounds the brain and the large – Lower jaw (Mandibula), unpaired
remote sensory organs: On the neurocranium the skull roof (Calvaria) can be morpho­
• Visual organ logically differentiated from the skull base (Basis cranii). The skull
• Hearing organ is used to hold and protect the brain and also includes parts of the
• Vestibular organ outer ear, the middle ear and the inner ear (› Chap. 9.1.6).
• Olfactory organ The viscerocranium forms the basis for the face (› Chap. 9.1.5).
• Gustatory sense Strictly speaking the incisive bone of the Maxilla (Os incisivum)
The respiratory and the digestive tracts begin in the head. Together should be listed with the abovementioned bones; however, it merg­
with the nose paranasal sinuses, the mouth, throat and masticatory es in utero with the Maxilla.
apparatus make a significant contribution to the shape of our face.
­Humans additionally use the oral cavity and its organs for articula­
tion, speech and singing. The head is movable and sits on the cervi­ 9.1.2 Skull development – Embryology
cal spine. The Protuberantia occipitalis externa (see below) on the
back of the skull, the base of the ears and the mandible mark the Desmocranium and chondrocranium
boundary between the head and the neck. When the skull is being divided functionally into neurocranium
and viscerocranium, a distinction can be made embryologically ac­
cording to the ossification mode of the individual bones between a
9.1 Skull desmocranium and a chondrocranium:
Lars Bräuer • In the case of desmal ossification bones emerge directly from an
embryonal connective tisue precursor.
• In contrast, in chondral ossification bones initially develop via
Skills the intermediate stage of a cartilage scaffold, which is later con­
verted to bone and mineralised by differentiation processes.
After working through this chapter, you should be able to: The construction material is, however, the same for both forms of
• outline the development of the skull and its bones ossification, namely the cranial mesenchyme, which comes from the
• name sutures and fontanelles (closure times)
the paraxial cranial mesoderm, the prechordal mesoderm, occipital
• outline the principal structure of the skull and of the facial
bones, as well as their connections to each other somites and the neural crest. The auditory ossicles hammer (Malle­
• know the structure of the neurocranium, viscerocranium, us) and anvil (Incus) are created as a continuation of ­MECKEL's
base of the skull, calvaria and Fossae cranii c­ artilage (1st pharyngeal arch) and the stirrup (Stapes) from
• name the major points of penetration, foramina, fissures, ­REICHERT's cartilage (2nd pharyngeal arch) – this is a purely chon­
impressions of the inner and outer surfaces of the skull base dral ossification mode. The Concha nasalis inferior and the Os eth­
moidale are also created purely chondrally (› Table 9.1). The Maxil­
la, Os zygomaticum, Os palatinum, Os nasale, Vomer, Os lacrimale,
Os frontale and Os parietale are created from desmal ossification
9.1.1 Neurocranium and viscerocranium (› Table 9.1). Mixtures of both ossification modi can be found in
the Os sphenoidale, Os temporale and Os occipitale (› Table 9.2).
The bony skull (Cranium) with the exception of the 3 auditory os­
sicles and the mandible is composed by of 22 single bones, which
are connected to one another by sutures. The mandible (Mandibula) Table 9.1 Ossification forms of the skull bones
articulates with the remaining skull in the paired temporomandi­ Bones Ossification mode
bular joint (Articulatio temporomandibularis) and can thus be
moved against the skull. Embryologically and functionally, the Maxilla Desmal

skull is divided into two portions: Mandibula Desmal (except Proc. condylaris)
• Skull (neurocranium): Os zygomaticum Desmal
– Temporal bone (Os temporale), paired Os palatinum Desmal
– Hammer (Malleus), anvil (Incus) and stirrup (Stapes) =
Os nasale Desmal
­auditory ossicles
– Parietal bone (Os parietale), paired Vomer Desmal

– Parts of the frontal bone (Os frontale), unpaired Os lacrimale Desmal

– Sphenoid bone (Os sphenoidale), unpaired Os frontale Desmal
– Ethmoid bone (Os ethmoidale), unpaired Os parietale Desmal
– Occipital bone (Os occipitale), unpaired
Os ethmoidale Chondral
• Facial skeleton (viscerocranium or splanchnocranium):
– the orbital parts of the frontal bone (Os frontale), unpaired Concha nasalis inferior Chondral
– Zygomatic bone (Os zygomaticum), paired Os temporale Chondral (except Pars squamosa and Proc. styloideus)
– Upper jaw (Maxilla), paired Os sphenoidale Chondral (except Lamina medialis)
– Lacrimal bone (Os lacrimale), paired
Os occipitale Chondral (except Pars squamosa)
– Nasal bone (Os nasale), paired
Malleus (hammer) Chondral from MECKEL's cartilage
– Palantine bone (Os palatinum), paired
– Vomer, unpaired Incus (anvil) Chondral from MECKEL's cartilage
Stapes (stirrup) Chondral from REICHERT's cartilage

411
9 Head

Table 9.2 Mixtures of ossification modi Table 9.3 Fontanelles.

Bones Parts Fontanelle Number Closure Location

Os sphenoidale Lamina medialis: desmal, remaining parts: chondral Fonticulus Unpaired 24th–36th month Between the two frontal and
anterior parietal bones, at the inter-
Os temporale Partes petrosa and tympanica: chondral, Pars squamo-
(front, large face between Sutura coronalis
sa: desmal, Proc. styloideus: of 2nd pharyngeal arch
fontanelle) and sagittalis (› Fig. 9.1a)
Os occipitale Pars squamosa: desmal, Partes laterales and Pars
Fonticulus Unpaired 2nd–3rd month Between the two parietal
basilaris: chondral
posterior bones and the occipital bone,
(posterior, at the interfaces of the Sutu-
The Mandibula is initially created as a cartilaginous continuation small fonta- rae sagittalis and lambdoidea
of the 1st pharangeal arch (MECKEL's cartilage), this then recedes nelle) (› Fig. 9.1b)
and the Mandibula is created from desmal ossification up to the Fonticulus Paired 5th–7th month Laterally between the frontal
Proc. condylaris (chondral) (› Table 9.1). sphenoidalis and parietal bones, as well as
(sphenoidal the large sphenoidal bone
fontanelle) wings (› Fig. 9.1b)
NOTE
The main part of the skull base develops from chondral ossifica- Fonticulus Paired 17th–20th month Laterally between parietal,
tion, the main part of the calvaria and facial skeleton by desmal os- mastoideus temporal and occipital bones
sification. (posterolater- and the Proc. mastoideus
al fontanelle) (› Fig. 9.1b)

Fontanelles bone edges come together, the sutures are expanded to fontanelles
At the time of birth and also a certain amount of time afterwards, (Fonticuli) and filled with connective tissue (› Table 9.3, › Fig.
the roof bones of the calvaria are separated from each other within 9.1). A distinction is made between 2 unpaired main fontanelles
the sutures by connective tissue – these ossify over the course of and 2 paired, smaller fontanelles that allow a slight deformation of
life through desmal ossification (› Chap. 9.1.3). If more than 2 the skull during parturition.

Fonticulus anterior Os parietale

(Sutura frontalis) Sutura coronalis

Os frontale, Tuber frontale

Maxilla, Proc. frontalis

Foramen supraorbitale
Os nasale
Os sphenoidale, Ala major Os temporale
Septum nasi osseum
Foramen infraorbitale Os zygomaticum
Dens deciduus
Maxilla Mandibula
Foramen mentale
a (Symphysis mandibulae)

Fonticulus anterior

Sutura coronalis

Os frontale, Tuber frontale

Os parietale, Tuber parietale
Fonticulus sphenoidalis

Fig. 9.1 Skull of a neonate with

Fonticulus posterior
fontanelles. The viscerocranium
Squama occipitalis is still much smaller than the
Mandibula neurocranium; during the devel-
Sutura lambdoidea
opment to an adult skull these
proportions will balance out or
Os temporale, Pars squamosa Fonticulus mastoideus be reversed due to the rapid
b Os temporale, Pars petrosa growth of the viscerocranium.
a Frontal view. b Lateral view.

412
 9.1 Skull

Clinical remarks bone plates. Often only the Lamina interna splinters. It can
lead to injury of the meninges and the brain. If the trauma af-
Disturbances of bone growth are summarised under the term fects a wider area of the skull, there are generally burst frac-
dysostosis. In the case of premature closure of cranial sutures tures (e.g. after falling on the head).
(craniosynostosis), this often leads to an disproportional
growth of the skull. If e.g. the Sutura coronalis ossifies prema-
turely, a tower skull (Turricephalus) or pointed skull (Oxyceph-
alus) is formed. If the Sutura sagittalis or the Sutura frontalis Sutures
closes prematurely, this results in a fragile skull (Scaphoce­ The bones of the skull are fused together with sutures (cranial
phalus) or a triangle skull (Trigonocephalus). If the Suturae seams, loose connective tissue seams, are among the syndesmoses,
lambdoidea and coronalis only close prematurely on one side,
false joints), which are particularly easy to determine on the bony
there is asymmetric skull growth. The skull is deformed by this
(unbalanced skull, Plagiocephalus). If the majority of the skull (macerated) skull in the area of the calvaria (› Fig. 9.2, also
sutures ossify too early, this may cause arrest of growth with › Fig. 9.9). The sagittal suture runs in the median line in which
formation of a microcephalus associated with a disruption of the two parts of the parietal bone are connected (Sutura sagittalis),
the brain growth and mental retardation. which is connected frontal vertically with the coronal suture (Su­
tura coronalis) and occipitally with the lambda suture (Sutura lamb­
doidea). The point of contact between the coronal suture and the
sagittal suture is referred to as the bregma and the contact point
9.1.3 Calvaria between the sagittal suture and the lambdoid suture as the lambda
(› Fig. 9.2). An anatomical variant is the interparietal bone (inca
The roof of the skull (Dome, calvaria) includes: bone, Os incae, Os interparietale ). This is an accessory bone (su­
• both Ossa parietalia tural bone) in the area of the lambdoid suture, which has no clini­
• Squama ossis frontalis cal relevance but in the radiological findings should be known as a
• Os occipitale variant. In a number of vertebrates, the Os interparietale occurs
• Pars squamosa of the Os temporale regularly. The squamous suture (Sutura squamosa) connects the
two Ossa temporalia with the Ossa parietalia in the form of an
Bone layers arch. The sutures of the skull ossify at different times well after the
The bones of the skull have a typical stratification from outside to birth (› Table 9.4).
inside:
• Lamina externa (corresponds to the outwardly directed com­
pact bone)
Clinical remarks
• Diploё (corresponds to the spongiosa) Hydrocephalus is the name for a pathological enlargement of
• Lamina interna (or Lamina vitrea, corresponds to the inward the cerebral ventricle and/or of the subarachnoid space. There
facing compact bone) are various forms of hydrocephalus, which are classified
On the outside the periosteum forms the pericranium; the perios­ ­according to localisation and cause. These can be innate (e.g.
monosomy 4p, malformations of the bony skull, microcepha-
teal sheet (Stratum periostale) lies on the inside of the skull di­
lus) as well as acquired (e.g. meningitis, brain tumours, trauma).
rectly on the dura mater (hard meninx). The latter is, with the ex­ If a hydrocephalus is present in neonates or infants, this leads
ception of the areas of venous sinus firmly fused with the meninge­ to a balloon-shaped swelling of the skull with various symp-
al sheet (Stratum meningeale) of the dura (SHARPEY's fibres). This toms because the skull growth adapts to the growth of the
also means that under physiological conditions there is no epidural brain. A hydrocephalus can develop approximately up to the
space (space between Lamina interna and dura mater). In contrast 10th year of life, after which the sutures no longer open and
the epidural space lies in the spinal canal between the periosteum those affected display intracranial pressure symptoms.
of the vertebral body and the dura mater, which is filled with adi­
pose tissue and the vertebral venous plexus. Therefore, a distinc­
tion is made between the Dura mater encephali and Dura mater Sulci, foveolae
spinalis. If one looks at the inner relief of the skull-cap, impressions of men­
ingeal arteries are apparent, Sulci arteriosi, (in addition to the su­
tures), which develop from the arterial pulse of the Aa. meningeae.
Clinical remarks Also the venous Sinus sagittalis superior leaves a wide depression
In the case of a traumatic brain injury, a meningeal artery (Sulcus sinus sagittalis superioris) medially on the inside of the
(usually the A. meningea media) can rupture causing bleeding
between the Lamina interna of the skull and the dura mater
(epidural bleeding). The patient often has neither external in-
juries to the head nor complaints in the first half an hour after Table 9.4 Sutures.
the trauma (symptom-free interval, see hospital case). The
­arterial bleeding subsequently detaches the dura from the Suture Ossification Localisation
cranial bone and the epidural haematoma relocates parts of Sutura lambdoidea 40th–50th year Between Ossa parietalia and Squama
the brain, the brain stem and the brain nerves and thus leads (lambdoid suture) of life occipitalis
to an increase of the intracranial pressure (brain pressure
symptoms). Severe deficits can occur. Without rapid treat- Sutura frontalis 1st–2nd year Between the Ossa frontalia
ment (closure of the source of bleeding and elimination of the (frontal suture) of life
haematoma), the patient generally dies after a short time due Sutura sagittalis 20th–30th year Between Ossa parietalia
to the sequelae. (sagittal suture) of life
In the case of local trauma in a small area (e.g. being hit with a
Sutura coronalis 30th–40th year Between the Os frontale and Os parietale
sharp object) there is usually an impression fracture of the
(coronal suture) of life

413
9 Head

Os frontale

Sutura coronalis

Bregma
Linea temporalis superior

Linea temporalis inferior

Os parietale

Vertex Fig. 9.2 Cranial bones with

sutures. Superior view. The
Sutura sagittalis (sagittal
Sutura sagittalis suture) connects the Ossa pari-
etalia (vertex), the Sutura coro-
nalis (coronal suture) connects
the Os frontale with the two
Ossa parietalia and the Sutura
Sutura lambdoidea Os occipitale lambdoidea (lambdoid suture)
Lambda Occiput connects the Ossa parietalia
with the Os occipitale.

skull bone. At the very front it is raised into a crest (Crista fronta­ Fossa cranii anterior
lis), which functions as an attachment point of the Falx cerebri (a The anterior cranial fossa (Fossa cranii anterior) is formed from
dural duplicature, which separates both hemispheres of the brain). the following bones:
Lateral of the Sulcus sinus sagittalis superioris small depressions • Os frontale (Partes orbitales), forms the front and side parts
are distributed irregularly but over the entire path of the Sulcus • Os ethmoidale (Lamina cribrosa), forms the base of the anterior
(Foveolae granulares). In these dimples there are the Granulationes cranial fossa
arachnoideae (PACCHIONI granulations) in living persons, • Os sphenoidale (Rostrum, Jugum and Alae minores), forms the
through which the cerebral fluid (Liquor cerebrospinalis) is reab­ border to the middle base of the skull
sorbed. At some points openings can be seen, which penetrate all The frontal lobe of the brain lie on the surface of the anterior cranial
three layers of the calvaria and can also be found on the surface fossa, which leaves corresponding impressiones gyrorum in the
anatomy of the skull. These are points of penetration for emissary thin bony lamellae. In the anterior portion medially there is the
veins (emissary veins, Vv. emissariae), venous shortcuts between Lamina cribrosa of the Os ethmoidale, through the foramina of
the superficial skull veins, the diploë veins and the blood-conducting which the Fila olfactoria of the N. olfactorius [I] penetrate to con­
sinus of the brain. nect with the Bulbus of the cranial nerve of the same name (› Fig.
9.4, › Table 9.5). Between the right and left Lamina cribrosa a
crest-shaped bone protrusion (Crista galli) is elevated, which
9.1.4 Base of the skull serves as an attachment point for the Falx cerebri (a loose connec­
tive tissue dural duplicature, which separates both cerebral hemi­
At the base of the skull (Basis cranii) an inner base of the skull spheres). At the rostral end of the Crista galli, directly on the tran­
­(Basis cranii interna) can be distinguished from a outer base of sition to the Crista frontalis, the Foramen caecum is located, which
the skull (Basis cranii externa). The inner and outer bases of the in children hosts an emissary vein for connection with the nasal
skull are interspersed by a large number of passageways, fissures cavity (in adults this Foramen is closed).
and apertures, through which the vascular, lymphatic and nervous
systems pass. A large part of the bone of the skull base is pneuma­ NOTE
tised (filled with air), reducing the weight of the skull. The anterior cranial fossa forms the roof of the nasal cavity (Cavitas
nasi) and the eye orbit (Orbita).
Inner surface of skull base
The inner surface of the skull base (Basis cranii interna, › Fig. 9.3)
is divided into 3 separate areas that together form the base of the Fossa cranii media
skull and serve as a contact surface for the brain: The middle cranial fossa (Fossa cranii media) is formed by the fol­
• The anterior cranial fossa (Fossa cranii anterior) lowing bones:
• The middle cranial fossa (Fossa cranii media) • Os sphenoidale (Alae majores), forms the front part of the floor
• The posterior cranial fossa (Fossa cranii posterior) • Os temporale (Pars squamosa), together with the Alae majores
forms the floor in the middle part

414
 9.1 Skull

Crista frontalis
Sulcus sinus sagittalis superioris
Foramen caecum

Crista galli
Impressiones gyrorum
Lamina et Foramina cribrosa
Dorsum sellae
Canalis opticus
Proc. clinoideus posterior

Fissura orbitalis superior

Fossa hypophysialis
Fossa cranii
Os sphenoidale, Ala minor anterior
Proc. clinoideus anterior
Foramen rotundum
Sulcus caroticus
Foramen lacerum
Sulcus arteriosus
Foramen ovale
Spina ossis sphenoidalis
Foramen spinosum

Os temporale, Pars squamosa Sulcus sinus petrosi inferioris

Fossa cranii
Fissura petrosquamosa media

Porus acusticus internus

Foramen jugulare

Os temporale, Pars petrosa Sulcus sinus sigmoidei

Canalis condylaris Fossa cranii

posterior
Foramen mastoideum
Canalis nervi hypoglossi

Clivus
Canalis nervi hypoglossi
Sulcus sinus transversi

Protuberantia occipitalis interna Foramen magnum

Sulcus sinus sagittalis superioris

Fig. 9.3 Inner skull base, Basis cranii interna. Superior view. Conspicuous structures of the internal surface of skull base are the Foramen
magnum (e.g. entry point of the extended spinal cord) within the Os occipitale, the Fossa hypophysialis (site of the pituitary within a dura
duplicature) as well as the ethmoid bone (Lamina cribrosa of the Os ethmoidale) through which the nerve fibres of the N. olfactorius [I] extend.
In particular in the area of the anterior cranial fossa one can also determine impressions of the gyri of the frontal lobe (Impressiones gyrorum
lobus frontalis).

• Os temporale (Facies anterior of the Pars petrosa), forms the

border to the posterior cranial fossa
The Corpus ossis sphenoidalis with the Sella turcica divides the
Fossa cranii media in two halves. In this area there are the Fossa Nn. olfactorius [I],
hypophysialis, which includes the Hypophysis cerebri (pituitary Fila olfactoria N. ophthalmicus [V/1]
gland), the Dorsum sellae with the Procc. clinoidei posteriores, and
N. trochlearis [IV]
in front of them is the Tuberculum sellae of the Sulcus prechias­
maticus (Chiasma opticum) and the Procc. clinoidei anteriores. It N. opticus [II] N. oculomotorius [III]
is also the site of several openings (› Fig. 9.3): N. abducens [VI]
N. maxillaris [V/2]
• Canalis opticus (N. opticus and A. ophthalmica) N. facialis [VII]
• Fissura orbitalis superior (Nn. oculomotorius [III], trochlearis N. mandibularis
[V/3]
[IV], ophthalmicus [V/1], lacrimalis, frontalis, nasociliaris and N. hypo-
abducens [VI] as well as V. ophthalmica) glossus [XII] N. mandibularis
• Foramen rotundum (N. maxillaris [V/2]) [V/3], R. meningeus
N. glosso-
• Foramen ovale (N. mandibularis [V/3]) pharyngeus [IX] N. vestibulo-
• Foramen spinosum (R. meningeus of the N. mandibularis [V/3] N. acces-
cochlearis [VIII]
and A. meningea media) sorius [XI]
Medial of the Foramen ovale lies the Foramen lacerum, which is N. vagus [X]
closed in vivo by connective tissue, but is traversed by various N. vagus [X],
structures (› Fig. 9.4): R. meningeus
• N. petrosus major
• A. canalis pterygoidei
• R. meningeus (from the A. pharyngea ascendens) Fig. 9.4 Points of penetration of the inner skull base. Superior view.

415
9 Head

Table 9.5 Points of penetration of the inner skull base and their etrates variably through the Fissura sphenopetrosa, Foramen lace­
­contents. rum or occasionally the Foramen ovale.
Point of penetration Content
NOTE
Foramina cribrosa • Nn. olfactorii [I]
The middle cranial fossa forms the bony basis for the two temporal
• A. ethmoidalis anterior (A. ophthalmica)
lobes of the brain and for the pituitary gland.
Canalis opticus • N. opticus [II]
• A. ophthalmica (A. carotis interna)
Fossa cranii posterior
• Meninges; Vaginae nervi optici
The posterior cranial fossa (Fossa cranii posterior) is formed by the
Fissura orbitalis Medial area: following bones:
­superior • N. nasociliaris (N. ophthalmicus [V/1])
• N. oculomotorius [III]
• Os sphenoidale (sphenoidal part of the clivus), forms the front
• N. abducens [VI] part
Lateral area: • Os temporale (Facies posterior of the Pars petrosa), forms the
• N. trochlearis [IV] anterolateral border to the middle cranial fossa
• Joint stem of: • Os occipitale (Partes basilaris and lateralis), forms the floor
– N. frontalis (N. ophthalmicus [V/1]) The Foramen magnum as the largest site of penetration of the
– N. lacrimalis (N. ophthalmicus [V/1])
skull represents the connection to the vertebral canal (Canalis ver­
• R. orbitalis (A. meningea media)
• V. ophthalmica superior tebralis). At its edge in close proximity to the Condyli occipitales
is the Canalis nervi hypoglossi. Rostrally the clivus rises up to the
Foramen rotundum • N. maxillaris [V/2]
Dorsum sellae of the Os sphenoidale. Occipitally the Crista occipi­
Foramen ovale • N. mandibularis [V/3] talis interna extends to the Protuberantia occipitalis interna. Be­
• Plexus venosus foraminis ovalis
hind the Foramen magnum the Sulcus sinus sigmoidei and the Sul­
Foramen spinosum • R. meningeus (N. mandibularis [V/3]) cus sinus transversi limit the Fossa cerebellaris laterally. The Fossa
• A. meningea media (A. maxillaris)
cranii posterior includes other points of penetration apart from the
Fissura sphenopetrosa, • N. petrosus minor (N. glossopharyngeus [IX]) Foramen magnum (› Fig. 9.3, › Fig. 9.4):
Foramen lacerum • N. petrosus major (N. facialis [VII]) • Foramen magnum – Medulla oblongata, Radix spinalis of the
• N. petrosus profundus (Plexus caroticus internus)
N. accessorius [XI], Aa. vertebrales, A. spinalis anterior, Aa. spi­
Apertura interna • A. carotis interna, Pars petrosa nales posteriores, meninges and venous connections between
­canalis carotici and • Plexus venosus caroticus internus
Plexus basilaris and vertebralis internus
Canalis caroticus • Plexus caroticus internus (Truncus sympathicus,
Ganglion cervicale superius)
• Canalis nervi hypoglossi – N. hypoglossus [XII]
• Foramen jugulare – Nn. glossopharyngeus [IX], vagus [X], ac­
Porus and Meatus • N. facialis [VII]
cessorius [XI], A. meningea posterior, V. jugularis interna
acusticus internus • N. vestibulocochlearis [VIII]
• A. labyrinthi (A. basilaris) • Porus acusticus internus – Nn. facialis, intermedius, vestibulo­
• Vv. labyrinthi cochlearis, A. and V. labyrinthi
Foramen jugulare Frontal area:
• Sinus petrosus inferior NOTE
• N. glossopharyngeus [IX] The bony portions of the posterior cranial fossa form the floor for
Posterior area: the cerebellum (Cerebellum), the bridge (Pons) and the extended
• A. meningea posterior (A. pharyngea ascendens) medulla (Medulla oblongata).
• Sinus sigmoideus (Bulbus superior venae jugularis)
• N. vagus [X]
• N. accessorius [XI]
Outer skull base
• R. meningeus (N. vagus [X]) Similar to the inner skull base the outer skull base (Basis cranii ex­
terna, › Fig. 9.5) is also subdivided into an anterior, middle and
Canalis nervi • N. hypoglossus [XII]
­hypoglossi • Plexus venosus canalis nervi hypoglossi rear section.
Canalis condylaris • V. emissaria condylaris
Frontal section
Foramen magnum • Meninges The point of contact between Os incisivum and Maxilla is the Fossa
• Plexus venosus vertebralis internus (Sinus marginalis)
incisiva with the rostrally lying Foramen incisivum and the Canalis
• Aa. vertebrales (Aa. subclaviae)
• A. spinalis anterior (Aa. vertebrales) incisivus. The N. nasopalatinus (N. maxillaris[V/2]) (› Fig. 9.6,
• Medulla oblongata/Medulla spinalis › Table 9.6) penetrates through this. At the point of contact between
• Radices spinales (N. accessorius [XI]) the Maxilla and the Os palatinum is the Foramen palatinum majus, as
well as the Foramina palatina minora, through which the N. palatinus
major and the A. palatina major or the Nn. palatini minores and Aa.
Above the Foramen lacerum at the Sella turcica is the Sulcus palatini minores pass. The hard palate (Palatum durum) ends dorsal
caroticus, in which the A. carotis interna courses. On the medial to the Choanae, which mark the entry into the nasal cavity.
Facies anterior of the Pars petrosa of the Os temporale there are
points of penetration of the N. petrosus major (Hiatus canalis nervi NOTE
petrosi majoris) as well as the N. petrosus minor (Hiatus canalis The front section of the outer skull base is actually part of the vis-
nervi petrosi minoris). With the N. petrosus minor the A. tympan­ cerocranium and forms the floor of the nasal cavity, as well as the
ica superior (from A. meningea media) penetrates the Hiatus cana­ hard palate (Proc. palatinus of the Maxilla, Os incisivum and Lamina
lis nervi petrosi minoris. The N. petrosus major leaves the middle horizontalis of the Os palatinum) and therefore the roof of the oral
cavity.
cranial fossa via the Foramen lacerum; the N. petrosus minor pen­

416
 9.1 Skull

Spina nasalis posterior Fossa incisiva; Foramen incisivum

Vomer, Alae vomeris Maxilla, Proc. palatinus

Os palatinum, Proc. pyramidalis Os palatinum, Lamina horizontalis

Maxilla, Proc. zygomaticus Foramen palatinum majus
Hamulus pterygoideus Fissura orbitalis inferior
Proc. pterygoideus, Lamina medialis
Arcus zygomaticus
Proc. pterygoideus, Lamina lateralis
Os sphenoidale, Ala major Proc. pterygoideus, Lamina medialis

Os temporale, Foramen ovale

Proc. zygomaticus
Os occipitale, Pars basilaris,
Foramen lacerum Tuberculum pharyngeum

Foramen spinosum Canalis caroticus

Spina ossis sphenoidalis

Proc. styloideus
Foramen
stylomastoideum
Meatus acusticus
externus
Proc. mastoideus
Fossa jugularis

Foramen jugulare Canalis nervi hypoglossi

Foramen mastoideum

Condylus occipitalis

Foramen magnum
Canalis condylaris

Linea nuchalis superior

Linea nuchalis inferior

Fig. 9.5 Outer skull base, Basis cranii externa. View from below. The front part includes the palate with the maxillary teeth, the middle part
extends from the posterior border of the hard palate to the anterior margin of the Foramen magnum and the rear part accordingly from the
anterior margin of the Foramen magnum to the Linea nuchalis superior. The outer skull base includes, in particular, the points of penetration of
the cranial nerves and vessels, as well as numerous attachment points for muscles and ligaments (e.g. Proc. styloideus or Proc. mastoideus).
Lateral on both sides of the Foramen magnum are the joint surfaces (Condyli occipitales) for the two upper cranial joints (Articulationes
atlantooccipitales).

Middle section Lateral and belonging to the surface of the Os temporale are the
The middle section is mainly formed from the Os sphenoidale and basis of the Pars petrosa, the Proc. mastoideus (mastoid process) as
the lower surface of the Os temporale. Prominent structures are the well as the Proc. styloideus (styloid process); in addition, at the side
Proc. pterygoideus belonging to the Os sphenoidale and the Fossa of it lie the Pars squamosa and the Pars tympanica.
pterygoidea. Lateral above the Proc. pterygoideus lies the Fossa Medial of the Proc. styloideus are the Foramen jugulare and the
pterygopalatina (pterygopalatine fossa) which hosts one of the Foramen stylomastoideum. Rostral and thus in front of the Proc.
parasympathetic cranial ganglia (Ganglion pterygopalatinum). The mastoideus, the Porus acusticus externus opens (opening of the
middle section also provides points of penetration for multiple bony part of the external acoustic meatus) and in front of it the
structures. In the following, only structures and points of penetra­ Fossa mandibularis, which takes up the joint head of the mandible
tion are named which are different from the Basis cranii interna and is limited at the front by the Tuberculum articulare.
(› Fig. 9.5, › Fig. 9.6):
• Fissura orbitalis inferior – Nn. infraorbitalis and zygomaticus Rear section
[V/2], A. infraorbitalis, V. ophthalmica inferior The main part of the posterior section is formed by the Os occipi­
• Canalis pterygoideus – N. canalis pterygoidei tale with the Pars basilaris and both Partes laterales; it extends to
• Fissura sphenopetrosa – Chorda tympani, A. tympanica major the rear via the Squama occipitalis through to the Protuberantia
(some authors are of the opinion that the Chorda tympani and occipitalis externa (Inion). The Os occipitale is penetrated by the
the A. tympanica major run through the Fissura petrotympanica Foramen magnum, which is accompanied on both sides by the
[GLASER's fissure]) Condyli occipitales. The Canalis condylaris containing the V. emis-
• Canaliculus mastoideus – R. auricularis of the N. vagus [X] saria condylaris runs through this structure. Behind the Proc.
• Canaliculus tympanicus – N. tympanicus [from IX] mastoideus lies the Foramen mastoideum, through which an emis­
• Foramen stylomastoideum – N. facialis [VII], A. stylomas­ sary vein passes (V. emissaria mastoidea).
toidea
• Canalis musculotubarius – M. tensor tympani, Tuba auditiva

417
9 Head

Table 9.6 Points of penetration of the outer skull base and their
N. nasopalatinus
contents.

Point of penetration Content

Foramen incisivum • N. nasopalatinus (N. maxillaris [V/2])
N. palatinus major
Foramen palatinum • N. palatinus major (N. maxillaris [V/2])
majus • A. palatina major (A. palatina descendens) N. mandibularis [V/3]

Foramina palatina • Nn. palatini minores (N. maxillaris [V/2]) N. mandibularis [V/3],
­minora • Aa. palatinae minores (A. palatina descendens) R. meningeus

Fissura orbitalis inferior • A. infraorbitalis (A. maxillaris) Chorda tympani

• V. ophthalmica inferior
• N. infraorbitalis (N. maxillaris [V/2]) N. petrosus major
• N. zygomaticus (N. maxillaris [V/2])
N. petrosus profundus
Foramen rotundum • N. maxillaris [V/2]
N. vagus [X],
Foramen ovale • N. mandibularis [V/3] R. auricularis
• Plexus venosus foraminis ovalis
N. facialis [VII]
Foramen spinosum • R. meningeus (N. mandibularis [V/3])
• A. meningea media (A. maxillaris) Nn. glossopharyngeus [IX],
vagus [X] and accessorius [XI]
Fissura sphenopetrosa, • N. petrosus minor (N. glossopharyngeus [IX])
Foramen lacerum • N. petrosus major (N. facialis [VII]) N. hypoglossus [XI]
• N. petrosus profundus (Plexus caroticus internus)
Apertura externa canalis • A. carotis interna, Pars petrosa
carotici and Canalis • Plexus venosus caroticus internus
caroticus • Plexus caroticus internus (Truncus sympathicus,
Ganglion cervicale superius)
Fig. 9.6 Points of penetration on the outer skull base. View from
Foramen • N. facialis [VII] below.
­stylomastoideum
Foramen jugulare Anterior area:
• Sinus petrosus inferior 9.1.5 Individual bones of the viscerocranium
• N. glossopharyngeus [IX]
Posterior area:
• A. meningea posterior (A. pharyngea ascendens)
Mandibula
• Sinus sigmoideus (Bulbus superior venae jugularis) The unpaired Mandibula (mandible), the largest bone of the vis­
• N. vagus [X] cerocranium consists of 1 Corpus and 2 Rami, which merge together
• R. meningeus (N. vagus [X]) at the Angulus mandibulae. With the exception of the auditory ossi­
• N. accessorius [XI] cles the Mandibula is the only movable bone of the skull. Both Rami
Canaliculus mastoideus • R. auricularis nervi vagi (N. vagus [X]) mandibulae have a Proc. coronoideus and at its free end a Proc. con­
Canalis nervi hypoglossi • N. hypoglossus [XII] dylaris, which articulates via its Caput mandibulae with the Fossa
• Plexus venosus canalis nervi hypoglossi mandibularis of the Os temporale and as such forms the mandibular
Canalis condylaris • V. emissaria condylaris
joint (Articulatio temporomandibularis, see below). The Corpus
consists of a base and a Pars alveolaris, which also bears the teeth of
Foramen magnum • Meninges
• Plexus venosus vertebralis internus
the lower jaw (› Fig. 9.7). The Pars alveolaris and basis are separat­
(Sinus marginalis) ed from each other by the Linea obliqua, which descends rostrally
• Aa. vertebrales (Aa. subclaviae) from the Proc. coronoideus. The indentation between the Proc. con­
• A. spinalis anterior (Aa. vertebrales) dylaris and Proc. coronoideus is referred to as the Incisura mandibu­
• Medulla oblongata/Medulla spinalis lae. The most rostrally lying point of the Mandibula is the Protuber-
• Radices spinales (N. accessorius [XI]) antia mentalis, which joins laterally on both sides of the Tubercula
mentalia (mental tubercle) and gives the chin its characteristic shape.
Between the Pars alveolaris and the Tubercula mentalia are the
Clinical remarks paired Foramina mentalia, through each of which the N. mentalis
As a result of violent force to the skull (especially sudden,
[V/3] runs and sensitively innervates large areas of the lower jaw.
blunt force violence, such as in a traffic accident) the bones of
the skull base can fracture. This can affect the front, middle or
posterior cranial fossa. Weakest points are the many openings
Clinical remarks
in the middle area of the skull base. The fracture lines run If, in the case of tooth loss of permanent teeth no replacement
through these when there is a skull base fracture. Often the is made, the Pars alveolaris mandibulae recedes in the area of
penetrating structures are injured, resulting in bleeding and/ the missing teeth. If left untreated, this progresses so far that
or leakage of cerebrospinal fluid (liquorrhoea) from the nose the Foramen mentale comes to rest directly on the upper edge
or the external ear canal and nerve failures may occur. of the lower jaw. Pain, neuralgia and sensory disturbances in
the supply area of the N. mentalis can be the result and those
affected are very severely restricted and food intake becomes
more difficult. Adaption of a dental prosthesis is very difficult
in these cases and often only succeeds after reconstructing
the bone structure.

418
 9.1 Skull

Maxilla, Proc. frontalis

Os lacrimale
Sutura coronalis

Os parietale,
Angulus sphenoidalis

Os sphenoidale

Os sphenoidale, Ala major

Os sphenoidale, Ala minor

Os sphenoidale, Ala major

Foramen infraorbitale

Septum nasi Os ethmoidale Concha nasalis media

osseum Vomer

Ramus mandibulae
Maxilla, Proc. alveolaris

Foramen mentale

Corpus mandibulae
Protuberantia mentalis

Fig. 9.7 Cranial bones, Ossa cranii. Rostral view. The front part of the Os frontale, Os nasale, Os zygomaticum, Maxilla and Mandibula have the
largest share in the formation of the facial structure. Maxilla, Os frontale, Os zygomaticum, Os sphenoidale, Os lacrimale and a small part of the
Os palatinum form the Orbita. The Foramen supraorbitale (Os frontale), Foramen infraorbitale (Maxilla) and Foramen mentale (Mandibula) rep-
resent the penetration portals for the sensory parts of the N. trigeminus [V] and are used in the physical examination of a patient as trigeminal
pressure points. The lower rim of the Maxilla is formed by the Proc. alveolaris, in which the teeth of the Maxilla are located. The Mandibula con-
sists of a Corpus and both Rami mandibulae, both of which converge at the Angulus mandibulae. The Mandibula also has a Pars alveolaris, in
which the teeth are anchored. Below this is the Basis mandibulae, which protrudes in the midline to the Protuberantia mentalis.

The paired Foramen mandibulae, which lead to the Canalis man- Clinical remarks
dibulae are located at the inside of the Ramus mandibulae. The N.
alveolaris inferior passes through the bony canal [from V/3], which The second most common fracture of the viscerocranium is the
emits sensory branches for innervation of the lower jaw. The Lin- mandibular fracture. Due to the exposed location and U-shape,
the lower jaw is often affected by fractures; particularly in the
gula mandibulae, is located in front of the Foramen manibulae
area of the Mentum (incisors) and of the Corpus (3rd molar).
which serves the Lig. sphenomandibulare as an attachment and Fracture-related injuries of blood vessels (often A. alveolaris
presents a dental guiding structure for block anaesthesia. The Sul- inferior) lead to small surface bleeding in the area of the floor of
cus mylohyoideus, which runs rostally, emerges at the Foramen the mouth (ecchymoses) that are characteristic for a fracture.
mandibulae. Further rostrally, the Linea mylohyoidea runs in tiers, The Os nasale is most commonly affected by fractures.
which serves the M. mylohyoideus as attachment and originates
from the level of the floor of the mouth. In 10–15 % of all Mandib­
ulae a Foramen retromolare can be found in the Fossa retromo­
laris immediately behind the last molar (Dens serotinus, wisdom Maxilla
tooth) which is connected via its own canal (Canalis retromolaris) The paired Maxilla (upper jaw bone) is connected to the upper
with the Canalis mandibulae. Variable branches of the N. alveolaris jaw (› Fig. 9.8) via the Sutura palatina mediana, which is connect­
inferior and the A. alveolaris inferior run through the foramen, ed to every other bone of the viscerocranium (exception: Mandib­
which occurs mainly unilaterally. The knowledge of this variant is ula). The upper jaw bone is shaped like a pyramid and forms part
significant in dental surgery and conductive anaesthesia in this re­ of the orbital floor and includes as Os pneumaticum the Sinus
gion. maxillaris (maxillary sinus). A total of 4 surfaces (Facies orbitalis,
anterior, nasalis and infratemporalis) and 4 processes (Procc. fron­
NOTE talis, zygomaticus, palatinus and alveolaris) can be differentiated.
The Articulatio temporomandibularis is also known as the second- The Sulcus infraorbitalis runs within the Facies orbitalis, it con­
ary temperomandibular joint. From an evolutionary perspective, verges to the Canalis infraorbitalis and, ultimately, to the Foramen
the joint between the 1st and 2nd auditory ossicles (hammer and infraorbitale, which has its outlet aperture (for N. and A. infraor­
anvil) are referred to as primary mandibular joint. This emerges bitalis) immediately below the bony lower orbital rim. The Facies
from the 1st pharyngeal arch.
nasalis forms the shape of the lateral nasal wall and is penetrated
by the Hiatus maxillaris. The Proc. alveolaris bears the teeth of the
Maxilla, comparable to the Mandibula. Above the Proc. alveolaris

419
9 Head

is is the Crista zygomaticoalveolaris, which represents a limit to the a Proc. orbitalis through which the Os palatinum is connected with
Proc. zygomaticus. The front two thirds of the hard palate are the Os sphenoidale. It is interrupted in this area by the Incisura
formed from the Proc. palatinus of the Maxilla. The Proc. frontalis sphenopalatine, which is simultaneously involved in the formation
of the Maxilla is connected to the Os frontale via the Sutura fronto­ of the Foramen sphenopalatinum (point of penetration of N. naso­
maxillaris, the Sutura zygomaticomaxillaris represents the corre­ palatinus, A. sphenopalatina). On its cranial side the Lamina hori­
sponding connection to the Os zygomaticum. The Os incisivum is zontalis forms the floor of the nasal cavity via the Facies nasalis and
a self-contained bone within the Maxilla, which is fused with it in with the Facies palatina forms the bony roof of the oral cavity.
the area of the incisors (already in utero) and forms the Foramen
incisivum and the Canalis incisivus. Os zygomaticum
The paired Os zygomaticum (zygomatic bone) consists of 3 pro­
cesses and 3 surfaces and is largely responsible for the contour of
Clinical remarks the cheek (› Fig. 9.9). It is connected via
Central midfacial fractures always include the Maxilla. They • the Proc. maxillaris with the Maxilla (Sutura zygomaticomaxil­
are classified according to LEFORT: laris),
• LEFORT I: horizontal avulsion of the Proc. alveolaris maxillae • via the Proc. frontalis with the Os frontale (Sutura zygomaticof­
from the nasal floor rontalis) and
• LEFORT II: pyramid-shaped avulsion (also pyramidal fracture)
• via the Proc. temporalis with the Os temporale (Sutura zygoma­
of the Maxilla along the Sutura frontomaxillaris, with the
participation of the Ossa nasalia, the infraorbital rims and of ticotemporalis)
the two orbital floors Its facies orbitalis forms part of the orbital floor, the Facies tempo­
• LEFORT III: complete avulsion of the midface from the skull- ralis is penetrated by the Foramen zygomaticotemporale (R. zygo­
base, which in addition to LeFort II also includes the Ossa maticotemporalis) and the Facies lateralis by the Foramen zygoma­
zygomatica. In this form, leakage of Liquor cerebrospinalis ticofaciale (R. zygomaticofacialis). The Proc. temporalis, together
(liquorrhoea), acute shortness of breath (dyspnoea) and with the Proc. zygomaticus of the Os temporale forms the Arcus
avulsion of the Fila olfactoria (anosmia) often occur.
zygomaticus (zygomatic arch).
LEFORT fractures typically occur as a result of traffic accidents
or severe blunt force (kicks).
NOTE
The Os zygomaticum, Os palatinum, Maxilla and Mandibula togeth-
er with the Os hyoideum, which does not belong to the skull, form
Os palatinum the jaw skeleton .
The paired L-shaped Os palatinum (palatine bone) forms the pos­
terior third of the hard palatine through its Lamina horizontalis
and is connected via the Sutura palatina transversa with the Proc. Os lacrimale
palatinus maxillae (Maxilla) (› Fig. 9.8). The palatine bone also The paired Os lacrimale (lacrimal bone) is the smallest single
consists of a Lamina perpendicularis with a Proc. sphenoidalis and bone of the viscerocranium and is involved to a minor degree in

Sulci arteriosi
Sutura coronalis
Os temporale, Pars squamosa
Dorsum sellae

Sella turcica Sutura squamosa

Lamina et
Foramina cribrosa

Sinus frontalis

Sutura lambdoidea
Crista galli

Os ethmoidale,
Lamina perpendicularis

Sinus sphenoidalis Squama occipitalis

Vomer
Protuberantia occipitalis
Canalis incisivus externa

Proc. palatinus,
Porus et Meatus acusticus internus
Crista nasalis Proc.
styloideus Canalis nervi hypoglossi

Os palatinum Lamina medialis

Lamina lateralis Proc. pterygoideus
Hamulus pterygoideus Fossa pterygoidea

Fig. 9.8 Skull bones (right), Ossa cranii. Medial view. In this mediosagittal section through the skull the bony parts of the nasal skeleton
(Lamina perpendicularis of the Os ethmoidale, vomer and Os nasale) can be recognised as well as the parts of the hard palate (Maxilla lamina
horizontalis of the Os palatinum). In addition, in the section the pneumatic parts of the Os frontale (Sinus frontalis) and of the Os sphenoidale
(Sinus sphenoidalis) become visible. The impressions of the meningeal vessels (Sulci arteriosi) between the hard meninges (Dura mater) and
the skull bone are conspicuous.

420
 9.1 Skull

Os temporale, Pars squamosa

Sutura coronalis
Linea temporalis superior

Linea temporalis inferior

Os frontale
Os parietale

Sutura squamosa
Os sphenoidale

Os lacrimale
Sutura lambdoidea
Os nasale

Os zygomaticum
Os occipitale
Maxilla Sutura occipitomastoidea

Spina nasalis anterior Os temporale, Proc. mastoideus

Porus acusticus externus

Sutura zygomaticomaxillaris
Condylus occipitalis
Proc. styloideus
Mandibula Articulatio temporomandibularis

Arcus zygomaticus
Protuberantia mentalis
Foramen mentale

Fig. 9.9 Skull bones, Ossa cranii. View from lateral left side. The main part of the lateral relief of the skull is formed from both Ossa parietalia
and temporalia (mainly Pars squamosa) which count as part of the neurocranium. The Os zygomaticum is adjacent to the Arcus zygomaticus
(zygomatic arch) of the Os temporale and forms the contours of the cheek. At the leading edge to the Proc. mastoideus is the Porus acusticus
externus which is part of the outer ear. Within the temporomandibular joint the Caput mandibulae (head of mandible) articulates with the Fossa
mandibularis (Os temporale) in the Articulatio temporomandibularis.

the structure of the Orbita (› Fig. 9.7). The medial part forms the cribrosa) (like a sieve), which enable the passage of the Fila olfacto­
Sulcus lacrimalis (for the Ductus nasolacrimalis) which continues ria (N. olfactorius [I]) from the anterior cranial fossa into the roof
cranially to the Fossa sacci lacrimalis (for the inclusion of the Sac­ of the nasal cavity. In the midline of the Lamina cribrosa the Crista
cus lacrimalis). The rear edge of the Fossa sacci lacrimalis contin­ galli (like a cock's comb) protrudes into the Fossa cranii anterior
ues into the Crista lacrimalis posterior and downwards into the and divides the Lamina cribrosa into two halves.
Hamulus lacrimalis.
Os nasale
Concha nasalis inferior The paired Os nasale (nasal bone) is connected laterally to the
The paired Concha nasalis inferior (inferior nasal concha) is a Maxilla and via the Sutura frontonasalis to the Os frontale (› Fig.
self-contained bone and is located beneath the Concha nasalis me­ 9.8). The two Ossa nasalia are connected in the midline via the
dia of the Os ethmoidale. It is connected on the lateral nasal wall ­Sutura internasalis. The Os nasale forms only a small proportion of
with the Os palatinum and via the Proc. maxillaris with the Maxil­ the nasal scaffold.
la. Below the Concha nasalis inferior is the lower nasal passage
(Meatus nasi inferior), into which the Canalis nasolacrimalis
opens.
Clinical remarks
Fractures of the nasal bone belong to the fractures of the na-
Vomer sal scaffold. They are the most common fractures of the vis-
The unpaired Vomer has the shape of a classical plough (› Fig. cerocranium. Nasal scaffold fractures typically occur in martial
9.8). It forms the lower and also largest part of the bony nasal sep­ arts, violent assaults and traffic accidents.
tum and is connected at the top with the Lamina perpendicularis
of the Os ethmoidale, as well as with the Os sphenoidale. The Sul­
cus vomeris runs on its outer side on which the cartilaginous part NOTE
of the nasal septum is anchored. It also forms the medial wall of The nasal skeleton is the bony basis of the nose and together with
each posterior nasal aperture. the nose cartilage forms the nasal scaffold. The Os nasale, Os eth-
moidale, Concha nasalis inferior, Vomer, Os frontale, Os lacrimale
Os ethmoidale and Maxilla are involved in the construction of the nasal skeleton.
The unpaired Os ethmoidale (ethmoid bone) is an irregular, po­
rous bone, which belongs to the Ossa pneumatica (› Fig. 9.8). It is
a component of the nasal cavity and includes the anterior and pos­ Orbita
terior cells of the ethmoidal sinusess (Cellulae ethmoidales ante- The orbit (Orbita) is a deep, pyramid-shaped pit with its tip facing
riores and posteriores). Its cranial part, the Lamina cribrosa, is occipitally. The penetration portals for nerves and blood vessels are
permeated right and left by a large number of holes (Foramina located in the Orbita:

421
9 Head

• Roof the roof of the Orbita (› Fig. 9.7) and the floor of the anterior cra­
– Incisura frontalis or Foramen supraorbitale: N. supraorbit­ nial fossa (› Fig. 9.3). Therefore the Os frontale forms the transi­
alis (N. ophthalmicus [V/1]), R. medialis tion between the viscerocranium and the neurocranium. The
• Lateral wall paired Sinus frontalis (frontal sinus) is located above the Orbita on
– Fissura orbitalis superior: N. oculomotorius [III], N. troch­ both sides within the Squama frontalis, which protrudes forward
learis [IV], N. nasociliaris (N. ophthalmicus [V/1]), N. fronta­ in a bulge as the Arcus superciliaris (the eyebrows are here)
lis (N. ophthalmicus [V/1]), N. lacrimalis (N. ophthalmicus (› Fig. 9.8). The Arcus superciliaris is more intensely formed in
[V/1]), N. abducens [VI], R. orbitalis (A. meningea media), V. men than in women. Between the two Arcus superciliares lies the
ophthalmica superior glabella (area between the eyebrows). In the view from below, the
– Fissura orbitalis inferior: N. zygomaticus (N. maxillaris Foveolae ethmoidales are found below the glabella on both sides,
[V/2]), N. infraorbitalis (N. maxillaris [V/2]), A. infraorbitalis which mark both the entrance to the frontal sinus and at the same
(A. maxillaris), V. ophthalmica inferior time are part of the roof of the ethmoidal cells. The front edge of
– Foramen zygomaticoorbitale: N. zygomaticus divided into the bilateral orbital roof is formed by the Margines supraorbitales
R. zygomaticotemporalis (N. maxillaris [V/2]) (via Foramen which show an Incisura frontalis or a Foramen frontale (point of
zygomaticotemporale) and R. zygomaticofacialis (N. maxillaris penetration of the N. supraorbitalis). The Os frontale extends to
[V/2]) (via Foramen zygomaticofacialis) the Sutura coronalis and is connected by this to the Os parietale.
• Medial wall Caudally, it borders on the Os ethmoidale and forms a part of the
– Canalis nasolacrimalis: Ductus nasolacrimalis medial orbital wall with the Foramina ethmoidalia anterius and
– Canalis opticus: N. opticus [II], A. ophthalmica posterius, which enable the passage of the vessels and nerves of the
– Foramen ethmoidale anterius: A. ethmoidalis anterior, N. same name. The Facies orbitalis, which also forms the roof of the
ethmoidalis anterior (N. ophthalmicus [V/1]) Orbita, is temporally deepened to the Fossa glandulae lacrimalis
– Foramen ethmoidale posterius: A. ethmoidalis posterior, N. (location of the lacrimal gland). Above the Sutura frontosphenoi­
ethmoidalis posterior (N. ophthalmicus [V/1]) dalis the frontal bone borders on the sphenoid bone. Inside the
• Floor skull, starting at the Foramen caecum, the Crista frontalis runs me­
– Canalis infraorbitalis and Foramen infraorbitale: N. infra­ dially, which continues into the Sulcus sinus sagittalis superioris.
orbitalis (N. maxillaris [V/2]), A. infraorbitalis As already described, on the inner side of the bone Sulci arteriosi
• Bones of the Orbita (location of the A. meningea anterior) and Foveolae granulares
– Os frontale (roof, in part) (PACCHIONI). can be recognised.
– Os zygomaticum (lateral wall)
– Os sphenoidale, Ala major (lateral wall) Os temporale
– Os sphenoidale, Ala minor (medial wall) The paired Os temporale (temporal bone) partly belongs to the vis­
– Maxilla, Proc. frontalis (medial wall) cerocranium and partly to the neurocranium (› Fig. 9.9). In addi­
– Os ethmoidale (medial wall) tion, it is involved in the formation of the temporomandibular
– Os lacrimale (medial wall) joint (Fossa mandibularis), the outer wall of the skull (› Fig. 9.8)
– Os frontale (medial wall) and the skull base (› Fig. 9.3). The temporal bone articulates with
– Maxilla (floor) the lower jaw in the Articulatio temporomandibularis (tempero­
– Os zygomaticum (floor) mandibular joint, › Fig. 9.9) via the Fossa mandibularis and the
– Os palatinum (floor) Tuberculum articulare lying in front of it. Dorsal of the Fossa man­
dibularis is the Meatus acusticus externus (outer ear canal), which
joins the Proc. mastoideus (mastoid process) and in adults is
Clinical remarks filled with air (Cellulae mastoideae). The Os temporale is divided
Fractures of the orbital floor are referred to as blow-out frac- into:
tures. They are created by frontal point force on the Bulbus oc- • Pars petrosa (petrous part of the temporal bone, petrous pyra­
uli (e.g. tennis ball). This results in the fracture of the Orbita mid): it borders at the back on the Ossa parietale and occipitale,
floor. In the process, structures within the eye socket (Mm. its central external opening is the Meatus acusticus externus. At
recti inferiores and obliquus inferior) can become clamped in
the back and below, it joins the Proc. mastoideus. The Pars pe­
the fracture gap or even pushed all the way into the Sinus
maxillaris (orbital hernia) in extreme cases. Symptoms may be trosa accomodates the middle and the inner ear. Openings/spac­
ghosting (by limitation of eyeball mobility), enophthalmus (re- es are the internal auditory canal (Meatus acusticus internus)
traction of the eyeball into the viscerocranium/facial skeleton) with passage of the N. facialis [VII], N. intermedius [VII], N.
or conjugate paralysis upwards. If the N. infraorbitalis running vestibulocochlearis [VIII] and A. labyrinthi and the Foramen
in the orbital floor is also affected, sensory disturbances in stylomastoideum with passage of the N. facialis [VII] and Cana­
the area of the facial skin of the Maxilla occur. The selective lis musculotubarius (passage of the Tuba auditiva [EUSTACHII]
application of force can also lead to fracture of the Lamina pa-
and position of the M. tensor tympani). In addition, it forms the
pyracea of the Os ethmoidale (medial orbital wall, with in-
volvement of the Cellulae ethmoidales). Apertura externa canalis carotici for the A. carotis interna and
together with the eardrum forms the side wall of the tympanic
cavity (Cavitas tympani).
• Pars tympanica: it limits the bony wall of the external auditory
canal from the front, bottom and rear, extends to the eardrum
9.1.6 Individual bones of the neurocranium and lies annularly on the Partes squamosa and petrosa.
• Pars squamosa (squamous = scale): it occupies the largest part
Os frontale according to area and borders the Os parietale via the Margo pa­
The anterior part of the skull is formed by the Squama frontalis of rietalis. It forms the front and top part of the temple. At the front
the Os frontalis (frontal bone) which also provides the shape of and above the Meatus, the Proc. zygomaticus bulges and stretch­

422
 9.1 Skull

es forward as part of the zygomatic arch. It is connected to the • Below via the Sutura lambdoidea with the Os occipitale
Os occipitale via the Sutura occipitomastoidea and to the Os • Medial to the respective contralateral Os parietale
sphenoidale via the Sutura sphenosquamosa. The inner relief of the Os parietale is characterised by the impres­
sions of the Aa. meningeae media and anterior (Sulci arterio-
Os sphenoidale si,› Fig. 9.8) as well as the Sinus durae matris (Sulcus sinus sig­
The butterfly-shaped unpaired Os sphenoidale (sphenoid bone) is, moidei). On the outer wall a Linea temporalis superior and a Linea
like the Os frontale and the Os temporale part of the neurocranium temporalis inferior can be recognized (› Fig. 9.9).
and the viscerocranium (› Fig. 9.3). It is located in the middle of
the skull base, contains points of penetration for numerous vessels Os occipitale
and nerves and is the interface to all other bones of the internal The unpaired Os occipitale (occipital bone) forms the main part of
surface of the skull base. The Os sphenoidale articulates at the front the skull base and consists of 4 bone parts (› Fig. 9.10) that to­
with the Os frontale and to a minor extent with the Os ethmoidale. gether make up the Foramen magnum (passage of the Medulla ob­
Laterally it is adjacent to the two Ossa temporalia and at the back it longata):
is connected with the clivus of the Os occipitale. It is also involved • Pars squamosa
in the structure of the Orbita. In the centre of the sphenoid bone is • Pars basilaris
the Turkish saddle (Sella turcica, › Fig. 9.8) and in its Fossa hy- • Partes laterales
pophysialis lies the pituary gland (Glandula pituitaria). A distinc­ • Planum occipitale
tion is made between 2 lower, large wings(Alae majores) and 2 The 4 bone parts fuse in the 4th year of life, so that in infants 4
­upper, small wings (Alae minores), which exit from the Corpus ­individual bones can be distinguished. Similar to the Ossa pari­
sphenoidale. The sphenoidal body is pneumatised and includes the etalia, to which it is connected via the Sutura lambdoidea, on the
Sinus sphenoidales (sphenoidal bone cavities) which belong to the inside to both the right and left impressions of the Sinus durae ma­
paranasal sinuses. From its lateral edges access to the Orbita can be tris can be seen: the Sulcus sinus sigmoidei, Sulcus sinus petrosi
attained through the Ala minor via the Canalis opticus. Between inferioris, Sulcus sinus occipitalis as well as the Sulcus transver-
the two sphenoidal wings the Fissura orbitalis superior also leads sus and Sulcus sinus sagittalis superioris (› Fig. 9.8). The latter
into the Orbita. The Alae majores are penetrated on both sides by merge at the Protuberantia occipitalis interna (Confluens sinuum).
the Foramina rotundum, ovale, spinosum. Caudal from the Corpus This is connected to the Crista occipitalis interna. Futhermore, on
the Procc. pterygoidei (pterygoid processes) rise on both sides; the inside within the respective Squama occipitalis the Fossa cere­
these are divided into the smaller Lamina medialis and larger bellarisa can be seen, in which the cerebellum is located. Externally
­Lamina lateralis. the Linea nuchalis inferior and the above lying Linea nuchalis su­
perior are raised up (in some bony skulls a Linea nuchalis suprema
Os parietale can also be found). The Condyli occipitales are located on the sur­
The paired Os parietale (parietal bone) constitutes the major part face of the Partes laterales, through which the skull articulates with
of the lateral skull and of the skull roof (› Fig. 9.9, › Fig. 9.10). It the first cervical vertebra (Atlas). Above the condyles, on the lateral
is convex and has 4 edges, through which it is connected to the edges of the Foramen magnum, lies the Canalis nervi hypoglossi
adjacent bones: (point of penetration of the N. hypoglossus [XII]).
• Anterior via the Sutura coronalis with the Os frontale
• Lateral via the Sutura squamosa with the Os temporale (and to a
minor degree with the Os sphenoidale)

Sutura sagittalis
Os parietale

(Os interparietale; Os incae)

Sutura lambdoidea

(Sutura occipitalis transversa, Var.)

Ossa suturalia

Sutura squamosa

Linea nuchalis inferior Os occipitale, Squama occipitalis

Proc. mastoideus

Proc. styloideus

Linea nuchalis superior Protuberantia occipitalis externa (= Inion)

Fig. 9.10 Skull bones, Ossa cranii. Dorsal view. The majority of the occiput is formed by the Os occipitale and its central structure is the Squama
occipitalis. The most protruding point of the occiput is the well palpable Protuberantia occipitalis externa (Inion), which continues on both
sides into the Linea nuchalis superior (attachment point for muscles of the autochthonous back muscles).

423
9 Head

Clinical remarks • Regio zygomatica*

• Regio buccalis
The stylohyoid syndrome or also EAGLE syndrome is a bunch
• Regio oralis*
of symptoms, which is triggered by a Proc. styloideus that is
too long. The Proc. styloideus can not only be too long, but in • Regio mentalis*
extreme cases also makes flexible joint-like contact with the • Regio parotideomasseterica
Os hyoideum. The Proc. styloideus which is too long sometimes • Regio temporalis*
touches the pharyngeal wall and leads to foreign body sensa- • Regio parietalis*
tion, swallowing problems (dysphagia) and unclear sore throat. • Regio occipitalis*
*The regions marked with an asterisk together form the Regio
­facialis.
The soft tissue includes skin, subcutaneous fat and facial muscles
9.2 Soft tissue covering that form a functional unit with respect to facial expression and
Lars Bräuer, Friedrich Paulsen physiognomy. The facial muscles originate at the skull bone and
­radiate via elastic tendons into the dermis of the skin.

Skills NOTE
The face-to-face encounter is an important aspect of the contact
After working through this chapter, you should be able to: between two individuals. Facial expression plays a major role for
• describe the mimic musculature with attachment, origin, the expression of emotions and a doctor can obtain valuable infor-
function and innervation mation about the emotional and health status of the patients. Un-
• be orientated in the face and the lateral facial region and derstanding the facial structures is therefore of great relevance for
systematically assign the areas practical medical activities.
• name the structure, blood supply, innervation and lymphat- With increasing age, the elasticity of the elastic tendons of the fa-
ic drainage as well as the function of the scalp cial muscles that radiate into the skin becomes reduced. The result
• describe the topographic course of blood vessels, nerves is the formation of wrinkles.
and lymph vessels in the various facial regions
• name important topographical clinical correlations of the The facial muscles are used in addition to facial expression and
lateral facial region
physiognomy for the protection of sensory organs and food intake.
• envisage the three-dimensional anatomical structures which
are lying deep in the lateral facial region and are not visible The masticatory muscles also have a great influence on the form of
from the outside the facial region. The muscles from the shoulder girdle (M. sterno­
cleidomastoideus) and from the vertebral column (neck muscles)
which extend onto the head are involved in head movements in re­
lation to the spine.

9.2.1 Overview
Table 9.7 Facial regions (Regiones faciales).
Friedrich Paulsen
Regio facialis anterior Regio facialis latera- Regio facialis
The skull is externally covered by soft tissues, which are divided lis superficialis ­lateralis profunda
into different regions (Regiones capitis) (› Table 9.7, › Fig. 9.11) • Regio orbitalis • Regio buccalis • Fossa infratemporalis
as in the throat area and torso: • Regio nasalis • Regio parotideomas- • Fossa pterygopalatina
• Regio frontalis • Regio infraorbitalis seterica
• Regio nasalis* • Regio zygomatica
• Regio orbitalis* • Regio oralis
• Regio infraorbitalis* • Regio mentalis

Regio frontalis

Regio orbitalis
Regio parietalis
Regio nasalis
Regio temporalis
Regio infraorbitalis
Regio zygomatica

Regio oralis Regio occipitalis

Regio mentalis Regio parotideomasseterica

Trigonum submentale Regio buccalis

Trigonum musculare (omotracheale) Regio submandibularis

of the Regio cervicalis anterior

Regio sternocleidomastoidea Fig. 9.11 Regions of the head.

[L126]

424
 9.2 Soft tissue covering

The soft tissues of the head can be divided into 3 parts due to struc­ Subcutis
tural features and regional affiorigin: The subcutis contains hair papillae, hair follicles and hair roots in
• SCALP (scalp) the area of the hairy scalp. The subcutis consists for the most part
• Frontal facial region of dense connective tissue, which anchors the skin to the underly­
• Lateral facial region ing Galea aponeurotica (see below). Arteries, veins and nerves for
– Superficial lateral facial region blood supply and innervation of the scalp also run here. In bald ar­
– Deep lateral facial region eas the subcutis is thinner.

Aponeurosis
9.2.2 Scalp The base of the scalp is the Galea aponeurotica, a widespread ten­
Friedrich Paulsen don, which radiates into the front, back and side muscles:
• At the front it is the Venter frontalis of the M. epicranius (M.
The soft tissues of the Calvaria (scalp) extend from the Arcus occipitofrontalis), its paired muscle bellies originate between the
­superciliaris to the Protuberantia occipitalis and the Linea nuchalis Arcus superciliares from the subcutaneous connective tissue of
superior, as well as laterally to the Arcus zygomaticus. the eyebrows and the Glabella and pass in a V-shape to the back.
• At the back it is also the paired Venter occipitalis of the M. epi­
Layers cranius, which originates at the Linea nuchalis suprema and ra­
The functional unit of skin, subcutis and tendon hub (Galea apo­ diates at the level of the middle of the auricle into the aponeuro­
neurotica), which lies above the roof of the skull (Calvaria) (total sis.
thickness approx. 5 mm), is referred to as the scalp. It consists of • Laterally it is the variably occurring M. temporoparietalis. The
several layers that can easily be remembered using the term part facing the skull is also referred to as the M. auricularis supe­
SCALP. (› Fig. 9.12): rior. It belongs to a rudimentary sphincter system that moves the
• S = Skin (Cutis) ear and can close the auditory canal.
• C = Connective tissue (Subcutis) The Galea aponeurotica is firmly fused with the subcutis due to its
• A = Aponeurosis (Aponeurosis epicranialis, Galea aponeurotica strong connective tissue trabecula (retinacula). On contraction the
with M. epicranius) muscles allow a small shift movement of the scalp on the skull. The
• L = Loose connective tissue (subgaleal movable layer) Venter frontalis of the M. epicranius can pull the forehead into
• P = Pericranium (periosteum of the outer surface of the skull wrinkles (frowning).
bones)
The loose subaponeurotic connective tissue connects the Galea Subgaleal layer
aponeurotica with the pericranium, thus allowing the free move­ The lower side of the Galea aponeurotica is attached to the perios­
ment of the scalp on the Calvaria. teum of the skull (pericranium) via loose connective tissue. It
forms the supraperiostal space and for functional reasons is re­
Cutis ferred to as the subgaleal (subgaleatic) layer.
The cutis forms the outer layer of the scalp. It is structurally de­
signed like the skin of the body surface but is coarse at the hairy Pericranium
head surface and contains a particularly large number of hair The periosteum of the Calvaria is firmly fused with the Lamina ex­
shafts, sebaceous glands and sweat glands. On the forehead there terna of the skull bones and the connective tissue of the cranial su­
are only few hairs and no terminal hairs. tures.

Cutis Lamina externa

Subcutis Diploe
Scalp Galea aponeurotica Lamina interna
Subgaleotic layer
a Periosteum (pericranium)

Cutis
Subcutis
Galea aponeurotica Scalp
Subgaleotic layer
Periosteum (pericranium)
Lamina externa
Fig. 9.12 Structure of the scalp.
Diploe
b Suture a SCALP. b Layers of the scalp.
Lamina interna
[L127]

425
9 Head

Clinical remarks • Temporal

– A. and V. temporalis superficialis
Due to the taut connective tissue in the subcutis, the arteries
– N. auriculotemporalis (from [V/2])
are often kept open after injury of the entire scalp. This can
create strong arterial bleeding. If only the skin and subcutis – R. zygomaticotemporalis nervi zygomatici (from [V/2])
are injured there is only little bleeding. Venous bleeding is in • Occipital
contrast mostly pronounced, as the vessels in the taut con­ – A. and V. occipitalis
nective tissue can practically not retract. – A. and V. auricularis posterior
Scalping, as known from Indian stories, involves the scalp be- – N. occipitalis major
ing pulled from the skull, whereby the periosteum can be rela- – N. occipitalis minor
tively easily detached from the bone. This can be taken advan-
– N. auricularis magnus
tage of when practising procedures on the brain by moving the
scalp using a temple cut (from one ear to the other) forwards
and backwards from the periosteum, repositioning it after the Arteries
operation and suturing the skin incision. Injuries (scalping The scalp is supplied with blood from branches of the A. ophthal­
injuries) are also possible in this way. If long hairs get caught mica or branches of the A. carotis externa.
up in a rotating machine, the entire scalp can be torn off. For
this reason, occupational health and safety dictates that a hat Branches of the A. ophthalmica
should be worn when working with such machines.
The front and upper sections of the scalp in the forehead are sup­
During birth, a bloody serous oedema in the subcutis of the
child can occur (particularly in the occiput and parietal bone plied by:
area), which appears as a head bulge (Caput succedaneum). • A. supratrochlearis
Subperiostal bleeding is also possible during birth. Sub- • A. supraorbitalis
periostal bleeding therefore remains limited to individual They branch off in the Orbita from the A. ophthalmica, pass
bones of the Calvaria (cephalhaematoma) since the perioste- through the Orbita rostrally and penetrate with veins and nerves of
um is very strongly fused in the area of the cranial sutures. the same name through the Septum orbitale and the A. supratroch­
learis through the Incisura or the Foramen supratrochleare. To­
gether with the nerves and veins the arteries run over the forehead
upwards and provide the scalp roughly up to the vertex with blood.
Vascular, lymphatic and nervous systems
The vascular, lymphatic and nervous systems reach the scalp from Branches of the A. carotis externa
a frontal, temporal and occipital direction. Here, the vessels, with The largest part of the scalp is supplied with blood from 3 branches
the exception of the forehead, lie in the subcutis. In the forehead of the A. carotis externa (› Fig. 9.13).
the blood vessels run in the subgaleal layer. Vascular, lymphatic • A. auricularis posterior: it is the smallest branch, exits back­
and nervous systems are: wards in the area of the Fossa retromandibularis from the A.
• Frontal carotis externa and then passes below and behind the auricle to
– A., V. and N. supraorbitalis the surface, to supply the area of the scalp.
– A. and V. supratrochlearis

A. temporalis media
A. temporalis superficialis, A. temporalis superficialis,
R. frontalis R. parietalis
A. zygomaticoorbitalis A. temporalis superficialis
Aa. temporales profundae
anterior and posterior A. stylomastoidea

A. transversa faciei
A. occipitalis,
Rr. occipitales
A. meningea media
A. auricularis posterior,
A. sphenopalatina
R. occipitalis
A. angularis
A. auricularis
A. infraorbitalis posterior
A. occipitalis
A. alveolaris
superior posterior R. mastoideus

A. labialis superior R. sternocleidomastoideus

A. maxillaris
A. palatina
descendens A. occipitalis
A. buccalis A. palatina ascendens
A. facialis
A. labialis inferior A. pharyngea ascendens
A. facialis A. carotis externa
R. mentalis A. lingualis
A. carotis interna
A. alveolaris inferior
Bifurcatio carotidis
A. submentalis A. thyroidea superior A. carotis communis Fig. 9.13 Branches of the A.
carotis externa.

426
 9.2 Soft tissue covering

V. temporalis superficialis

V. diploica frontalis V. emissaria parietalis

V. diploica temporalis anterior V. diploica temporalis

posterior

V. supratrochlearis
V. diploica occipitalis
V. nasofrontalis

Plexus pterygoideus

V. angularis
V. emissaria mastoidea

V. occipitalis
V. labialis superior

V. maxillaris

V. cervicalis profunda
V. labialis inferior
V. pharyngea

V. retromandibularis
V. submentalis
V. jugularis externa

V. comitans nervi hypoglossi V. jugularis interna

Fig. 9.14 Tributaries Contribu­
V. thyroidea superior V. facialis ting vessels of the V. jugularis
interna.

• A. temporalis superficialis: it is a terminal branch of the A. entiated (› Fig. 9.15), whereby the temporal, parietal and occipi­
carotis externa, which runs cranially directly in front of the auri­ tal regions always have lymph nodes in the head, while the frontal
cle and divides on the Os temporale into anterior and posterior region drains variably to lymph nodes in the head or throat area:
branches. • Frontal – Nodi lymphoidei preauriculares, Nodi lymphoidei
• A. occipitalis: it exits from the A. carotis externa a little further submandibulares (variable Nodi lymphoidei faciales)
down, passes further to the back and rises, sloping through the • Temporal – Nodi lymphoidei parotidei
neck muscles on the surface anatomy to supply the scalp at the • Parietal – Nodi lymphoidei infraauriculares
occiput and back of the head. • Occipital – Nodi lymphoidei occipitales, Nodi lymphoidei
mastoidei (Nodi lymphoidei retroauriculares, Nodi lymphoidei
Veins auriculares posteriores)
The veins, which drain the blood from the scalp, run with the re­ Finally, from these primary lymph node stations, the lymph reach­
spective arteries (› Fig. 9.14): es the deep cervical lymph nodes.
• V. supratrochlearis and V. supraorbitalis: they collect the blood
from the front scalp from the vertex to the Arcus supraciliaris, Innervation
enter the Orbita with the arteries of the same name and drain The scalp is sensitively innervated (› Fig. 9.16) via the cranial nerves
into the V. ophthalmica superior. There are anastomoses in front and the Plexus cervicalis. The vertex can be considered as the limit.
of the entrance into the Orbita to the V. angularis (branch of the The M. occipitofrontalis and the M. temporoparietalis are, like all fa­
V. facialis) in the nasal angle of the eyelid. cial muscles, innervated by branches of the N. facialis [VII].
• V. auricularis posterior: it collects blood behind and below the
auricle and drains into the V. retromandibularis. Rostral from the vertex
• V. temporalis superficialis: it collects blood from the entire lat­ The area in front of the vertex and in front of the auricle is inner­
eral scalp above the auricles and also drains also into the V. ret­ vated by branches of the N. trigeminus [V]:
romandibularis. • N. supraorbitalis (branch of the N. frontalis from [V/1]): it
• V. occipitalis: it drains the rear section of the scalp between the leaves the Orbita with a R. lateralis (enters through the Foramen
Protuberantia occipitalis externa and the Linea nuchalis superior supraorbitale/Incisura supraorbitalis) and a R. medialis (enters
to the vertex. Below the Linea nuchalis superior it runs through through the Incisura frontalis). Both branches penetrate the
the neck muscles into the depth in the dorsal section of the Venter frontalis of the M. occipitofrontalis and sensitively inner­
throat area. Here, the strong vein is involved in the drainage of vate the frontal area up to the vertex region.
the neck region and flows variably into the V. vertebralis, V. • N. supratrochlearis (branch of the N. frontalis from [V/1]): af­
jugularis externa or V. jugularis interna. In addition, it is con­ ter leaving the Orbita slightly above the nasal angle of the eyelid
nected to the V. diploica occipitalis. its branches innervate the lower middle forehead region.
• R. zygomaticotemporalis nervi zygomatici ( branch from
Lymph vessels [V/2]): its branches innervate a small area of the temporal scalp.
The lymph drainage from the scalp also essentially follows the • N. auriculotemporalis (branch from [V/3]): it extends with the
catchment area of the arteries. A total of 4 drainage areas are differ­ Vasa temporalia superficialia in front of the ear on the surface

427
9 Head

Nodi lymphoidei parotidei superficiales

Nodus lymphoideus buccinatorius

Nodus lymphoideus facialis Nodi lymphoidei mastoidei

M. digastricus, Venter anterior Nodus lymphoideus

jugulodigastricus

Nodi lymphoidei submandibulares

Nodi lymphoidei occipitales

Nodi lymphoidei submentales

Nodi lymphoidei cervicales laterales, M. sternocleidomastoideus

Nodi lymphoidei profundi superiores M. splenius capitis
M. omohyoideus, Venter superior Nodi lymphoidei cervicales laterales,
Nodi lymphoidei superficiales
Nodi lymphoidei cervicales laterales,
Nodi lymphoidei profundi inferiores M. levator scapulae
N. accessorius [XI]
Nodus lymphoideus juguloomohyoideus
M. scalenus medius
A. carotis communis
M. trapezius
V. jugularis interna
M. scalenus posterior
Nodus lymphoideus cervicalis lateralis, Plexus brachialis,
Nodus lymphoideus profundus inferior Pars supraclavicularis
M. scalenus anterior M. omohyoideus, Venter inferior

Fig. 9.15 Superficial lymph nodes of the face.

R. zygomaticofacialis and into the lateral occipital region, from where it directs sensory in­
R. zygomaticotemporalis Crown formation of the scalp.
of N. zygomaticus • N. occipitalis major (R. posterior of C2): it arises below the M.
obliquus capitis inferior (› Chap. 3.2.2) from the depth of the
Trigonum vertebrale upwards, penetrates the Mm. semispinalis
capitis and trapezius and then runs with its branches from the
occipital region to the vertex, to sensitively innervate the largest
N. supra- part of the scalp.
trochlearis
• N. occipitalis tertius (R. posterior of C3): like the N. occipitalis
N. supra- major, it initially penetrates the Mm. semispinalis and trapezius.
orbitalis N. occipitalis In doing so, it runs on the centre line and then innervates a
major
small area at the rear of the scalp close to the midline.
N. occipitalis
tertius
N. occipitalis
minor 9.2.3 Face and facial soft tissue
C4 Lars Bräuer, Friedrich Paulsen
N. auriculo-
temporalis N. auricularis
magnus Surface anatomy
Friedrich Paulsen
Fig. 9.16 Innervation of the scalp. [L126]
The face extends from the nose root and the eyebrows up to the
ears, including the auricles, as well as to the rear edge of the Man­
and innervates the usually hairy part of the temporal region and dibula and comprises the Regiones orbitalis, nasalis, infraorbitalis,
the scalp with its Rr. temporales superficiales. zygomatica, oralis and mentalis (› Fig. 9.11).
From a clinical perspective the face is divided into:
Occipital from the vertex • A middle (frontal) area (Regio facialis medialis)
Behind the auricle and the vertex, the scalp is sensitively innervated • A paired lateral area (Regio facialis lateralis)
by branches of the Plexus cervicalis (› Fig. 9.16). The lateral area is divided into:
• N. auricularis magnus (from the Punctum nervosum [ERB's • Superficial (Regio facialis lateralis superficialis) and
point], Rr. anteriores of C2 and C3): the powerful nerve inner­ • Deep (Regio facialis lateralis profunda)
vates the skin behind the auricle with its branches. The branches Anatomically, the frontal region (Regio facialis, › Fig. 9.11)
also reach skin areas in the throat area underneath the auricle. ­belongs to the Calvaria due to its relationship with the cranial cavity;
• N. occipitalis minor (from the Punctum nervosum [ERB's however, in general usage the face extends up to the hairline and
point], R. anterior of c2): It runs along the rear edge of the M. therefore includes the forehead. Characteristics of the face (Facies)
sternocleidomastoideus up via the attachment area of the muscle are the eyes, nose and mouth. If the eyes and mouth are taken as

428
 9.2 Soft tissue covering

the horizontal limits, the face can be divided into an upper, a mid­ strongly developed on the cheeks and chin. The vessels and nerves
dle and a lower section. run in the subcutis.
The foundations of the face are the skull skeleton and cartilaginous
skeleton from the external nose and auricle. They are covered with
a relatively thin soft tissue coat, which includes the skin, the subcu­
Clinical remarks
taneous connective and fatty tissues and the mimic muscles. Prom­ Due to the loose subcutaneous connective tissue on the eye-
inent points of the face are the eyebrow bulges (Arcus supracili­ lids, severe swelling may occur, which make it impossible to
ares), the outer nose, the zygomatic arch (Arcus zygomatici), the open the eyelids (lid oedema). The incision during surgical in-
auricles and the chin (Mentum). terventions on the face always follow the tension lines of the
skin (RSTL, ‘relaxed skin tension lines’) in order to avoid visi-
The fatty material of the cheek is involved in the formation of the
ble scars to a large extent.
lateral facial region as well as (Corpus adiposum buccae, BI-
CHAT'S fat-pad), the M. masseter and the Glandula parotidea.

Eye area, Regio orbitalis Mimic muscles (Mm. faciei)

The Regio orbitalis (› Fig. 9.11) is determined by the eyelids (Pal­ Lars Bräuer
pebrae) and by the shape, density and position of the eyebrows The Mm. faciei are muscles, which are decisively responsible for
(Supercilii). An upper (Palpebra superior) and a lower (Palpebra the expression of the face and the formation of an individual face
inferior) eyelid limit the palpebral fissure (Rima palpebrarum) expression (physiognomy). They are also important for food in­
and cover the front part of the eyeball when the eyes are closed. On take and speech development (muscles in the area of the mouth).
the side the eyelids merge at the nasal and temporal palpebral angle Moreover, they have protective functions (muscles of the eye, cor­
(Angulus oculi medialis and Angulus oculi lateralis) (› Fig. neal reflexes). On an evolutionary level the facial muscles, which
9.11). are arranged around the eyes, ears, nose and mouth, have a protec­
tive function because they can close the corresponding body open­
Nasal region, Regio nasalis ing; however, some of these muscles in humans are only in rudi­
The Regio nasalis (› Fig. 9.11) is determined by the external scaf­ mentary form (around the ear).
fold of the nose. The foundations are the root of the nose (Radix The paired M. orbicularis oculi, the unpaired M. orbicularis oris
nasi), the the nasal bridge (Dorsum nasi), the paired nose wings and unpaired M. occipitofrontalis form the largest area of the facial
(Alae nasi), the tip of the nose (Apex nasi), the nostrils (Nares) muscles (› Fig. 9.17). The small facial muscles are highly individ­
and the interjacent nasal septum (Septum nasi). The nasal orifices ually distinct and enable delicate and unique facial expressions
form the entrance to the respiratory tract. The nasolabial folds de­ (e.g. M. risorius, M. corrugator supercilii).
scend laterally on the nasal wings (Sulcus nasolabialis) to the cor­ The facial muscles are directly connected with the dermis above
ners of the mouth (› Fig. 9.11). It is only weakly formed in young the superficial muscular aponeurotic system (SMAS, see below), so
people and emerges more prominently from the 4th decade of life. that by corresponding contraction or relaxation they stretch or
compress and therefore enable the facial expressions. The excep­
Oral region, Regio oralis tion is the M. buccinator, which has a muscle fascia. The facial
The Regio oralis (› Fig. 9.11) is limited by the upper lip (Labium muscles originate mostly from bony or cartilaginous structures of
superius) and bottom lip (Labium inferius), which merge on the the skull skeleton and are attached to elastic tendons in the skin.
corners of the mouth (Angulus oris) (Commissura labiorum). A Circularly routed muscles around the ocular and oral cavities re­
small bump is formed in the midline on the upper lip (Tubercle semble a sphincter, which facilitates the closing of the mouth and
labii superioris), and the border of the vermilion to the facial skin eye cavities. The facial muscles (including the Platysma) develop as
describes a double arch (Cupid's bow). From here a 8-10 mm wide a unit of the 2nd pharyngeal arch with the nerve (N. facialis [VII]),
groove runs, narrowing from the bottom upwards (Philtrum) to which innervates them. In the following the two larger and circular
the nose root (in ancient times, the Philtrum was considered as one muscles running around the eye and mouth openings are de­
of the erogenous zones of the body, therefore Cupid's bow) (› Fig. scribed in detail. All facial muscles are summarised in › Table 9.8.
9.11).
M. orbicularis oris
Chin area, Regio mentalis The M. orbicularis oris is an annular muscle around the mouth
The Regio mentalis (› Fig. 9.11) is limited from the Regio oralis opening (› Fig. 9.17). It forms the muscular basis for the lips and
by the transverse chin-lip furrow (Sulcus mentolabialis) (› Fig. is motorically innervated by 3 branches of the N. facialis:
9.11). The different protrusion at the chin is mainly based on the • Upper lip – Rr. zygomatici
amount of subcutaneous fat and less on the bony chin protrusion • Corner of the mouth – Rr. buccales
(Protuberantia mentalis). In some people the M. mentalis • Lower lip – R. marginalis mandibulae
­(› Table 9.8), which radiates into the skin, causes an intense dim­ The arch-shaped muscle fibres can be divided according to their
ple in the skin of the chin. location and their course into 2 large parts:
• Pars marginalis – around the oral fissure
Facial skin • Pars labialis – the largest part of the muscle, extends from the
The nature and properties of the skin and subcutis show large re­ upper lip to the nasal septum and from the lower lip to the chin
gional differences. Above the nasal wings, the cheeks and the chin A further part known as the M. rectus labii, is formed from the in­
the skin is comparatively thick, in contrast it is relatively thin above dividual radially running muscle fibres. If the peripheral parts of
the eyelids. The distribution of sweat and sebaceous glands also the muscle (Pars labialis) are contracted, the lips become pointed
show extreme variation on a regional level. On the eyelids and on (pouting, whistling).
the auricle there is a lack of subcutaneous fat tissue; in contrast it is

429
9 Head

Galea aponeurotica

M. procerus

M. epicranius, M. occipitofrontalis, M. corrugator supercilii

Venter frontalis

M. depressor supercilii

M. levator labii superioris

M. temporoparietalis alaeque nasi

M. nasalis
M. orbicularis oculi,
Pars palpebralis M. levator labii superioris

M. orbicularis oculi,
Pars orbitalis M. zygomaticus minor
M. levator labii
superioris alaeque nasi M. zygomaticus major

M. zygomaticus minor M. depressor septi nasi

M. levator labii superioris
M. levator anguli oris
M. zygomaticus major
Ductus parotideus
M. levator anguli oris M. buccinator
M. orbicularis oris M. masseter

M. risorius
Platysma
Platysma

M. depressor anguli oris

M. depressor anguli oris M. depressor labii inferioris
M. sternocleidomastoideus
M. depressor labii inferioris
Platysma
M. mentalis
M. orbicularis oris, Pars labialis

Fig. 9.17 Muscles of the face (Mm. faciei). Rostral view.

Clinical remarks • Pars orbitalis: the Pars orbitalis lies completely externally, runs
above and below the bony orbital rim, and overlaps the Venter
The Orbicularis oris reflex (moustache reflex) is for checking and frontalis of the M. occipitofrontalis at the top. The Pars orbitalis
excluding disorders of the upper motor neuron of the N. facialis emits fibres to the eyebrows, which lowers them (M. depressor
[VII] or the nerve tracts between the pons and cortex. By tapping
the face above the corner of the mouth affected patients con-
supercilii). The lower part of the Pars orbitalis borders on the
tract the M. orbicularis oris as a reflex and the point of their lips. M. zygomaticus minor.
Healthy people and patients with damage of the lower motor • Pars palpebralis: the Pars palpebralis forms the foundation for
neuron do not show this reflex. The N. trigeminus [V] is an affer- the eyelids and lies between subcutis and tarsus or Septum orbit­
ent leg of the reflex, the facial nerve [VII] is the efferent leg. ale. The muscle fibres originate at the Lig. palpebrale mediale
The highly toxic exotoxins of the bacterial species Clostridium and run when the lid is closed to the Lig. palpebrale laterale. On
botulinum and Clostridium butyricum have been increasingly the edge of the eyelid muscle fibres radiate from the Pars palpe­
applied in recent years very highly diluted in clinical and plas-
tic/cosmetic treatment. As such Botox has achieved record
bralis into the tarsus and entwine the excretory ducts of the
sales worldwide as a drug and wrinkle treatment. This involves Glandulae tarsales located in the tarsus. These muscle fibres are
low concentrations of the botulinus toxin being injected subcu- referred to as Fasciculi ciliares or RIOLAN's muscles.
taneously or intramuscularly, depending on the indications. • Pars lacrimalis: the part also designated as HORNER's muscle
is covered by the other two muscle units. It runs from the Saccus
lacrimalis to the Pars palpebralis and entwines on the way the
M. orbicularis oculi Canaliculi lacrimales superior and inferior. It is essential for the
The M. orbicularis oculi is the only muscle which can close the eye tear transport when the eyelids are closed.
(› Fig. 9.17). It has a similar arch-shaped course as the M. orbicu­ The M. orbicularis oculi is integrated into the reflex arch to be able
laris oris. Its fibres run around the bony edge of the Orbita and are to quickly close the eye if required (e.g. opticofacial reflex, corneal
used for the tight closure of the eye by the eyelids. The muscle, and conjunctival reflex).
which is also innervated by the N. facialis [VII] (upper lid – Rr.
temporales, lower eyelid – Rr. zygomatici) is divided into the fol­
lowing three parts:

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 9.2 Soft tissue covering

Table 9.8 Mimic muscles. The facial nerve [VII] is responsible for innervation.

Origins Attachment Function

Forehead, vertex, temples
M. occipitofrontalis
• Venter frontalis: skin of the forehead (› Fig. 9.17) Galea aponeurotica Forehead:
• Venter occipitalis: Linea nuchalis suprema (› Fig. 9.18) • Venter frontalis: frowning (amazement)
• Venter occipitalis: smooths forehead wrinkles
M. temporoparietalis (› Fig. 9.18)
Skin of the temple, Fascia temporalis Galea aponeurotica Moves the scalp downwards
M. occipitofrontalis and M. temporoparietalis are referred to together as the M. epicranius

Auricle
M. auricularis anterior (› Fig. 9.18)
Fascia temporalis Front of the auricle Moves the auricle upwards to the front
M. auricularis superior (› Fig. 9.18)
Galea aponeurotica Top of the auricle Moves the auricle upwards to the back
M. auricularis posterior (› Fig. 9.18)
Proc. mastoideus At the back of the auricle Moves the auricle backwards

Eyelids
M. orbicularis oculi (surrounds the Aditus orbitalis like a sphincter), › Fig. 9.17)
• Pars orbitalis: Pars nasalis of the Os frontale, Proc. frontalis of • Pars orbitalis: Lig. palpebrale laterale Closes the eyelids (tight closure)
the Maxilla, Os lacrimale, Lig. palpebrale mediale
• Pars palpebralis: Lig. palpebrale mediale, Saccus lacrimalis • Pars palpebralis: Lig. palpebrale laterale
• Pars lacrimalis: crista lacrimalis posterior of the Os lacrimale,
Saccus lacrimalis • Pars lacrimalis: lacrimal canaliculus, eyelid Eyelid closure
margins

Extends the lacrimal sac

M. depressor supercilii (separation of the Pars orbitalis from the M. orbicularis oculi, › Fig. 9.17)
Pars nasalis of the Os frontale, bridge of the nose Medial third of the skin of the eyebrows Lowers the skin of the eyebrows
M. corrugator supercilii (› Fig. 9.17)
Pars nasalis of the Os frontale Middle third of the skin of the eyebrows Pulls the skin of the forehead and eyebrows towards
the root of the nose, creates a vertical fold above the
root of the nose (anger, thinking)
M. procerus (› Fig. 9.17)
Os nasale Skin of the glabella Horizontal folding of the bridge of the nose (frowning)

Nose
M. nasalis (› Fig. 9.17)
• Pars alaris: Maxilla at the level of the lateral incisor tooth • Pars alaris: nasal wings, edge of the nostrils Moves the nostrils and thus the nose
• Pars transversa: Maxilla at the level of the canine tooth • Pars transversa: tendon plate of the bridge • Pars alaris: expands the nostrils
of the nose • Pars transversa: narrows the nostrils
M. depressor septi nasi (› Fig. 9.17)
Maxilla at the level of the medial incisor tooth Cartilago septi nasi Moves the nose downwards

Mouth
M. orbicularis oris (› Fig. 9.17)
Pars marginalis and Pars labialis: lateral of the Angulus oris Skin of the lips Closes the lips, tips of the mouth
M. buccinator (› Fig. 9.17)
Maxilla, Raphe pterygomandibularis, Mandibula Angulus oris Tenses the lips, results in an increase of the internal
pressure of the oral cavity, e.g. when blowing or
chewing
M. levator labii superioris (› Fig. 9.17)
Maxilla via Foramen infraorbitale Upper lip Pulls the upper lip laterally upwards
M. depressor labii inferioris (› Fig. 9.17)
Mandibula below the Foramen mentale Bottom lip Pulls the lower lip laterally downwards
M. mentalis (› Fig. 9.17)
Mandibula at the level of the lower lateral incisor tooth Skin of the chin Creates chin dimples, pushes the lower lip forwards
(together with the M. orbicularis oris; ‘pout’)

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9 Head

Table 9.8 Mimic muscles. The facial nerve [VII] is responsible for innervation (continued)

Origins Attachment Function

M. transversus menti
Transverse separation from the M. mentalis Skin of chin bulge Moves the chin skin
M. depressor anguli oris (› Fig. 9.17)
Lower rim of the Mandibula Angulus oris Pulls the mouth downwards
M. risorius (› Fig. 9.17, › Fig. 9.18)
Fascia parotidea, Fascia masseterica Angulus oris Broadens the mouth (grin), creates dimples
M. levator anguli oris (› Fig. 9.17)
Fossa canina of the Maxilla Angulus oris Pulls the mouth angle medially upwards
M. zygomaticus major (› Fig. 9.17)
Os zygomaticum Angulus oris Pulls the mouth angle laterally upwards
M. zygomaticus minor (› Fig. 9.17)
Os zygomaticum Angulus oris Pulls the mouth angle laterally upwards
M. levator labii superioris alaeque nasi (› Fig. 9.18)
Proc. frontalis of the Maxilla (medial Orbita wall) Nasal wings, upper lip Lifts the lips and the nasal wing

Throat
Platysma (› Fig. 9.17, › Fig. 9.18)
Basis mandibulae, Fascia parotidea Skin underneath the Clavicula, Fascia pecto- Tenses the skin of the neck, generates longitudinal
ralis folds

M. auricularis anterior Galea aponeurotica

M. epicranius, M. occipitofrontalis,
M. epicranius, M. temporoparietalis
Venter frontalis

M. orbicularis oculi, Pars palpebralis M. auricularis superior

M. depressor supercilii
M. procerus
M. epicranius,
M. orbicularis oculi,
M. occipitofrontalis,
Pars orbitalis
Venter occipitalis
M. nasalis

M. levator labii M. auricularis

superioris alaeque nasi posterior
M. levator labii superioris
M. semispinalis
M. zygomaticus minor capitis

M. orbicularis oris M. sternocleido-

mastoideus
M. zygomaticus major
M. splenius capitis
Panniculus adiposus
M. trapezius
M. orbicularis oris
M. depressor labii inferioris
M. mentalis
M. depressor anguli oris
M. risorius
Platysma

Fig. 9.18 Facial muscles (Mm. faciei) left. Lateral view. The M. occipitofrontalis is connected by a connective tissue plate (Galea aponeurotica)
and is divided into a front (Venter frontalis) and posterior part (Venter occipitalis). The Platysma is in scope and size highly variable, developed
more strongly in men than in women and ranges from the base of the Mandibula to above the Clavicula (sometimes even up to the Fascia pec-
toralis).

432
 9.2 Soft tissue covering

Clinical remarks the M. masseter (where it is strongly coiled [reserve stretching ap­
paratus]), laterally at the corner of the mouth and past the nose to­
A paralysis of the M. orbicularis oculi is a common symptom
wards the nasal corner of the eye. It enters here as the A. angularis
in facial paralysis and leads to the inability to close the eye.
The result is an avulsion of the lacrimal film with subsequent into the Orbita. It its course the artery is located
opacity of the cornea, as the lacrimal film no longer moistens • below the Platysma, M. risorius, M. zygomaticus major, M. zy­
the cornea when blinking. gomaticus minor
• above the M. masseter, M. buccinator, M. levator anguli oris
• above the M. levator labii superioris or penetrates it
Branches of the A. facialis are:
Vascular, lymphatic and nervous systems • A. labialis inferior: supplies the upper lip with blood
Friedrich Paulsen • A. labialis superior: supplies the upper lip and with an A. septi
In the Regio facialis anterior the arteries, veins and nerves run nasi anterior parts of the nasal septum with blood
largely independently of each other to supply the soft tissue coating. • A. nasalis lateralis: serves the blood supply of nasal wing and
the bridge of the nose
Arteries The terminal branch of the A. facialis is the A. angularis. It anasto­
The arterial blood supply is mostly undertaken by branches of the moses with the A. dorsalis nasi (see below).
A. carotis externa (› Fig. 9.13, › Fig. 9.19, › Fig. 9.20) and to a
minor degree by a branch of the A. carotis interna. NOTE
The Aa. labiales inferiores and the Aa. labiales superiores on both
A. carotis externa sides anastomose with each other and form a vascular ring around
The A. facialis is the most important arterial vessel of the middle the mouth.
facial region. It originates in the throat area in the Fossa retroman­
dibularis from the A. carotis externa and passes diagonally towards The A. maxillaris (› Fig. 9.20) emits several branches for the sup­
the upper front . It runs on the inside of the Angulus mandibulae ply of the face:
runs up to the posterior margin of the Glandula submandibularis • A. infraorbitalis: enters through the Foramen infraorbitale and
to the front and turns at the Corpus mandibulae from the outside supplies the Regio infraorbitalis with blood
over the bones. From here it continues in a diagonal course past

V. temporalis media A. temporalis superficialis, R. frontalis

N. zygomaticus, R. zygomaticotemporalis N. supraorbitalis, R. lateralis

A. temporalis superficialis, R. parietalis N. zygomaticus, R. zygomaticofacialis

N. supraorbitalis, R. lateralis
A. temporalis superficialis
A. supratrochlearis
A. zygomaticoorbitalis
N. supraorbitalis, R. medialis
N. auriculotemporalis
A. masseterica
A. maxillaris
N. supratrochlearis
V. maxillaris
N. infratrochlearis
N. auricularis posterior N. ethmoidalis anterior,
R. nasalis externus
A. auricularis posterior
A. angularis
N. occipitalis major
N. infraorbitalis
A. occipitalis
N. massetericus with
N. facialis [VII] accompanying A. masseterica

A. occipitalis A. buccalis

M. buccinator
M. sternocleidomastoideus

N. occipitalis minor A. facialis

N. buccalis
M. trapezius
M. orbicularis oris
R. digastricus (VII)
N. mentalis with accompanying A. mentalis
R. stylohyoideus (VII)
N. alveolaris inferior
A. carotis interna
A. alveolaris inferior
A. carotis externa A. facialis
A. lingualis V. submentalis

V. retromandibularis V. facialis

Fig. 9.19 Vessels and nerves in the Fossa retromandibularis.

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9 Head

N. massetericus; A. masseterica A. temporalis profunda posterior;

N. temporalis profundus
A. temporalis superficialis,
R. parietalis M. pterygoideus lateralis

A. temporalis media A. supratrochlearis

A. zygomaticoorbitalis A. angularis

A. transversa faciei A. infraorbitalis

A. tympanica anterior Nn. alveolares superiores,

Rr. alveolares superiores
posteriores
A. maxillaris

Rr. dentales; A. alveolaris

A. meningea media
Rr. peridentales superior posterior

A. carotis externa N. buccalis

A. buccalis
N. lingualis
A. facialis
Raphe pterygomandibularis A.; N. alveolaris inferior
A. facialis
N. mylohyoideus
A. submentalis
Fig. 9.20 Arteries and nerves of
the deep facial regions.

• A. alveolaris inferior, R. mentalis: passes through the Foramen A. carotis interna

mentale to the chin and supplies a small area of the chin with blood The A. ophthalmica lies in the Orbita and emits smaller branches
• A. buccalis: arrives at the outside of the M. buccinator to the for the blood supply of the face:
face and supplies a border area of the mid-facial region • A. dorsalis nasi: terminal branch of the A. ophthalmica, exits
The A. temporalis superficialis ascends in the lateral facial region mostly at the nasal corner of the eyelid and supplies the bridge of
in front of the ear to the temporal region and emits branches in the the nose
direction of the mid-facial region: • R. nasalis externus of the A. ethmoidalis: passes at the carti­
• A. transversa faciei: arrives at the front edge of the Glandula pa­ lage-bone demarcation of the bridge of the nose to the surface
rotidea in the lateral facial region and reaches the Regio infraor­ and contributes to the blood supply to the external nose
bitalis with its branches • A. zygomaticofacialis: branch of the A. lacrimalis, passes
• A. zygomaticoorbitalis: passes above the Arcus zygomaticus to through the Foramen zygomaticofaciale into the face and sup­
the lateral corner of the eye

Ramus mandibulae Plexus pterygoideus

N. massetericus; A. masseterica V. temporalis media

N. auriculotemporalis
N. supraorbitalis, R. lateralis
V. temporalis media
N. supraorbitalis, R. medialis
N. auriculotemporalis

V. temporalis superficialis A. angularis

A. maxillaris A. dorsalis nasi

V. maxillaris A. facialis
N. facialis [VII]
N. infraorbitalis
Lig. sphenomandibulare
N. buccalis
V. retromandibularis

A. carotis externa V. profunda faciei

N.; A. alveolaris inferior A. buccalis

N. lingualis V. facialis
A. carotis externa
N. mentalis
A. carotis interna
Plexus dentalis inferior
A. lingualis

V. retromandibularis N. mylohyoideus

V. facialis V. submentalis Fig. 9.21 Veins and nerves of

the lateral deeper facial region.

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 9.2 Soft tissue covering

plies the area above the Arcus zygomaticus to above the lateral Table 9.9 Sensory innervation of the face.
area of the upper eyelid
Branch Innervation area Point of penetration
• Aa. palpebrales laterales: branches of the A. lacrimalis, which
pass through the Foramen zygomaticotemporale or Foramen zy­ N. ophthalmicus [V/1]
gomaticofaciale to the Regio zygomatica and to the Fossa tem­ • N. lacrimalis Lateral area of the upper
poralis; are involved in the formation of the Arcus palpebrales in lid
the upper and the lower eyelids • N. frontalis
• Aa. palpebrales mediales: branches of the A. supratrochlearis • R. medialis of the Middle portions of the Incisura frontalis
and are involved in the formation of the Arcus palbebrales of the N. supraorbitalis forehead to the vertex
upper and the lower eyelids • R. lateralis of the Lateral portions of the Incisura supraorbitalis
N. supraorbitalis forehead to the vertex (Foramen supraorbitale)
Veins • N. supratrochlearis Medial area of the upper From the Orbita
The main vessel of the middle facial region is the V. facialis, which and the lower eyelids
originates as V. angularis in the nasal corner of the eye (› Fig. 9.14).
• N. nasociliaris
First, the vein runs behind the artery, then passes more dorsally
• N. infratrochlearis Skin at the nasal corner From the Orbita
­below the Mm. zygomatici major and minor in front of the M.
of the eyes
masseter over the M. buccalis. At the Corpus mandibulae, the V.
and A. facialis lie next to each other again, the artery crosses the • Rr. nasales externi Skin of the bridge of the
from N. ethmoidalis nose
Mandibula in front of the vein before both vessels reach the Glan­
anterior
dula submandibularis. The V. angularis is connected via the Orbita
N. maxillaris [V/2]
to the V. ophthalmica superior and via this with the Sinus cav­
ernosus. There are connections from the V. facialis via the V. trans- • N. infraorbitalis Foramen infraorbitale
versa faciei to the V. temporalis superficialis. The V. facialis com­ • Rr. palpebrales Lower eyelids, particular-
bines with the V. retromandibularis and flows into the V. jugularis ­inferiores ly lateral area
interna (› Fig. 9.21). In addition, all of the abovementioned arter­ • Rr. nasales externi and Outer nose and Vestibu-
ies of the middle facial region are accompanied by veins, which interni lum nasi
connect to the larger vein stems. They are named the same as the • Rr. labiales superiores Upper lip
arteries. The course of the veins varies greatly in the facial area.
• N. zygomaticus
• R. zygomaticofacialis Skin above the Foramen
Lymph vessels
Os ­zygomaticum ­zygomaticofaciale
The lymph of the middle facial region (› Fig. 9.15) is drained to the:
• Nodi lymphoidei submentales • R. zygomatico­ Frontal area of the Foramen
temporalis t­ emple ­zygomaticotemporale
• Nodi lymphoidei submandibulares
• Nodi lymphoidei faciales buccales (inconstant) N. mandibularis [V/3]
• Nodi lymphoidei parotidei • N. auriculotemporalis
• Rr. temporales Temporal region in front
Innervation ­superficiales and above the auricle
Sensory • Nn. auriculares The front part of the
Sensory information from the middle facial region passes via the ­anteriores ­auricle surface
branches of the N. trigeminus [V] and a branch from the Plexus • N. buccalis Skin of the cheek
cervicalis to the CNS (› Fig. 9.19, › Fig. 9.20, › Fig. 9.21). In­
• N. mentalis from N. Skin of the chin and the
nervation by the
alveolaris inferior lower lip
• N. ophthalmicus [V/1] of the upper part of the face, including
Plexus cervicalis
the forehead to the vertex, the upper eyelids, the nasal corner of
the eyelid and bridge of the nose • N. auricularis magnus Jaw angle and ear lobes From Punctum nervosum
• N. maxillaris [V/2] of the middle face from the lower eyelids up to (ERB's point)

the corners of the mouth including the upper lip and the nostrils
• N. mandibularis [V/3] of the lower part of the face with lower branches a number of fibres are exchanged (hence Plexus parotide­
lip and chin up to the lower rim of the Mandibula us) within the parotid gland in the procedure. At the top, front and
• N. auricularis magnus (Rr. anteriores of C2 and C3) of a small lower rim of the Glandula parotidea, 5 terminal branch groups
area in front of and below the ear lobes and the mandibular angle emerge from the plexus parotideus: Rr. temporales, Rr. zygomati-
Detailed information on sensoy innervation is summarised in ci, Rr. buccales, R. marginalis mandibulae and R. colli. In princi­
› Table 9.9. ple, the distribution pattern is variable, but basically the 5 terminal
branch groups, which according to › Table 9.10innervate the fa­
Motor cial muscles, can be distinguished. Shortly after leaving the Fora­
The facial muscles, the mimic muscles around the auricle and men stylomastoideum, the N. auricularis posterior runs back to
those inserted on the scalp emerge from the 2nd pharyngeal arch. innervate the mimic muscles behind and above the ear and the
The nerve of the 2nd pharangeal arch is the N. facialis [VII], which Venter posterior of the M. occipitofrontalis (› Table 9.10).
innervates all the facial muscles(› Fig. 9.22). After leaving via the
Foramen stylomastoideum on the external skull base, the nerve Vegetative
turns forward and enters the Glandula parotidea, where it forms Postganglionic parasympathetic nerve fibres for the innervation of
the Plexus parotideus. Its main stem often divides into an upper blood vessels and skin glands of the middle facial region originate
R. temporofacialis and a lower R. cervicofacialis. Between the two from the Ganglion pterygopalatinum and the Ganglion oticum.

435
9 Head

Table 9.10 Motor branches of the N. facialis [VII] for innervation of Sympathetic nerve fibres are derived from postganglionic neurons
the facial muscles. of the Ganglion cervicale superius, which run as periarterial plexusi
Muscle Branch with the branches of the A. carotis externa (Plexus caroticus exter­
nus) or the A. carotis interna (Plexus caroticus internus) and e.g. in­
Venter frontalis of the M. occipitofron- Rr. temporales nervate blood vessels, sweat glands and hair. Some nerve fibres con­
talis
nect in the area of the Ganglion trigeminale to the branches of the
M. corrugator supercilii Rr. temporales N. trigeminus [V] and reach their target areas of the face in this way.
M. orbicularis oculi (above the eyelids) Rr. temporales
M. procerus Rr. temporales and/or Rr. zygomatici
M. depressor supercilii Rr. temporales and/or Rr. zygomatici
9.2.4 Superficial lateral facial region
Friedrich Paulsen
M. orbicularis oculi (below the eyelids) Rr. zygomatici
M. levator labii superioris alaeque nasi Rr. zygomatici Limits of the Regio facialis lateralis superficialis are the Sulcus na­
M. zygomaticus major Rr. zygomatici solabialis, the external ear to the Proc. mastoideus, the Arcus zygo­
M. zygomaticus minor Rr. zygomatici maticus and the lower margin of the Corpus mandibulae. It is di­
vided into
M. levator labii superioris Rr. zygomatici
• Regio buccalis and
M. nasalis Rr. zygomatici and/or Rr. buccales
• Regio parotideomasseterica.
M. depressor septi nasi Rr. zygomatici and/or Rr. buccales
M. buccinator Rr. zygomatici and/or Rr. buccales Surface anatomy
M. levator anguli oris Rr. zygomatici and/or Rr. buccales Regio buccalis
The central element of the Regio buccalis is the M. buccinator
M. orbicularis oris Rr. buccales
(› Fig. 9.19, › Fig. 9.20), which forms the basis of the cheek. It is
M. depressor anguli oris Rr. buccales the only mimic muscle with a fascia (Fascia buccopharyngea). Its
M. transversus menti Rr. buccales front muscle fibres radiate into the corner of the mouth, where
M. risorius Rr. buccales they end in muscular nodes (Modiolus anguli oris). Here all muscles
M. depressor labii inferioris R. marginalis mandibulae
extending to the corners of the mouth interlace. Mucous mem­
brane of the oral vestibule in this area is fused with the underlying
M. mentalis R. marginalis mandibulae
musculature and is immovable. At the level of the second upper
Platysma R. colli molar the Ductus parotideus (STENSEN's duct) penetrates the
Venter occipitalis of the M. occipito­ N. auricularis posterior muscle. To the rear, the M. buccinator passes into the Raphe ptery-
frontalis gomandibularis, which originates at the Proc. pterygoideus and
M. temporoparietalis R. auricularis of the N. auricularis runs to the Ramus mandibulae. It is not only the attachment point
­posterior for the M. buccinator, but also for the M. constrictor pharyngis su­
M. auricularis inferior R. auricularis of the N. auricularis perior and forms the border to the Regio parotideomasseterica. Be­
­posterior tween the Raphe pterygomandibularis and the M. pterygoideus
M. auricularis anterior R. auricularis of the N. auricularis medialis running on the inside of the Ramus mandibulae there is a
­posterior gap. It is filled by a fatty body (Corpus adiposum buccae, BI-
M. auricularis superior R. auricularis of the N. auricularis CHAT's fat-pad) (› Fig. 9.23), the front part of which bulges out
­posterior into the Regio buccalis over the rear end of the M. buccinator. The
fatty body consists of structural fat.
On the bottom edge of the fatty body, the Ductus parotideus ex­
tends into the depth and penetrates the M. buccinator. The juxta­
(R. temporofacialis) oral organ (CHIEVITZ's organ) lies on the M. buccinator near to
the site where the Ductus parotideus penetrates (› Fig. 9.23). The
M. zygomaticus major, the M. risorius and the upper part of the
Rr. temporales Platysma run in the Regio buccalis.

Clinical remarks
Rr. zygomatici
In the case of severe emaciation (e.g. due to cancer cachexia
N. auricularis
[wasting]) existing cheek fat made from structural fat can be
posterior broken down. The cheeks then appear sunken. the same is
true for the structural fat in the Orbita, the eyes ‘fall back into
N. facialis the eyeball’. The BICHAT's fat-pad therefore gives the cheek its
Rr. buccales [VII]
contour.
(R. cervico-
facialis)
Rr. marginales
mandibulae NOTE
The juxtaoral organ (CHIEVITZ's organ) is a small, approximately
8×3 mm epithelial organ in the cheek, which is embedded in con-
R. colli
nective tissue rich in nerves and cells, and surrounded by a tight
perineural sheath. A branch of the N. buccalis reaches the organ,
Fig. 9.22 Terminal branches of the N. facialis [VII]. [E402]

436
 9.2 Soft tissue covering

Fascia temporalis, Lamina profunda

Arcus zygomaticus Galea aponeurotica

M. epicranius, M. occipitofrontalis,
Venter frontalis Pericranium

M. corrugator supercilii Fascia temporalis,

Lamina superficialis
Pars palpebralis;
M. orbicularis oculi
Pars orbitalis
M. epicranius,
M. procerus M. temporoparietalis

M. depressor supercilii M. epicranius,

M. occipitofrontalis,
Lig. palpebrale mediale
Venter occipitalis
M. levator labii superioris
alaeque nasi Articulatio temporomandibularis,
Capsula articularis, Lig. laterale
M. nasalis

M. levator labii superioris Glandula parotidea accessoria

M. zygomaticus minor Glandula parotidea

M. levator anguli oris
Ductus parotideus
M. orbicularis oris
Organum juxtaorale*
M. zygomaticus major

M. orbicularis oris M. masseter

M. depressor labii inferioris M. sternocleidomastoideus

M. mentalis
Corpus adiposum buccae
M. risorius

M. depressor anguli oris M. buccinator

M. digastricus, Venter anterior Glandula submandibularis

Fascia cervicalis, Lamina superficialis

Fig. 9.23 Facial muscles, Mm. faciei, masticatory muscles and juxtaoral organ∗ CHIEVITZ's organ.

providing blood supply from the Fossa infratemporalis (see below) superficial part of the Glandula parotidea the ductus parotideus
via the A. buccalis. The function of the juxtaoral organ has not been (STENSEN's duct) leaves the gland and passes in a horizontal
conclusively clarified. It is assumed to have a receptor function, course through the fascia of the M. masseter up to its front edge.
which recognises dynamic changes in chewing, swallowing and
Here it bends into the depths and penetrates the M. buccinator (see
speaking and, among other things, helps to ensure that one does
not bite the cheeks when chewing. above). In its course, it is accompanied in variable shape by the sal­
ivary gland tissue (Glandulae parotideae accessoriae).

Clinical remarks Fascia of the superficial lateral facial region

The M. masseter and M. temporalis have their own fascia. The Fascia
In the past due to a lack of knowledge the juxtaoral organ was masseterica covers the M. masseter and divides into a superficial
frequently confused with a malignant tumour, which resulted and a deep layer that includes as a fascia compartment the Mm. pter­
in extensive and partially disfiguring operations.
ygoidei lateralis and medialis as well as the M. masseter. The superfi­
cial layer is connected to the fascia sheet that covers the Glandula pa­
rotidea (Fascia parotidea). Both leaves together form the Fascia pa-
Regio parotideomasseterica rotideomasseterica. The deep layer includes the Mm. pterygoidei.
The Regio parotideomasseterica extends from the anterior margin The Fascia temporalis also consists of a superficial and a deep lay­
of the M. masseter upwards to the Arcus zygomaticus and down­ er. The strong Fascia temporalis originates along the Linea tempo­
wards to the front edge of the upper part of the M. sternocleido­ ralis superficialis. It is the original field for the superficial parts of
mastoideus. Between the rear edge of the Ramus mandibulae and the M. temporalis. It therefore covers the M. temporalis and splits
the anterior border of the M. sternocleidomastoideus or Proc. mas­ approximately 1–1.5 cm above the zygomatic arch into a superficial
toideus is the retromandibular space (Fossa retromandibularis), and a deep layer. The superficial layer inserts at the outer edge of
which is filled mainly from the deep part of the Glandula parot- the zygomatic arch, the deep layer extends to the inner edge of the
idea (› Chap. 9.7.9). The superficial part of the gland partially zygomatic arch. Therefore, a fat-filled osteofibrous space is created
overlaps the M. masseter. The glandular tissue extends upwards between both sheets.
variably until the tragus and extends caudally to close to the Glan­ The M. buccinator, as the only mimic muscle, is enveloped by a
dula submandibularis (› Fig. 9.23). The parotid gland is covered ­fascia (Fascia buccopharyngea). In addition, the Glandula parot­
on the surface by a single fascia (Fascia parotidea, see below). idea is enclosed by a fascia (Fascia parotidea). The Fascia masseter­
Through the fascia and the Fossa retromandibularis, a compart­ ica and Fascia parotidea are part of the superficial throat fascia lay­
ment is created (parotid gland compartment). On the front of the er (Fascia cervicalis superficialis).

437
9 Head

Clinical remarks region with blood. It generally branches in the gland parenchyma
of the Glandula parotidea almost at right angles from the Aa. tem­
In conjunction with loose subcutis connective tissue of the
poralis superficialis and then runs in a horizontal, slightly descend­
facial skin and with the facial muscles in the face, the fasciae
form a thin, but surprisingly resistant layer, which is referred ing direction over the upper part of the M. masseter through the
to in its entirety as the superficial muscular aponeurotic sys- lateral facial region forwards to the Regio infraorbitalis. Anasto­
tem (SMAS). It extends to the scalp. The SMAS plays the deci- moses with branches of the A. facialis are possible.
sive role in plastic surgery for facelifting: the SMAS can be dis- The V. retromandibularis (› Fig. 9.19) forms the continuation of
sected in the direction of the face and released from the base the V. temporalis superficialis caudally and drains its blood. Its
by means of an arc-shaped incision in front of the ear. A part largest portion runs within the Glandula parotidea. Here it incor­
of the dissected tissue is then removed and the cut edge with
porates the Vv. maxillares and usually runs superficially to the A.
all pertaining hanging structures is moved in the direction of
the ear and firmly sutured. The facial skin is practically carotis externa. At the lower gland pole it leaves the gland and
tautened in the process (› Fig. 9.24). flows after a short course into the V. facialis.
The N. facialis [VII] after leaving the Foramen stylomastoideum
from dorsal extends into the Glandula parotidea. It divides here su­
perficially to the abovementioned vessels usually within the glan­
Vascular, lymphatic and nervous systems dular tissue into an upper and a lower branch (› Fig. 9.22). Both
The vascular, lymphatic and nervous systems of the superficial lat­ branches exchange numerous fibres (Plexus intraparotideus), con­
eral facial region are divided according to their course: tinue to branch out and eventually form 5 terminal branch groups
• Vascular, lymphatic and nervous systems in the parotid gland (› Chap. 9.2.3):
compartment (either for the innervation of the gland or as a • Rr. temporales
transit route) • Rr. zygomatici
• Vascular, lymphatic and nervous systems outside the parotid • Rr. buccales
gland compartment • R. marginalis mandibulae
• R. colli
Vascular, lymphatic and nervous systems of the parotid gland
compartment
These include the A. carotis externa, the V. retromandibularis, the
Clinical remarks
N. facialis [VII] and the N. auriculotemporalis (from [V/3]). Operations within the Glandula parotidea (e.g. in the case of
The A. carotis externa reaches the Fossa retromandibularis from parotid gland tumours) are extremely challenging due to the
medial below the throat area, where it still runs in the carotid ar­ close topographic relationship between the gland and the N.
tery sheath, Glandula parotidea and rises in a cranial direction. It facialis [VII], since all nerve branches have to be retained to
avoid triggering a partial paralysis of the facial muscles (pe-
then divides usually at the level of the Collum mandibulae into the
ripheral damage of the N. facialis [VII]). Since the Fascia parot-
A. maxillaris and the A. temporalis superficialis (› Fig. 9.19). The idea does not stretch swelling caused by inflammation (e.g. in
A. maxillaris remains in the depth of the Fossa retromandibularis the case of Parotitis epidemica = mumps) is extremely painful.
and generally extends behind the Ramus mandibulae into the later­
al deep facial regions (see below). The A. temporalis superficialis
rises upwards through the gland parenchyma and reaches the sur­
face at the upper edge of the Glandula parotidea together with the The N. auriculotemporalis (from [V/3]) extends behind the Col­
V. temporalis superficialis. Both vessels run from the outer ear via lum mandibulae into the Fossa retromandibularis (› Fig. 9.20). In
the zygomatic arch further cranially into the Regio temporalis and doing so, it often envelops the A. meningea media in a loop form.
branch out. The A. transversa faciei is a branch of the A. tempora­ Shortly after its entry into the Glandula parotidea, it divides into
lis superficialis and supplies a part of the superficial lateral facial several branches:
• The main trunk runs cranially in front of the outer ear and
merges with the A. temporalis superficialis (Rr. temporales su-
perficiales).
• The other branches within the Glandula parotidea extend
– to the mandibular joint capsule (R. capsularis articulationis
temporomandibularis)
– to the front surface of the auricle (Nn. auriculares anteriores)
– to the external auditory canal (N. meatus acustici externi)
– to the tympanic membrane (Rr. membranae tympani)
– directly to the Glandula parotidea (Rr. parotidei)
Cutting edge – indirectly via the branches of the N. facialis (Rr. communi-
cantes cum nervo faciali)
Subcutaneous
The Rr. parotidei and the Rr. communicantes cum nervo faciali
mobilisation lead postganglionic parasympathetic fibres for the innervation of
area the parotid gland. The cell body of the preganglionic fibres origi­
nate from the Nucleus salivatorius inferior and extend via the N.
glossopharyngeus via the N. tympanicus (JACOBSON's plexus),
Plexus tympanicus and N. petrosus minor to the Ganglion oticum
where the switch to postganglionic is made. From here, the
post-gangionic fibres initially extend to the N. mandibularis [V/3]
Fig. 9.24 Facelifting. [L126] and then into the N. auriculotemporalis. Recent research suggests

438
 9.2 Soft tissue covering

that the parasympathetic fibres reach the Glandula parotidea only Ala major, Crista infratemporalis
via Rr. parotidei of the N. auriculotemporalis and not via Rr. com­ M. pterygoideus lateralis,
municantes cum nervo faciale; however, this has not yet been con­ Caput superius
clusively clarified. Os temporale,
Proc. zygomaticus
Vascular, lymphatic and nervous systems outside the parotid Fossa mandibularis,
gland compartment Facies articularis
These include (› Fig. 9.19, › Fig. 9.20) the A. and V facialis, the Discus articularis
A. transversa faciei, the A. and V. buccalis and the N. buccalis. Caput mandibulae
The A. facialis and V. facialis usually run separately via the front Capsula articularis
portion of the M. buccinator and in front of the M. masseter. The Tuberculum articulare
artery runs in a coiled path and lies mostly in front of the vein – its
pulse can be felt above the Corpus mandibula. In the Regio bucca­ M. pterygoideus lateralis,
lis anastomoses with the A. transversa faciei (from A. temporalis Caput inferius
superficialis) and the A. buccalis (a branch of the A. maxillaris) are Os zygomaticum, Proc. temporalis
common. The vein extends via the Angulus mandibulae caudally M. pterygoideus medialis,
and to the rear and merges below the Angulus mandibulae with the (Pars medialis)
V. retromandibularis to flow into the V. jugularis interna. M. pterygoideus medialis,
(Pars lateralis)
The A. buccalis and V. buccalis reach the lateral facial region from
the rear (› Fig. 9.20). They extend between the M. pterygoideus Fig. 9.25 Location of the Mm. pterygoidei in the Fossa infratempora-
medialis and M. buccinator to the surface and branch out onto the lis.
M. buccinator to supply blood to the muscle. Anastomoses often
occur to the A. and V. facialis. • M. buccinator: only a small rear part of the muscle with the
The N. buccalis reaches the cheek together with the Vasa buccalia transition to the M. constrictor pharyngis superior lies in the
via the Fossa infratemporalis (see below) (› Fig. 9.20). It is re­ Fossa infratemporalis and is covered by the M. pterygoideus me­
sponsible for the sensory innervation of the skin above the cheek dialis. The front portion is part of the superficial lateral facial re­
and the buccal and vestibular gingiva in the area of the molar teeth; gion (see above).
however, the innervation can extend to the canine teeth.
Vascular, lymphatic and nervous systems
Vascular, lymphatic and nervous systems of the Fossa infratempo­
9.2.5 Deep lateral facial region ralis are the intermuscular part of the A. maxillaris (Pars ptery­
Friedrich Paulsen goidea), of the venous Plexus pterygoideus the branching of the N.
mandibularis [V/3], the Ganglion oticum and the Chorda tympani.
Fossa infratemporalis The A. maxillaris is one of the two terminal branches of the A.
The temporal fossa (Fossa temporalis) continues below the Arcus carotis externa. It moves at a right angle behind the mandibular ra­
zygomaticus caudally into the infratemporal fossa (Fossa infra- mus into the Fossa infratemporalis (› Fig. 9.20). It therefore runs
temporalis). As such the latter belongs to the deep part of the lat­ in front of the Lig. sphenomandibulare. It penetrates the Fossa in­
eral facial region (Regio facialis lateralis profunda) and stretches fratemporalis mostly lateral to the M. pterygoideus lateralis and
into the depth of the external skull base. Its limitations and rela­ less often it penetrates the muscle medially. Its end section extends
tionships are summarised in › Table 9.11(› Fig. 9.5). into the Fossa pterygopalatina. The artery has numerous vessel ex­
The contents of the Fossa infratemporalis are muscles and vascular, its and is divided into three sections (› Table 9.12).
lymphatic and nervous systems. Muscles are (› Fig. 9.25): The Plexus venosus pterygoideus is a distinctive venous plexus
• M. pterygoideus medialis: its attachment to the mandibula between M. temporalis, M. pterygoideus lateralis and M. pterygoi­
forms the caudal limit to the Fossa infratemporalis. The slit-like deus medialis (› Fig. 9.21). Its inflows and outflows are sum­
pterygomandibular space (Spatium pterygomandibulare) lies marised in › Table 9.13. In addition to the drainage of blood it
between the muscle and the mandibula. also has a function within the scope of temperature regulation of
• M. pterygoideus lateralis the brain.

Table 9.11 Bony margins and relationships of the Fossa infratemporalis.

Direction Limitation Connection/neighbourhood relationships

Cranial Facies infratemporalis of the Ala major ossis sphenoidalis, lower front Foramen ovale (N. mandibularis [V/3]), Foramen spinosum (A. meningea
part of the Os temporale media, R. meningeus from [V/3]) with the middle cranial fossa, under the
zygomatic arch with the Fossa temporalis
Medial Lamina lateralis of the Proc. pterygoideus ossis sphenoidalis Opens into the Fossa pterygopalatina
Rostral Facies infratemporalis and Proc. alveolaris maxillae, Facies temporalis Fissura orbitalis inferior with the orbit, Regio buccalis, Foramina alveolar-
ossis zygomatici ia to the Tuber maxillae
Lateral Ramus mandibulae with Proc. coronoideus (and the attachment of the Foramen mandibulae with the mandibula
M. temporalis), Arcus zygomaticus
Occipital Arcus zygomaticus ossis temporalis Fossa retromandibularis (parotid gland compartment), peripharyngeal
space (Spatium peripharyngeum)

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9 Head

Table 9.12 Sections and branches of the A. maxillaris.

Section Branch Blood supply

Pars A. auricularis profunda Temporomandibular joint, auditory canal, tympanic membrane

mandibularis A. tympanica anterior Middle ear
(Fossa retromandibu-
A. alveolaris inferior Lower teeth, chin, floor of the mouth
laris)
• Rr. dentales
• Rr. peridentales
• R. mentalis
• R. mylohyoideus
A. meningea media Meninges
(A. pterygomeningea [A. meningea accessoria]) (not regularly formed) M. pterygoideus lateralis, M. pterygoideus medialis, M. tensor veli
palatini, Tuba auditiva, Meninges

Pars pterygoidea A. masseterica M. masseter

(Fossa infratemporalis) A. temporalis profunda anterior M. temporalis
A. temporalis profunda posterior M. temporalis
Rr. pterygoidei M. pterygoideus lateralis, M. pterygoideus medialis
A. buccalis M. buccinator

Pars pterygopalatina A. alveolaris superior posterior Maxilla, upper teeth, upper jaw gums, Sinus maxillaris
(Fossa pterygopalatina) • Rr. dentales
• Rr. peridentales
A. infraorbitalis Adjacent extra-ocular muscles, upper part of the efferent lacrimal
• Aa. alveolares superiores anteriores ducts, upper teeth, Sinus maxillaris, upper part of the front face half
– Rr. dentales under the Orbita
– Rr. peridentales
A. canalis pterygoidei Nasopharynx, Tuba auditiva
A. palatina descendens Palate
• A. palatina major
• Aa. palatinae minores
A. sphenopalatina Large parts of the nose and paranasal sinuses, KIESSELBACH's area

Table 9.13 Inflows and outflows of the Plexus venosus pterygoideus. Clinical remarks
Inflows Outflows Due to the connection of the valveless veins of the Plexus ve-
• V. sphenopalatina • V. maxillaris nosus pterygoideus to the Sinus cavernosus pathogen trans-
• V. ophthalmica inferior • V. retromandibularis mission with subsequent thrombosis of the Sinus cavernosus
• V. alveolaris inferior • V. profunda faciei can occur in bacterial infections of the face (Sinus cavernosus
• Vv. temporales profundae • V. facialis thrombosis) (› Chap. 11.5.8).
• Vv. meningeae mediae • Sinus cavernosus

The Chorda tympani (› Fig. 9.37) lies on the N. lingualis medial

The N. mandibularis [V/3] reaches the Fossa infratemporalis via the of the M. pterygoideus medialis. It reaches the Fossa infratempora­
Foramen ovale. Here, it divides into its branches, whose courses lis after passing through the Fissura sphenopetrosa (medial and
within the sub-temporal fossa are summarised in › Table 9.14 dorsal of the mandibular joint) in the skull base (the Fissura
(› Fig. 9.26, › Fig. 9.35). petrotympanica [GLASER's fissure] lies in close proximity laterally
from the Fissura sphenopetrosa); however, contrary to popular

Table 9.14 Branches and courses of the N. mandibularis [V/3] in the Fossa infratemporalis; innervation areas.

Branch Course Innervation

R. meningeus Backflow through the Foramen spinosum into the middle cranial Parts of the meninges
fossa
N. massetericus From medial through the Incisura mandibulae to the M. masseter
Nn. temporales profundi From medial to the M. temporalis
N. pterygoideus lateralis From medial to the M. pterygoideus lateralis
N. pterygoideus medialis From medial to the M. pterygoideus medialis
N. musculi tensoris veli palatini To the M. tensor veli palatini
N. musculi tensoris tympani To the M. tensor tympani
N. buccalis Between Caput superius and Caput inferius of the M. pterygoide- Skin and mucosa of the cheek and gingiva of the lower jaw
us lateralis to the

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 9.2 Soft tissue covering

Table 9.14 Branches and courses of the N. mandibularis [V/3] in the Fossa infratemporalis; innervation areas. (continued)

Branch Course Innervation

N. auriculotemporalis Includes in a loop-shape the A. meningea media and then flexes Postganglionic fibres from the Ganglion oticum to the parotid
between the mandibular joint and the external ear canal cranial to gland, external ear canal, tympanic membrane, skin of the auri-
the temporal region cle, skin of the rear part of the temporal region
N. lingualis Picks up the Chorda tympani and passes between Mm. pterygoi- Skin of the soft palate, mucous membrane of the floor of the
dei lateral from N. alveoaris inferior, below rostrally to the tongue mouth, sensory innervation and palate fibres of the anterior two
thirds of the tongue, preganglionic parasympathetic fibres to the
Ganglion submandibulare
N. alveolaris inferior Passes behind and to the side of the N. lingualis under the Teeth and gingiva of the lower jaw, M. mylohyoideus and Venter
M. pterygoideus lateralis caudally, penetrates through the Fora- anterior of the M. digastricus, skin of the chin
men mandibulae into the mandibula

opinion it is not the usual point of penetration for the Chorda tym­ tral junction or distribution point for vessels and nerves of the Re­
pani through the skull base. gio facialis lateralis profunda.
The parasympathetic Ganglion oticum (› Fig. 9.39) is located
close below the Foramen ovale on the medial side of the N. man­ Vascular, lymphatic and nervous systems
dibularis [V/3]. Via the Rr. ganglionares it is in contact with the N. Vascular, lymphatic and nervous systems of the Fossa pterygopala­
mandibularis [V/3]. tina are the Pars pterygopalatina of the A. maxillaris (› Fig. 9.28),
accompanying veins of the arterial branches of the Pars pterygopa­
Fossa pterygopalatina latina (Vv. infraorbitalis, sphenopalatina, palatina descendens, Vv.
The funnel-shaped pterygopalatine fossa (Fossa pterygopalatina), canalis pterygoidei), the branches of the N. maxillaris [V/2] and
which tapers from cranial to caudal, forms the medial continuation the Ganglion pterygopalatinum.
of the Fossa infratemporalis. Like the Fossa infratemporalis it be­ The end section of the A. maxillaris extends into the Fossa ptery­
longs to the deep part of the lateral facial region (Regio facialis lat­ gopalatina (Pars pterygopalatina). The vessel exits are summarized
eralis profunda) and stretches even further into the depths of the in › Table 9.12.
external skull base. The Maxilla, Os palatinum and Os sphenoidale The veins of the same name accompany the arterial branches of the
are involved in the bony border of the more or less triangular space Pars pterygopalatina and can be taken from › Table 9.16. They are
(› Fig. 9.27). Together the bones form the Fissura pterygomaxil- also connected to the Plexus pterygoideus, the V. facialis and the V.
laris as the boundary to the Fossa infratemporalis. The limits and ophthalmica inferior.
relationships of the Fossa pterygopalatina are summarised in The N. maxillaris [V/2] passes through the Foramen rotundum
› Table 9.15. Functionally, the Fossa pterygopalatina forms a cen­ into the skull base to the Fossa pterygoidea and divides into its

N. auriculotemporalis
A. temporalis superficialis, A. temporalis media
R. parietalis
A. temporalis profunda posterior;
N. meatus N. temporalis profundus
acustici externi
N. mandibularis [V/3]
R. auricularis
N.; M. pterygoideus lateralis
A.; N. auricularis
posterior A. maxillaris
A. temporalis N. infraorbitalis
superficialis N. supratrochlearis
N. facialis [VII] N. infratrochlearis
R. digastricus A. infraorbitalis
A. meningea media A. angularis
A. occipitalis A. sphenopalatina
A. maxillaris N. infraorbitalis
Chorda tympani Rr. alveolares superiores
A. alveolaris inferior posteriores
A. palatina ascendens N. massetericus
N. hypoglossus [XII] N. buccalis
A. lingualis A. buccalis
N. vagus [X] N. alveolaris inferior
(Ansa cervicalis profunda) Mandibula
A. carotis communis N. lingualis
A. facialis Glandula sublingualis
N. hypoglossus [XII] A. sublingualis
Ganglion submandibulare N. hypoglossus [XII]
N. mylohyoideus A. submentalis Fig. 9.26 Arteries and nerves in
the deep lateral facial region.

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9 Head

Table 9.15 Limits and relationships of the Fossa pterygopalatina.

Direction Limit Connection/neighbourhood relationship

Cranial Corpus ossis sphenoidalis, Radix alae majoris of the Os sphenoi-
dale
Medial Lamina perpendicularis ossis palatini (at the same time, it forms Foramen sphenopalatinum with the nasal cavity
the lateral wall of the nasal cavity in the area of the choane)
Rostral Tuber maxillae, Proc. orbitalis ossis palatini Fissura orbitalis inferior with the Orbita, Foramina alveolaria pos-
teriora to the Tuber maxillae
Lateral Fossa infratemporalis Fissura pterygomaxillaris
Occipital Facies maxillaris of the Ala major ossis sphenoidalis, front edge of Foramen rotundum to the middle cranial fossa, Canalis pterygoi-
the Proc. pterygoideus ossis sphenoidalis deus (VIDIANUS canal) with the external skull base
Caudal Oral cavity Canalis palatinus major, Canales palatini minores with the palate

branches which leave the fossa again via different exit points
Os zygo-
(› Table 9.16, › Fig. 9.29).
maticum The parasympathetic Ganglion pterygopalatinum lies at the level
Os sphenoidale,
Ala major of the Foramen sphenopalatinum. It is located medially and below
the N. maxillaris [V/2] (› Fig. 9.30). Cranially there are fibre con­
Fossa
Os palatinum, nections to the N. maxillaris [V/2]. From the rear the N. canalis
pterygo-
Lamina per-
palatina
pendicularis pterygoidei reaches the ganglion from the Canalis pterygoideus. It
carries preganglionic parasympathetic fibres that can be switched
in the ganglion to postganglionic. The sympathetic fibres from the
Proc. pterygoideus
N. canalis pterygoidei (via N. petrosus profundus) are already
Tuber maxillae postganglionic and pass through the ganglion without switching.
Maxilla The sensitive Rr. ganglionares emerging from the Orbita, nose and
throat pass the Ganglion pterygopalatinum to the N. maxillaris.

Table 9.16 Connections and relationships of the Fossa pterygopala-

Fig. 9.27 Bony margins of the Fossa pterygopalatina. [E402]
tina to neighbouring regions, and penetrating structures.

Connection via Connection Pathway

to
Fissura orbitalis Orbita A. infraorbitalis, V. infraorbitalis, N. infraor-
inferior bitalis (from [V/2]), N. zygomaticus (from
A. infraorbitalis [V/2]), Rr. orbitales (from [V/2])
Foramen Middle N. maxillaris [V/2] (with small accompanying
­rotundum c­ ranial fossa arteries)
A. sphenopalatina
Canalis pterygoi- External skull A. canalis pterygoidei, Vv. canalis pterygoi-
deus (VIDIANUS base dei, N. canalis pterygoidei (fibres from
R. pharyngeus canal) N. petrosus major – parasympathetic and
N. petrosus profundus – sympathetic)
A. canalis pterygoidei Foramen spheno- Nasal cavity A. sphenopalatina (Aa. nasales posteriores
palatinum laterales and Rr. septales posteriores), V.
A. maxillaris sphenopalatina, Rr. nasales posteriores supe-
riores mediales and laterales (from [V/2])

A. alveolaris Canalis palatinus Palate A. palatina descendens, A. palatina major,

superior posterior major, Canales Aa. palatinae minores, V. palatina descen-
palatini minores dens, N. palatinus major (from [V/2]),
A. palatina Nn. palatini minores (from [V/2])
descendens
Fissura pterygo- Fissura infra- A. maxillaris, Plexus pterygoideus
A. palatina major maxillaris temporalis

A. alveolaris Foramina Aa. alveolares superiores posteriores (with

superior anterior alveolaria at accompanying veins), N. alveolaris superior-
the Tuber is posterioris (from [V/2])
Fig. 9.28 A. maxillaris in the Fossa pterygopalatina. [E402] maxillae

442
 9.3 Cranial nerves

N. zygomaticus

R. zygomaticotemporalis N. alveolaris superior posterior

N. pharyngeus N. pharyngeus
Foramen sphenopalatinum
N. ophthalmicus Canalis palatovaginalis
[V/1] R. nasalis posterior superior
Foramen
R. zygomatico- Rr. orbitales rotundum
facialis N. maxillaris
[V/2] N. zygomaticus N. maxillaris [V/2]
N. infraorbitalis
N. infra- N. mandibularis N. canalis
orbitalis [V/3] N. alveolaris pterygoideus
superior posterior with Canalis
N. palatinus pterygoideus
N. alveolaris major
superior anterior
Rr. ganglionares ad N. palatinus Ganglion
Palatum molle
ganglion pterygopalatinum major pterygopalatinum
a Nn. palatini minores b
N. alveolaris
superior medius

Fig. 9.29 N. maxillaris in the fossa pterygopalatina. a Terminal branches; b spatial relationship with the Ganglion pterygopalatinum. [E402]

N. canalis pterygoidei Diagnostics

Fissura orbitalis inferior The gynaecologist initially suspects a pregnancy, but this is
Fossa not confirmed. A subsequent mammography (x-ray of the
pterygopalatina chest) shows no pathological changes of the glandular tissue.
Breast cancer can be ruled out. The patient casually reports
that she has sometimes noticed blind spots in her field of vi-
sion. The gynaecologist takes a sample of the patient’s blood
to determine her hormonal status, and refers her to an oph-
thalmologist in the same house for clarification of the ocular
symptoms. The ophthalmologist inspects the blind spots
more closely and describes the symptoms as ‘sporadic bitem-
poral hemianopsia’. Because this indicates a possible process
at the Chiasma opticum (visual nerve intersection), the oph-
thalmologist immediately arranges for magnetic resonance
imaging (MRI) in a radiological practice. The MRI images show
a large tumour (macroadenoma) of the pituitary gland (Sella
turcica) which is already pressing on the Chiasma opticum
Preganglionic Postganglionic
parasympathetic sympathetic from below.
nerve fibres nerve fibres The examination of the blood values by the gynaecologist,
shows prolactin levels of 240 ng/ml (reference: < 20 ng/ml),
Fig. 9.30 Sympathetic and parasympathetic fibres in the Fossa pter- which explain the gynaecological symptoms. The doctors di-
ygopalatina. [E402] agnose a prolactinoma (most frequent pituitary tumour).

Treatment
An immediately initiated drug therapy with bromocriptine (do-
9.3 Cranial nerves pamine antagonist) causes the tumour to shrink, thus reduc-
Lars Bräuer ing the visual field defects and also the gynaecological com-
plaints recede and after some time disappear completely.

Skills Long-term follow-up

However, after 3 years the patient suffers from the symptoms
After processing this chapter, you should be able to: again and it is concluded that the tumour has grown again
• describe the basic anatomical aspects of origin, course, fi- ­(relapse). This time the patient is advised to have it surgically
bre quality and innervation areas of the 12 cranial nerves removed through a procedure in which a neurosurgeon gains
transnasal and transphenoidal access. After the operation the
patient is without complaints.

Clinical case
Note: the cranial nerves are also presented in › Chap. 12.5.
Prolactinoma The human brain has 12 pairs of cranial nerves, which are num­
Case study bered using Roman numerals and have their exit and entry points on
A 32-year-old patient consults her gynaecologist because of the brain and brain stem (› Fig. 9.31). All nerves, with the excep­
amenorrhoea. She also states that there is an enlargement of tion of the N. vagus [X] have their supply area in the head and throat
the breasts, with sporadically occurring milk flow (galactor- area where they innervate all structures, such as glands but also mus­
rhoea).
cles (both striated, as well as smooth). By definition the cranial
nerves, with the exception of the N. olfactorius [I] and the N. opticus

443
9 Head

N. oculo-
motorius
N. olfactorius [I] [III]
N. opticus N. troch-
[II] learis [IV]
N. abducens
[VI]
N. trigeminus [V]

N. intermedius [VII]
N. facialis [VII]

N. vestibulocochlearis [VIII]

N. glossopharyngeus [IX]

N. vagus [X]
N. accessorius [XI]
N. hypoglossus [XII]

Efferent (motor) fibres

Afferent (sensory) fibres
Spinal nerve fibres

Fig. 9.31 Cranial nerves, overview. At the base of the brain there are 12 pairs of cranial nerves exiting (entering), which have different fibre
qualities and are numbered from frontal to occipital with Roman numerals from I-XII.

[II] are peripheral nerves. The N. olfactorius [I] and N. opticus [II], rius to the 2nd neuron. They then run as Tractus olfactorius to the
however, are an extension of the telencephalon [I] or of the dien­ corresponding primary and secondary olfactory areas (e.g. Corpus
cephalon [II] and thus belong to the central nervous system. Al­ amygdaloideum) (› Chap. 13.6.2). A special feature of the N. ol­
though the cranial nerves III – XII belong to the peripheral nerves, factorius [I] is that fibres without prior interpretation (extratha­
they differ significantly from them (and from spinal nerves): they lamic) pass directly to the primary and secondary olfactory areas.
are not segmentally arranged have no separate roots for afferent or Smells are therefore of very special significance within the context
efferent fibres and also differ significantly with respect to their of the long-term memory. The Fila olfactoria only have a limited
function and fibre quality. The cranial nerves V, VII, IX, X and XI life span (about 60 days) and must therefore be constantly renewed
are derived from the site of the pharyngeal arches (branchial from corresponding stem cells.
arches) and are therefore also referred to as branchial nerves. The
following elaborates on the individual nerves, innervation areas
and the corresponding ganglia.
Clinical remarks
In the context of basal skull fractures the Fila olfactoria can
become detached at the point of penetration at the Lamina
9.3.1 N. olfactorius [I] cribrosa. This results in a generally irreversible inability to
smell (anosmia). If not all Fila olfactoria are damaged, there is
an olfactory reduction (hyposmia). In this instance, those
The N. olfactorius (olfactory nerve), which has special somatoaffer­
­affected can generally no longer perceive aromatic substances,
ent (SSA) fibres, consists of the Fila olfactoria. These thin axons ‘irritating’ inorganic compounds, on the other hand (e.g. ammo-
that are less myelinated correspond to primary sensory cells origi­ niac) are perceived via the N. trigeminus [V] and felt as pain
nating in the Regio olfactoria (olfactory mucosa) at the roof of the (nociception). Very often the patients also suffer from im-
nose (› Fig. 9.32). From there they extend through the foramina paired taste sensation as no flavours but only isolated sweet,
of the Lamina cribrosa of the Os ethmoidale (ethmoid bone) into sour, salty, bitter and umami can be perceived.
the anterior cranial fossa to be switched within the Bulbus olfacto-

444
 9.3 Cranial nerves

Area subcallosa; Gyrus paraterminalis

gyrus paraolfactorius
Fibres from the Contralateral
Fibres to the Bulbus olfactorius

Commissura anterior

Stria olfactoria medialis

Bulbus olfactorius Substantia perforata

anterior

Sensory cells Gyrus dentatus

(olfactory cells)
Fila olfactoria Gyrus parahippo-
Os ethmoidale, Lamina cribrosa campalis
Nucleus olfactorius anterior
Uncus
Dura mater cranialis
Tractus Fig. 9.32 N. olfactorius with Fila
olfactorius Gyrus ambiens
olfactoria. In the roof of the
Trigonum olfactorium; Corpus amygdaloideum nasal cavity lies the Regio olfac-
Tuberculum olfactorium
toria with its olfactory sensory
Stria olfactoria lateralis Nucleus tractus olfactorii lateralis cells (primary, bipolar sensory
cells = olfactory neurons).

9.3.2 N. opticus [II] Clinical remarks

The optic tract can be damaged at several points in its course.
The N. opticus [II] (optic nerve) also has specific somatoafferent
If the N. opticus [II] is affected before the Chiasma opticum, in
(SSA) fibre qualities. During ocular development, it forms as a di­ particular in the Canalis opticus, e.g. after traumatic brain in-
verticulum of the diencephalon and is thus an integral part of the jury, this can lead to blindness of the affected eye. If the dam-
brain. The optic tract (› Chap. 13.3.1) starts within the retina age is in the area of the Chiasma opticum, e.g. in the case of
• for colour vision (photopic) with the first three projection neu­ pituitary tumours (most frequent tumour: prolactinoma) a bi-
rons (1. cone cells, 2. cone bipolars, 3. ganglion cells) and inter­ temporal hemianopsia is generally the result: both temporal
neurons (horizontal cells, amacrine cells) visual fields fail (see tunnel vision), while the nasal visual
fields are still intact, as the cells and projecting neurons in the
• for light-dark vision (scotopic) containing up to 40 rod cells (1st
Chiasma opticum located in the temporal retina run at the
neuron) which transmit their signal to a bipolar rod (2nd neu­ edge and are not initially affected by the tumour. Lesions of
ron) and then transmit the signal by an indirect way while relay­ the Tractus opticus (e.g. bleeding) lead to failure of the tem-
ing amacrine cells (3rd neuron) to a ganglia cell (4th neuron) poral visual field of the contralateral eye and nasal visual field
The approximately 1 million axons are non-myelinated and run to of the ipsilateral eye (homonymous hemianopia). If the visual
the Papilla nervi optici (blind spot) and leave the eyeball there. radiation running at the front in the temporal lobes is dam-
From the Lamina cribrosa scleri the specific somatoafferent fibres are aged (e.g. by ischemia), the result is an upper quadrant ano­
psia. Lesions of the entire visual radiation (e.g. from mass
myelinated by oligodendrocytes. In the physiological ageing process­
bleeding), such as lesions of the Tractus opticus lead to a
es everyone loses approximately 5,000 axons/year. The N. opticus [II] homonymous hemianopsia.
is surrounded by meninges (Pia mater, Arachnoidea, Dura mater). It
leaves the Orbita through the Canalis opticus, in order to shortly
afterwards unite with its contralateral part in the Chiasma opticum.
From this point it is no longer referred to as N. opticus, but as Tractus
opticus. In the Chiasma opticum the nasal retinal fibres (­ depiction of 9.3.3 N. oculomotorius [III]
the temporal fields of vision) cross to the contralateral side but the
temporal retinal fibres (depiction of nasal fields of vision) do not. The N. oculomotorius [III] (› Fig. 9.34) innervates the outer optic
The largest part of the fibres then proceeds as the Tractus opticus to muscles with the exception of the M. obliquus superior (N. troch­
the Corpus geniculatum laterale (thalamus). After switching it learis [IV]) and the M. rectus lateralis (N. abducens [VI]). It is a
­continues to the Area striata within the occipital cortex at the Sulcus mixed nerve with general somatoefferent and visceroefferent quali­
calcarinus. The course of the N. opticus [II] and Tractus opticus ties (GSE, GVE), with preganglionic parasympathetic neurons in
from the Bulbus opticus up to the Sulcus calcarinus within the Lobus the Nucleus accessorius nervi oculomotorii EDINGER-WEST-
occipitalis is presented in › Fig. 9.33. About 10 % of the fibres run PHAL (Mesencephalon). Its somatomotoric neurons, on the other
extragenicularly to the Colliculi superiores (Lamina quadrigemina) hand, are in the Nucleus nervi oculomotorii. The N. oculomotori­
and are responsible for optical reflexes by way of the corresponding us [III] exits at the front edge of the bridge within the Fossa inter­
interneurons (e.g. corneal reflex). peduncularis and runs between A. cerebri posterior and A. superi­
or cerebelli, to extend medially from the Tentorium cerebelli to­

445
9 Head

The central darker stain

represents the Macula lutea.

The lighter areas represent

monocular visual fields,
the darker areas overlapping
fields of view.

Each quadrant is displayed in

a different colour.

Projection Projection
to the left retina to the right retina

Projection in the left Corpus Projection in the right Corpus

geniculatum laterale geniculatum laterale

Fig. 9.33 N. opticus and config-

uration in retina and optic tract
(simplified). The first three
­neurons (colour vision) or 4
Radiatio optica Radiatio optica ­neurons (light-dark vision) of the
visual tract lie within the retina.
They leave the Bulbus oculi as
the N. opticus [II] and later after
partial fibre crossing over in the
Chiasma opticum as the Tractus
opticus. They run to a large
Sulcus calcarinus extent to the Corpus genicula-
Sulcus calcarinus ([Fissura calcarina]) tum laterale and after switching
([Fissura calcarina])
run as the Radiatio optica to the
Projection in the left Lobus occipitalis Projection in the right Lobus occipitalis Sulcus calcarinus in the area of
the Lobus occipitalis.

wards the Sinus cavernosus. From there, it runs via the Fissura Ganglion ciliare
orbitalis superior into the Orbita and divides into a R. superior, an The Ganglion ciliare lies within the Orbita, lateral of the N. opticus
R. inferior and a branch to the Ganglion ciliare (› Chap. and approximately 1.5 cm behind the Bulbus oculi (› Fig. 9.34).
12.5.6). The R. superior innervates the Mm. levator palpebrae su­ In the ganglion, the parasympathetic fibres of the N. oculomotori­
perioris and rectus superior; the R. inferior supplies the M. rectus us [III] are switched from preganglionic and then innervate the
medialis, the M. rectus inferior and the M. obliquus inferior. The ­inner eye muscles. The sympathetic and sensitive fibres that also
parasympathetic fibres coming from the EDINGER -WESTPHAL run through the ganglion are not switched here. The ganglion gets
core extend to the Ganglion ciliare, are switched from pregangli­ its afferents from 3 different roots:
onic to postganglionic and run as Nn. ciliares breves to the M. cil- • From a parasympathetic root (Radix parasympatica) of the
iaris and to the M. sphincter pupillae, which they innervate. By N. oculomotorius which is responsible for the innervation of the
innervation of the corresponding eye muscles the N. oculomotori­ inner eye muscles (M. sphincter pupillae and M. ciliaris)
us [III] is responsible for raising the eyelid (M. levator palpebrae • From a sympathetic root (Radix sympatica) with fibres from
superioris) and for the eyeball movement upwards laterally, upper the cervical sympathetic trunk for the innervation of the M. di­
medially, medially and lower medially. The M. tarsais, which con­ lator pupillae (inner eye muscle which governs the width of the
sists of smooth muscle and is responsible for tightening of the eye­ pupil)
lids is also positioned in the eyelids. It is innervated by the sympa­ • From a sensory root (Radix sensoria) with fibres from the N.
thetic system, so that in the event of failure of the N. oculomotori­ nasociliaris for sensory innervation of the cornea and conjunc­
us III] it is still possible to slightly open the eyelids. The tiva
parasympathetic fibres mediate via the M. ciliaris the accommoda­ Both the sensory as well as the sympathetic fibres run through the
tion of the lens and regulate via the M. sphincter pupillae the nar­ Ganglion ciliare without switching. The Nn. ciliares breves leave
rowing of the pupils. the Ganglion ciliare as postganglionic efferents, to pass through the
sclera to the inner eye muscles.
Clinical remarks
Damage to the N. oculomotorius [III] leads to ptosis (drooping 9.3.4 N. trochlearis [IV]
of the affected eyelid), mydriasis (widening of the pupil), as
well as the inability for accommodation. In addition, patients The N. trochlearis [IV] is a purely motor nerve (general somatoef­
display an abducted and downward facing eyeball. ferent, GSE), which innervates the M. obliquus superior that be­
longs to the external ocular muscles. Its original neurons are locat­

446
 9.3 Cranial nerves

Radix sensoria [nasociliaris] ganglii ciliaris Radix sympathica ganglii ciliaris

Ganglion ciliare
N. oculomotorius [III],
N. ciliaris longus R. superior
Nn. ciliares
M. obliquus superior N. frontalis
breves N. oculomotorius Nucleus accessorius
N. lacrimalis [III] nervi oculomotorii

N. naso- N. ophthal- Nucleus nervi

M. levator palpebrae ciliaris micus [V/1] oculomotorii
superioris
Nucleus nervi
M. rectus trochlearis
superior

Nucleus nervi
M. sphincter abducentis
pupillae
M. dilatator N. trochlearis [IV]
pupillae
A. carotis interna
M. ciliaris
N. abducens [VI]

M. obliquus
inferior N. petrosus major

Radix parasympathica N. infraorbitalis M. rectus lateralis;

[oculomotoria] N. abducens [VI]
ganglii ciliaris M. rectus inferior Ganglion pterygopalatinum

M. rectus medialis N. oculomotorius [III], R. inferior

Efferent (motor) fibres Afferent (sensory) fibres

Sympathetic fibres Parasympathetic fibres

Fig. 9.34 Motor eye nerves and core areas, Nn. oculomotorius, trochlearis and abducens. Lateral view, opened Orbita, retrobulbar adipose
­tissue is removed, M. rectus lateralis resection.

ed in the Nucleus nervi trochlearis of the mesencephalon (› Fig. 9.3.5 N. trigeminus [V]
9.34). Its fibres leave the brain at the back of the brainstem at the
lower part of the Lamina quadrigemina (quadrigeminal plate) as a The N. trigeminus [V] is the strongest of the 12 cranial nerves and,
thin nerve. From there, it passes lateral of the two brain halves to at the same time, also the first pharyngeal arch nerve (mandibular
the Tentorium cerebelli to enter into the Dura mater. Together with arch). It carries both motor and sensory fibres (SVE, GSA), which
the N. oculomotorius [III] and the N. ophthalmicus [V/1] it passes respectively originate from different core areas. Three cores are
through the Fissura orbitalis superior into the Orbita and runs out­ generally somatosensory and range from the brain stem to the up­
side the Anulus tendineus communis (annulus of ZINN) to the M. per cervical medulla (› Fig. 9.35):
obliquus superior, for motor innervation. The contraction of the • Nucleus mesencephalicus nervi trigemini (GSA, proprioception)
M. superior oblique, which is deflected via a connective tissue loop • Nucleus pontinus nervi trigemini (GSA, mechanoreception)
(trochlea, giving the name of the nerve) functioning as a hypomo­ • Nucleus spinalis nervi trigemini (GSA, nociception, thermo­
chlion leads to the medial rotation of the eyeball with simultaneous ception and mechanoreception)
movement to lateral below. If the Bulbus is already in an adducted The special visceroefferent (SVE) core of the N. trigeminus, the
position, the M. obliquus superior lowers the Bulbus laterally Nucleus motorius nervi trigemini, is located within the pons. All
downwards. nerve fibres are bundled in the area of the pons, to leave the brain
at its lateral border and to run as a common nerve (Radix sensoria
and Radix motoria) rostrally via the Pars petrosa of the Os tempo­
Clinical remarks rale. There, the nerve enters at the level of the Foramen lacerum
A lesion of the N. trochlearis [IV] is associated with double into a Dura duplicature (Cavum trigeminale = MECKEL). At this
vision in patients. This is evoked by a strabismus (squinting) point the perikaryon of sensory fibres forms the Ganglion trigemi­
in a nasal direction and upwards. Affected patients try to com- nale (Ganglion semilunare, GASSER's ganglion) which divides
pensate for the misalignment of the eyeball with correspond- into 3 large main branches (hence the name triplet nerve):
ing head movements, which can be seen in a tilting of the
• The N. ophthalmicus [V/1] (GSA, purely sensory, › Table
head. The patients also report difficulty in climbing stairs, as a
glance downwards through the eyeball is no longer possible. 9.17) passes through the Fissura orbitalis superior into the Or­
bita and then into the upper facial region. It innervates the eye
(in parti­cular cornea and conjunctiva), the skin of the upper
eyelid, forehead, back of the nose and the mucous membranes of
the nasal cavities and sinuses. It also stores vegetative fibres for
the innervation of the lacrimal gland within the Orbita.

447
9 Head

N. nasociliaris
N. lacrimalis
N. frontalis
Ganglion ciliare

Rr. temporales
superficiales
N. ethmoidalis posterior
Nucleus motorius
N. supratrochlearis nervi trigemini

N. supraorbitalis
Nucleus pontinus
N. infratrochlearis nervi trigemini

Nn. ciliares longi N. trigeminus [V]

Nn. ciliares breves
Ganglion trigeminale
N. maxillaris [V/2]
N. ophthalmicus [V/1]
N. zygomaticus
N. infraorbitalis
N. canalis pterygoidei Ganglion geniculi
Ganglion
pterygopalatinum
Chorda tympani
Rr. alveolares superiores (from N. facialis [VII])

Rr. nasales posteriores superiores;

N. auriculotemporalis
N. nasopalatinus

Nn. temporales profundi

Rr. parotidei; Rr. communi-
cantes cum nervo faciali
Nn. palatini major and minores
Ganglion oticum
N. buccalis
N. mandibularis [V/3]
N. mentalis
Efferent (motor) fibres
Plexus dentalis N. mylohyoideus N. alveolaris inferior
inferior Parasympathetic fibres
Ganglion submandibulare N. lingualis Afferent (sensory) fibres

Fig. 9.35 N. trigeminus [V], core areas and fibre qualities. Lateral view, Arcus zygomaticus and Proc. coronoideus removed. The N. trigeminus
[V] is divided into 3 parts and penetrates with each branch through another opening of the skull base.

• The N. maxillaris [V/2] (GSA, purely sensory, › Table 9.19) and the pertaining gums. It motorically innervates the mastica­
leaves the skull through the Foramen rotundum. It innervates the tory muscles, two muscles at the floor of the mouth (M. mylohy­
skin of the anterior temporal region, the upper part of the cheek, oideus, Venter anterior of the M. digastricus), as well as the M.
the lower eyelid and underlying skin. It is also responsible for the tensor veli palatini and the M. tensor tympani. Similar to the N.
sensory innervation of the palate, teeth of the upper jaw, the cor­ ophthalmicus [V/1] it stores vegetative fibres for the innervation
responding gingiva, and the mucosa of the Sinus maxillaris. of several glands (Glandulae linguales, sublingualis, subman­
• The N. mandibularis [V/3] (GSA, SVE, sensory and motoric, dibularis), as well as additional fibres for sensors (taste) of the
› Table 9.20) enters through the Foramen ovale and sensory anterior two thirds of the tongue (Chorda tympani).
innervates the skin of the posterior temporal region, the lower The course of the N. trigeminus and its branches is summarised in
part of the cheek, the chin, as well as the teeth of the lower jaw › Table 9.17-› Table 9.20.

Table 9.17 Branches of the N. ophthalmicus [V/1] (purely somatoafferent).

Branch Sub-branches Innervation area

R. meningeus recurrens Parts of the meninges
(R. tentorius)
N. frontalis N. supraorbitalis Skin of forehead and mucosa of the frontal sinus
N. supratrochlearis Skin and conjunctiva at the nasal corner of the eye
N. lacrimalis Lacrimal gland (for secretary innervation postganglionic parasympathetic fibres are attached
to the N. zygomaticus), skin and conjunctiva of the temporal corner of the eye
N. nasociliaris › Table 9.18 Nasal sinuses, anterior part of the nasal cavity and iris, Corpus ciliare, cornea of the eye
(› Table 9.18)

448
 9.3 Cranial nerves

Table 9.18 Branches of the N. nasociliaris [from V/1].

Branch Course Innervation area

Radix sensoria ganglii ciliarii Controls the sensory component for Eyeball and conjunctiva (together with the Nn. ciliares longi)
(R. communicans cum ganglio the Ganglion ciliare, from which the
­ciliarii) Nn. ciliares breves emerge
Nn. ciliares longi Attached to the N. opticus [II] and Eyeball (Bulbus oculi) and its conjunctiva; the sympathetic fibres innervate the M. dilatator
extend with the Nn. ciliares breves pupillae
from the Ganglion ciliare to the Bul-
bus oculi; also joined by sympathet-
ic fibres from the Plexus caroticus
N. ethmoidalis posterior Runs through the identically named Mucosa of the posterior ethmoidal cells and the sphenoidal sinus
foramen to the posterior ethmoidal
sinuses and the sphenoidal sinus
N. ethmoidalis anterior Runs through the identically named Mucosa of the anterior nasal cavity and the anterior ethmoidal cells; skin of the dorsum of
foramen back into the anterior crani- the nose
al fossa, courses through the Lami-
na cribrosa into the nasal cavity; it
ends with the Rr. nasales externi in
the skin of the dorsum of the nose
N. infratrochlearis Extends below the trochlea to the Skin at the nasal corner of the eye
nasal corner of the eye

NOTE abducens [VI] exits within the Sulcus bulbopontinus between pons
The exit points from the sensory facial branches (Foramen supraor-
and medulla and runs parallel to the A. basilaris in the direction of
bitale, Foramen infraorbitale and Foramen mentale) are referred to
as trigeminal pressure points and are of practical clinical signifi- the clivus, to enter into the Dura mater. Within the Dura mater it
cance for the examining doctor (› Chap. 12.5.8). runs together with the Nn. oculomotorius [III] and trochlearis [IV]
to the Sinus cavernosus, where it does not run as a single cranial
nerve in the lateral wall but through the middle right of the venous
Clinical remarks plexus. From here it passes through the Fissura orbitalis superior
into the Orbita, enters through the Anulus tendineus communis
Trigeminal neuralgia (tic douloureux) is a complex and senso- (common tendinous ring) and innervates the M. rectus lateralis.
ry disorder of the trigeminal root, which leads to severe pain
The course and the fibre quality of the N. abducens [VI] is present­
and sometimes even to skin irritation in the face. The patho-
genesis has not yet been fully elucidated. It is thought that ed in › Fig. 9.34(together with the Nn. oculomotorius [III] and
disorders or stenoses of the supplying vessels, especially in trochlearis [IV]).
the area of the Ganglion trigeminale and the cerebellopontine
angle, lead to a reduction in supply to nerve cells. The pa-
tients suffer from acute and sudden severe pain that reaches Clinical remarks
maximum values on a subjective pain scale. Even the lightest
Due to its long extradural course and its passage through the
touch or even wind can trigger the pain, mainly in the supply
Sinus cavernosus the N. abducens is particularly susceptible
areas of the N. mandibularis [V/3] and of the N. maxillaris
to damage (abducens palsy). If the patient is asked to move
[V/2]. Pain medication or anaesthesia can bring symptomatic
the affected eye to the temporal side, the eyeball remains
relief. The patients often turn to suicide as a way to escape the
pointing straight ahead, since the M. rectus lateralis is para-
pain. Trigeminal neuralgia can also occur as a result of infec-
lysed. It is comparable to trochlearis palsy and patients often
tion with the varicella zoster virus (postherpetic neuralgia).
suffer from the development of double vision (diplopia).
Since the N. ophthalmicus [I] is used as a transport route for
the virus (axonal transport), there are restrictions in its inner-
vation area. The involvement of the surface of the eye is par-
ticularly feared, which is not only associated with very severe
pain, but in extreme cases can lead to a loss of sight (Zoster
ophthalmicus). 9.3.7 N. facialis [VII]

The N. facialis [VII] is the second pharyngeal arch nerve. Its main
function is the special visceroefferent (SVE) innervation of the fa­
cial muscles. It consists of two major parts (N. facialis [VII] and N.
9.3.6 N. abducens [VI] intermedius) with different fibre qualities. According to its con­
ducting qualities the parts of the N. facialis [VII] have 3 different
The N. abducens [VI] is comparable to the N. trochlearis [IV] a origin cores:
general somatoefferent nerve (GSE), which only innervates one • The special visceromotor (SVE) Nucleus nervi facialis that lies
muscle, the M. rectus lateralis. Muscle contraction of this external within the pons consists of an upper cell group (innervation of
ocular muscle leads to the abduction of the eyeball and thus to gaze the forehead and eyelid muscles, controlled by the Gyrus precen­
in a temporal direction (abducens = abduction). The neurons are tralis of ipsilateral and contralateral sides) and a lower cell group
in the Nucleus nervi abducentis within the pons. The abducens (innervation of the remaining [lower] facial muscles, controlled
core is dorsally encircled by the fibres of the N. facialis [VII] that by the Gyrus precentralis of the contralateral side). The upper
still runs in the pons (internal genu of the facial nerve). The N. nuclear portion therefore receives double innervation from both

449
9 Head

Table 9.19 Branches of the N. maxillaris [V/2] (purely somatoafferent).

Branch Sub-branches Innervation area

R. meningeus Meninges of the middle cranial fossa
N. zygomaticus R. zygomaticotemporalis Skin in the area of the temple
R. zygomaticofacialis Skin in the upper cheek region; for secretory innervation of the lacrimal gland postganglionic
parasympathetic fibres run with the N. zygomaticus, which it emits to the N. lacrimalis
(R. communicans cum nervo zygomatico)
Rr. ganglionares to ganglion Control sensitive fibres for the Ganglion pterygopalatinum, innervation of the palate and
pterygopalatinum nose, it connects to the sympathetic and parasympathetic fibres for the Glandulae nasales
and palatinae (especially visceroefferent) as well with the taste fibres
N. infraorbitalis (terminal branch of Nn. alveolares superiores with Mucosa of the maxillary sinus, teeth of the upper jaw and corresponding gingiva
the N. maxillaris) Rr. alveolares superiores posteri-
ores, medii and anteriores (Plexus
dentalis superior)
Rr. palpebrales inferiores, Skin and conjunctiva of the lower eyelid, lateral skin area of the nasal wings, skin of upper lip
Rr. nasales externi et interni and and lateral cheek region between lower eyelid and upper lip
Rr. labiales superiores
N. palatinus major Runs via the Canalis palatinus Mucosa of the hard palate, Glandulae palatinae, palatine taste buds
major through the Foramen palati-
num majus
Nn. palatini minores Leave the Canalis palatinus major Mucosa of the soft palate, Tonsilla palatina, Glandulae palatinae, palatine taste buds
through the Foramina palatina
minora
Rr. nasales posteriores superiores Pass through the Foramen spheno- Mucosa of the nasal conchae, nasal septum, mucosa of the anterior part of the hard palate,
laterales and mediales palatinum into the nasal cavity and upper incisors and gingiva, Glandulae nasales
emit the N. nasopalatinus which
reaches the hard palate through
the Canalis incisivus

Table 9.20 Branches of the N. mandibularis [V/3] (somatofferent and visceroafferent).

Branch Sub-branches Innervation area

R. meningeus Parts of the meninges
N. massetericus M. masseter
Nn. temporales profundi M. temporalis
N. pterygoideus lateralis M. pterygoideus lateralis
N. pterygoideus medialis M. pterygoideus medialis
N. musculi tensoris veli palatini M. tensor veli palatini
N. musculi tensoris tympani M. tensor tympani
N. buccalis Skin and mucosa of the cheek and gingiva of the lower jaw
N. auriculotemporalis Rr. parotidei Postganglionic parasympathetic fibres from the Ganglion oticum join and innervate the
parotid gland
Rr. communicantes cum nervo Postganglionic parasympathetic fibres from the Ganglion oticum join and innervate the
faciali parotid gland (controversial)
N. meatus acustici externi External ear canal, tympanic membrane
Nn. auriculares anteriores Skin of the external ear
Rr. temporales superficiales Skin of the posterotemporal region
N. lingualis Rr. isthmi faucium Skin of the soft palate
N. sublingualis Mucosa of the floor of the mouth
Sensory innervation of the anterior two thirds of the tongue, taste fibres of the anterior two
thirds of the tongue, association with preganglionic parasympathetic fibres from the Chorda
tympani and transfer to the Ganglion submandibulare
N. alveolaris inferior Plexus dentalis inferior Teeth and gingiva of the lower jaw
N. mylohyoideus M. mylohyoideus and Venter anterior of the M. digastricus
N. mentalis Skin of the chin

450
 9.3 Cranial nerves

hemispheres. The lower part is only reached by corticonuclear through the Canalis nervi facialis in the petrous bone, the N. fa­
fibres of the contralateral side. cialis [VII] emits 3 more branches:
• The general visceroefferent (GVE) (parasympathetic) Nucleus • The N. petrosus major (parasympathetic) runs through the Hia­
salivatorius superior also lies within the pons and is responsible tus canalis nervi petrosi majoris and then runs in the middle
for the autonomic innervation of the salivary glands (exception: cranial fossa between dura and the Pars petrosa of the Os tem­
Glandula parotidea) of the lacrimal gland and a part of the nasal porale to the Foramen lacerum (› Fig. 9.36). Sympathetic fibres
glands. connect to it, forming the N. petrosus profundus. After both
• The special visceroafferent (SVA) (taste) Nuclei tractus soli- nerves have penetrated through the Foramen lacerum the para­
tarii (Pars superior) which extend from the pons to the Medulla sympathetic fibres of the N. petrosus major and the sympathetic
oblongata, contain the original neurons for sensory innervation fibres of the N. petrosus profundus merge to the N. canalis
of the anterior two thirds of the tongue (taste). pterygoidei (VIDIANUS), which passes through the canal of the
Additionally, general somatoafferent fibres (GSA) from the audi­ same name into the Fossa pterygopalatina to the Ganglion ptery­
tory canal rear wall, the skin behind the ear, the outer ear and the gopalatinum (see below).
eardrum also run with the N. facialis [VII]. The fibres run for a • The N. stapedius (› Fig. 9.36) remains within the petrous bone
short distance with the N. vagus [X] (R. communicans nervi vagi) and runs to the M. stapedius lying in the Proc. pyramidalis of
and dock in the Pars petrosa of the N. facialis [VII]. The cell bodies the petrous bone, to innervate it motorically (muscle contraction
of neurons lie, just as the perikarya of taste fibres, in the Ganglion leads to tilting of the stirrup base plate in the oval window with
geniculi and project via the intermediate part of the N. facialis resulting stiffening of the auditory ossicles and reduced sound
[VII] into the Nucleus spinalis nervi trigemini. transmission).
The two main parts (facial and intermediate parts) leave the brain at • Shortly before the N. facialis [VII] exits from the bony Canalis
the cerebellopontine angle, Then, together with the N. vestibulo­ nervi facialis through the Foramen stylomastoideum, the Chor-
cochlearis [VIII] enter into the Porus and Meatus acusticus inter- da tympani branches off (› Fig. 9.36). After a short course
nus. Shortly before reaching the inner ear the main part of the through an independent canal in the temporal bone it comes
nerve bends almost at a right angle dorsally and downwards into the tympanic cavity. Surrounded by middle ear mucosa, it
(› Fig. 9.36). This bending point is referred to as the external runs through the tympanic cavity towards the ossicles, passes
genu of the facial nerve (internal genu of the facial nerve: course between Collum mallei (hammer neck) and the upper part of
of intrapontine fibres of the N. facialis [VII] around the Nucleus the Crus longum incudis (long limb of the incus) and then
nervi abducentis). The exterior genu of the facial nerve is based in bends down to the Fissura sphenopetrosa and via which in
the Ganglion geniculi, which contains pseudo-unipolar perikarya most cases leaves the middle ear (much less frequently the Chor­
for the sensory fibres (taste) of the anterior two thirds of the tongue da tympani penetrates the skull base via the Fissura petrotym-
and the sensory nerve fibres from the outer ear. During the course panica [GLASER's fissure]). The Chorda tympani runs to the

M. stapedius
Ganglion geniculi N. facialis [VII]
M. stapedius, Tendo
Stapes
M. tensor tympani, Tendo
Incus
N. petrosus minor
Malleus
N. stapedius
N. petrosus major
Proc. pyramidalis

M. tensor tympani
N. facialis [VII]
Semicanalis musculi
tensoris tympani
Chorda tympani
Tuba auditiva [auditoria],
Pars ossea Membrana tympanica
A. carotis interna
Proc. mastoideus
Tuba auditiva [auditoria],
Pars cartilaginea A. carotis
Fissura interna
Foramen
sphenopetrosa
stylomastoideum
Chorda tympani

R. stylohyoideus
N. auricularis posterior

M. stylohyoideus R. digastricus

M. digastricus, Venter posterior

Fig. 9.36 Course of the N. facialis [VII]. Vertical section through the Canalis facialis, view from the left.

451
9 Head

area behind or medial of the Fossa mandibularis via both fis­ NOTE
Although parasympathetic fibres partially run with the N. facialis
sures and runs medial from the Condylus and Ramus mandibu­ [VII] and it passes through the Glandula parotidea,it does not in-
lae downwards. About 1 cm below the Incisura mandibulae the nervate the parotid gland. The parasympathetic fibres for this pur-
Chorda tympani connects to the N. lingualis. pose run with the N. glossopharyngeus [IX] (› Chap. 9.3.9).
– From the N. lingualis the Chorda tympani takes up gustatory
sensory fibres from the taste buds of the anterior two thirds of
the tongue, which have their perikarya in the Ganglion ge­ Clinical remarks
niculi of the N. facialis [VII] and project into the Nucleus spi­
In the case of space occupying processes in the cerebellopon-
nalis nervi trigemini.
tine angle (usually a benign but displacingly growing acoustic
– Parasympathetic fibres run along with the Chorda tympani, neurinoma, see above next clinical box) both the N. vestibulo-
the core area of which is the Nucleus salivatorius superior. cochlearis [VIII] (hearing and balance disturbances) as well as
They branch off from the N. lingualis and pass to the Gangli­ the N. facialis [VII] can be affected. Possible consequences of
on submandibulare (see below). an infranuclear lesion (lesion below the facial core) are:
The main part of the N. facialis [VII] leaves the skull base through • Limited tear secretion (Result: dry eye)
the Foramen stylomastoideum of the Os temporale. Shortly after • Failure of the N. stapedius (Result: hyperacousia)
• Failure of the Chorda tympani (Result: problems with sense
its exit, it emits motor branches:
of taste, limited production of saliva on one side)
• N. auricularis posterior for the innervation of the M. occipito­ • Failure of the motor branches (Result: peripheral facial pare-
frontalis, Venter posterior sis with lagophthalmus [inability to close the eye due to pa-
• R. auricularis (mostly as a branch of the N. auricularis posteri­ ralysis of the M. orbicularis oculi] and resulting detachment
or) for the innervation of the rudimentarily created facial Mm. of the lacrimal film or signs of dehydration on the surface of
auriculares the eye up to clouding and subsequent blindness on the
• A direct branch for the innervation of the M. digastricus, Ven­ ­affected side)
ter posterior Supranuclear lesions describe damage in the area of cortico-
nuclear fibres of the nerve. They are also referred to as central
• A direct branch for the innervation of the M. stylohyoideus facial palsy. This is characterised by motor deficits of the con-
The main trunk then enters into the Glandula parotidea, where it tralateral lower facial muscles (so-called lower facial palsy).
branches to the Plexus intraparotideus (› Fig. 9.37). It usually As the eye and forehead muscles are innervated by both
divides into an upper R. temporofacialis and a lower R. cervicofa­ halves of the brain, the upper half of the face is not affected in
cialis. Resulting terminal branches leave the parotid gland at the central facial palsy but the forehead can be wrinkled.
front and lower margins as Rr. temporales (also referred to clini­
cally as the forehead branch), Rr. zygomatici, Rr. buccales, R. mar-
ginalis mandibulae and R. colli for the innervation of the mimic
muscles (› Chap. 9.2.3) in the face.

N. petrosus profundus Ganglion geniculi

(Plexus caroticus internus)

Meatus acusticus
internus

N. petrosus major

N. intermedius

N. canalis pterygoidei 1
1 N. facialis [VII]
1
Ganglion 1
pterygopalatinum 1 N. stapedius

2 Chorda tympani

2
N. auricularis pos-
2 2 terior, R. occipitalis

N. auricularis pos-
3 terior, R. auricularis Terminal motor branches:
3 1 Rr. temporales
3 2 Rr. zygomatici
Foramen stylo- 3 Rr. buccales
mastoideum 4 Rr. marginales mandibulae
4 5 Rr. colli
4 4 5
N. auricularis
5 posterior Efferent (motor) fibres
5 Afferent (sensory) fibres
Glandula Chorda tympani
sublingualis Spinal nerve fibres
N. lingualis [V/3] Sympathetic fibres
Glandula submandibularis
Ganglion submandibulare Parasympathetic fibres

Fig. 9.37 N. facialis [VII], core and fibre qualities. View from the left.

452
 9.3 Cranial nerves

Ganglion pterygopalatinum their innervation and the innervation of the Glandula sublingualis
The N. petrosus major (preganglionic parasympathetic fibres) and the and the Glandulae linguales (› Fig. 9.37). The parasympathetic
N. petrosus profundus (postganglionic sympathetic fibres) reach the fibres run with the Chorda tympani, , which connect to the N. lin­
Ganglion pterygopalatinum as the N. canalis pterygoidei (› Fig. gualis. The fibres only run for a short distance with the N. lingualis
9.37). Furthermore, the ganglion is still used by sensory fibres of the [V/3], then subdivide and reach the Ganglion submandibulare
palate, as a transit route on the way to the N. maxillaris [V/2]: lying medial of the Angulus mandibulae. Here, the fibres are
• A part of the parasympathetic fibres from the N. petrosus major switched from preganglionic to postganglionic, then part of the fi­
connects after switching from preganglionic to postganglionic to bres passes directly into the neighbouring Glandula submandibu-
the N. zygomaticus and extends together with it through the laris and innervates this while the other part again docks at the N.
Fissura orbitalis inferior into the Orbita. These fibres pass via the lingualis and either passes with it into the tongue for innervation of
connection to the R. zygomaticotemporalis and then to the R. the Glandula lingualis anterior (Apicis linguae, BLAN-
communicans cum nervo zygomatico to the N. lacrimalis, to DIN-NUHN gland) located in the tongue tip or leaves the N. lin­
finally innervate the Glandula lacrimalis (lacrimal gland). gualis [V/3] again after a short distance to innervate the Glandula
• A second part of the parasympathetic fibres extends from the sublingualis.
Fossa pterygopalatina with the N. nasalis posterior superior Similar to the Ganglion pterygopalatinum the parts of the Radix
through the Foramen sphenopalatinum into the nose. The fibres sympathica originate from the Plexus caroticus, which originate
spread out into the nasal mucosa and innervate the Glandulae from the cervical Truncus sympathicus. Within the ganglion only
nasales. the parasympathetic fibres are switched; the sympathetic fibres run
• A third part of the parasympathetic fibres extends with the N. through the ganglion unswitched.
palatinus major and the Nn. palatini minores after passing the
identically named foramina to the hard and soft palate and in­
nervates the Glandulae palatinae. 9.3.8 N. vestibulocochlearis [VIII]
• Postganglionic sympathetic fibres run with the named parasym­
pathetic fibres from the N. petrosus profundus to the correspond­ The N. vestibulocochlearis [VIII], which is also clinically referred
ing glands, which have already been switched from preganglionic to as N. statoacusticus, is a specially somatoafferent (SSA) nerve
to postganglionic in the Ganglion cervicale superius. that also contains efferent fibres referred to as olivocochlear bun­
• Sensory branches from the soft palate run with the N. palatinus dles (› Chap. 12.5.11). It is divided into two parts (› Fig. 9.38):
major and the Nn. palatini minores to the Ganglion pterygopal­ • The cochlear part relays information from the hearing organ
atinum, extend through this without switching and connect (Cochlea) to the core areas in the brainstem.
shortly before the Foramen rotundum to the N. maxillaris [V/2]. • The vestibular part relays information of the balance organ
Their perikarya reside in the Ganglion trigeminale and project (vestibular organ) to corresponding core areas in the brainstem.
to the Nucleus pontinus nervi trigemini. The special somatoafferent nerve fibres of the N. cochlearis origi­
nate in the organ of CORTI of the cochlea. The perikarya of bipo­
Ganglion submandibulare lar neurons lie within the cochlea in the Ganglion spirale cochleae
The Ganglion submandibulare is located in the immediate vicinity within the modiolus. Here, the primary sensory cells of the organ
(above) of the Glandula submandibularis and is responsible for of CORTI are switched to the peripheral N. cochlearis. This passes

N. petrosus N. facialis [VII],

Ganglion spirale cochleae major Ganglion geniculi

Canalis facialis
N. vestibularis
Cavitas tympani
with ossicles
N. cochlearis
Chorda tympani
N. vestibulocochlearis
[VIII]

Medulla oblongata Ampulla

membranacea
anterior

Ampulla
membranacea
lateralis

Utriculus

Ganglion Sacculus Ampulla membranacea

vestibulare posterior
Nucleus vestibularis
Pars superior
medialis [SCHWALBE's N. vestibularis
Meatus acusticus Pars inferior
nucleus]
internus
Nucleus vestibularis superior
[BECHTEREW's nucleus] Nuclei cochlearis anterior and posterior Fig. 9.38 N. vestibulocochlearis
Nucleus vestibularis Nucleus vestibularis lateralis [DEITERS's nucleus] Afferent (sensory) fibres
[VIII], cores and fibre qualities.
inferior [ROLLER's nucleus] View from above, Pars petrosa
opened.

453
9 Head

(with the N. vestibularis and the N. facialis) through the internal laris interna caudally to the M. stylopharyngeus, which serves as a
auditory canal and via the cerebellopontine angle into the brain­ guiding structure. Along the muscle it extends to the pharynx from
stem to project to the Nuclei cochleares anterior and posterior. behind and along the parapharyngeal space to the tongue. On its
The central processes of the 1st neuron of the vestibular pathway way, it emits the following branches:
from Sacculus (vertical linear acceleration), Utriculus (horizontal • N. tympanicus (JACOBSON) (GVE and GSA): it branches at
linear acceleration) and the three semicircular canals (rotational the level of the Ganglion inferius directly below the Foramen
acceleration) initially merge into 2 bundles, Pars superior and jugulare and reaches the tympanic cavity via a bony canal. Here
Pars inferior, which converge to the N. vestibularis and together its nerve fibres branch out into the mucosa of the tympanic cavi­
with the N. cochlearis run through the internal auditory canal and ty and form, together with sympathetic fibres from the Plexus
enter the brainstem via the cerebellopontine angle. Their perikarya caroticus, the Plexus tympanicus (› Fig. 9.39). The sensory
reside in the Ganglion vestibulare on the edge of the internal au­ nerve fibres innervate the middle ear mucosa, a part rejoins the
ditory canal. They project to the 4 Nuclei vestibulares superior R. tubarius and innervates the mucosa of the Tuba auditiva. The
(BECHTEREW), inferior (ROLLER), medialis (SCHWALBE) nerve cell bodies of the sensory fibres are located in the Gangli-
and lateralis (DEITERS) (› Fig. 9.38). Some fibres pass via the on superius and project into the Nucleus and Tractus spinalis
Pedunculus cerebellaris inferior to the cerebellum. nervi trigemini. Preganglionic parasympathetic fibres from the
Nucleus salivatorius inferior run without switching with the N.
tympanicus and the Plexus tympanicus through the middle ear
Clinical remarks and then merge with sympathetic fibres of the Plexus caroticus
An acoustic neurinoma is a slow (years to decades), but sup- internus, which also runs in the middle ear mucosa to the N.
pressingly growing benign tumour which originates from petrosus minor. This enters through the Hiatus canalis nervi
SCHWANN cells of the nerve cell sheath of the N. vestibuloco- petrosi minoris into the middle cranial fossa and leaves it via
chlearis [VIII] (schwannoma). It usually develops in the area of the Foramen lacerum. From here the fibres run to the Ganglion
the Porus acusticus internus. First symptoms are often a hear-
oticum at the stem of the N. mandibularis [V/3] and the Fora­
ing loss (especially a high-frequency hearing loss) and/or tin-
nitus and as the third most common symptom dizziness (bal- men ovale. In the ganglion the switching of the parasympathetic
ance disorders). These 3 signs are already manifested when fibres from preganglionic to postganglionic takes place, the sym­
the acoustic neurinoma is still relatively small and is primarily pathetic fibres are already postganglionic and continue un­
or exclusively in the bony auditory canal (intrameatal). The switched. The postganglionic fibres attach onto the N. auricolo-
N. facialis [VII] can be affected by the suppression of growth. temporalis to the Glandula parotidea and within the parotid
Following diagnosis, the neurinoma is removed neurosurgically. gland partially to the intraparotideal fibres of the N. facialis
[VII] with which they pass into the parenchyma of the gland.
The connection from the Nucleus salivatorius inferior to the pa­
rotid gland is referred to as JACOBSON's plexus. Some fibres
9.3.9 N. glossopharyngeus [IX] continue and innervate the Glandulae buccales and labiales.
• R. sinus carotici (GVA): nerve fibres run within the R. sinus
The 3rd branchial nerve, the N. glossopharyngeus [IX], is a mixed carotici which originate in the Sinus caroticus (pressoreceptors
nerve with general visceroefferent (GVE), special visceroefferent – blood pressure regulation) and in the Glomus caroticum
(SVE), general somatoafferent (GSA), as well as general vis­ (chemoreceptors O2, CO2 partial pressure) (› Fig. 9.39). Their
ceroafferent (GVA) and special visceroafferent (SVA) units. It is nerve cell bodies are located in the Ganglion inferius of the N.
therefore very similar to the N. vagus [X] (› Chap. 9.3.10). Ac­ glossopharyngeus and project into the Tractus solitarius.
cording to its different fibre qualities, it has a large innervation • Rr. pharyngei (GVE, SVE, GSA, SVA): the branches have differ­
area: it innervates the Glandula parotidea, muscles and epithelium ent fibre qualities (› Fig. 9.39):
of the pharynx as well as sensory innervation to the rear third of – Afferent (sensory) fibres (GSA) come from the pharyngeal
the tongue. It also relays information from the Glomus caroticum wall. The nerve cell bodies reside in the Ganglion inferius and
and from the Sinus caroticus and is thus involved in blood pres­ project to the Tractus spinalis nervi trigemini.
sure regulation. Its 4 core areas are in the Medulla oblongata: – Motor fibres (SVE) derived from the Nucleus ambiguus in­
• Nucleus salivatorius inferior (GVE), secretory core nervate the pharyngeal muscles and the muscles of the soft
• Nucleus ambiguus (SVE), motor core palate in conjunction with motor fibres of the N. vagus [X] as
• Nucleus spinalis nervi trigemini (ASA), core for surface sensi­ Plexus pharyngeus.
tivity – Parasympathetic fibres (GVE) from the Nucleus salivatorius
• Nucleus tractus solitarii [Nucleus solitarius] (SVA, GVA), sen­ inferior reach the mucous Glandulae pharyngeales.
sory core for taste fibres • Rr. tonsillares and linguales (GSA, SVA): they have 2 fibre
The N. glossopharyngeus [IX] exits together with (and above) the qualities (› Fig. 9.39):
N. vagus [X] (› Chap. 9.3.10) and the N. accessorius [XI] – Afferent (sensory) fibres (GSA) originate in the base of the
(› Chap. 9.3.11) from the Medulla oblongata in the Sulcus ret- tongue and from the Isthmus faucium including the tonsils.
roolivaris (› Fig. 9.39). It passes hidden from the cerebellum be­ The nerve cell bodies reside in the Ganglion inferius and proj­
low the Flocculus cerebelli to the Foramen jugulare, through ect to the Tractus spinalis nervi trigemini.
which it leaves the skull together with the N. vagus [X] and N. ac­ – Spinal nerve fibres (SVA) conduct taste sensations from the
cessorius [XI]. At the level of the Foramen jugulare are its 2 senso­ posterior third of the tongue and the neighbouring mucous
ry ganglia (Ganglion superius [inside the skull] and Ganglion in- membrane in the area of the Isthmus faucium to the Nucleus
ferius [outside the skull]), which are thrown up by pseudo-unipo­ and Tractus solitarius. Its nerve cell bodies reside in the Gan­
lar nerve cell bodies of sensory (Ganglia superius and inferius) and glion inferius.
spinal (only Ganglion inferius) nerve fibres. After passing through • R. musculi stylopharyngei (SVE): this branch of the Nucleus
the skull base, it runs between the A. carotis interna and V. jugu­ ambiguus innervates the M. stylopharyngeus (› Fig. 9.39).

454
 9.3 Cranial nerves

Plexus tympanicus Nucleus salivatorius inferior Nucleus tractus

solitarii
N. petrosus profundus [Radix
sympathica ganglii pterygopalatini] Nucleus
ambiguus
N. caroticotympanicus
(Plexus caroticus internus)

N. petrosus minor

N. mandibularis [V/3]

Ganglion oticum

Glandula parotidea N. glosso-

pharyngeus [IX]
N. auriculotemporalis

R. tubarius (Plexus tympanicus) Ganglion superius

Foramen jugulare
Tuba auditiva [Auditoria]
N. tympanicus [JACOBSON's nerve]

Ganglion inferius

Plexus pharyngeus
N. vagus [X]

R. lingualis

R. sinus carotici

Truncus sympathicus

A. carotis interna Efferent (motor) fibres

A. carotis externa Afferent (sensory) fibres
Sinus caroticus
Glomus caroticum Spinal nerve fibres
A. carotis communis Parasympathetic fibres

Fig. 9.39 N. glossopharyngeus [IX], cores and fibre qualities. Schematic median section, view from the left side.

Ganglion oticum 9.3.10 N. vagus [X]

The Ganglion oticum is located at the stem of the N. mandibularis
[V/3] near the Foramen ovale. In the ganglion parasympathetic fi­ The N. vagus [X] (› Fig. 9.40) has the largest innervation area of
bres are switched from preganglionic to postganglionic. The nerve all cranial nerves. It innervates up into the abdomen and is the main
cell bodies of the fibres reside in the Nucleus salivatorius inferior nerve of the cranial parasympathetic nervous system (autonomic
and initially run with the N. glossopharyngeus [IX] via the above­ nervous system). It has the same fibre qualities as the N. glossopha­
mentioned JACOBSON's plexus to the Ganglion oticum. The post­ ryngeus [IX] (GVE, SVE, GSA, GVA, SVA, › Chap. 9.3.9) and for
ganglionic fibres pass via the N. auriculotemporalis [V/3] and part­ the most part uses the same core areas:
ly with intraparotidal branches of the N. facialis [VII] into the pa­ • Nucleus ambiguus (SVE), motor core
rotid gland and innervate it parasympathetically. Further • Nucleus tractus solitarii [nucleus solitarius] (SVA, GVA), sen­
parasympathetic fibres extend from the Ganglion oticum to the sory core for taste fibres
base of the tongue and innervate the Glandulae linguales. Postgang­ • Nucleus spinalis nervi trigemini (GSA), core for surface sensi­
lionic parasympathetic fibres also pass through the Ganglion oti­ tivity
cum without switching and reach the described target tissue with • Nucleus dorsalis nervi vagi (GVE, GVA), parasympathetic core
the parasympathetic fibres. The nerve exits as a relatively flat bundle between the N. glossopha­
ryngeus [IX] (› Chap. 9.3.9) and the N. accessorius [XI]
(› Chap. 9.3.11) in the Sulcus retroolivaris from the Medulla ob­
Clinical remarks longata and passes together with the other two nerves to the Fora­
Lesions of the N. glossopharyngeus [IX] primarily cause swal- men jugulare. It also has 2 ganglia (Ganglion superius [Ganglion
lowing difficulties, because the motor innervation of the M. jugulare in the Foramen jugulare or inside the skull] and Ganglion
constrictor pharyngis superior is disrupted. Other typical inferius [Ganglion nodosum, outside of the skull]). It picks up 2
symptoms are a deviation of the uvula to the healthy side branches when still within the cranial cavity:
(also referred to as the backdrop phenomenon; paralysis of
• R. meningeus (GSA): sensory fibres of the meninges of the pos­
the Mm. levator veli palatini, palatoglossus, palatopharyn-
geus and uvulae), sensory disturbances in the upper pharynx terior cranial fossa
(e.g. absence of gag reflex) and disorders of taste sensation at • R. auricularis (GSA): sensory fibres from the external auditory
the base of the tongue. canal

455
9 Head

R. meningeus Nucleus ambiguus N. accessorius [XI],

Radix cranialis
N. vagus [X]
Nucleus dorsalis
nervi vagi
R. auricularis
Nucleus tractus
Ganglion superius [X] solitarii

Foramen jugulare

Ganglion inferius [X]

R. pharyngealis

Rr. linguales R. communicans

cum ramo sinus carotici [IX]

Plexus pharyngeus
R. cardiacus cervicalis
superior R. internus
N. laryngeus superior
Rr. tracheales and oesophageales R. externus

R. cardiacus cervicalis inferior

A. subclavia dextra R. cardiacus thoracicus

N. laryngeus recurrens sinister

N. laryngeus recurrens dexter
Plexus pulmonalis
Plexus pulmonalis Plexus cardiacus
and Rr. bronchiales
Plexus oesophageus
Truncus vagalis anterior
Truncus vagalis posterior

R. hepaticus
Rr. gastrici anteriores

Rr. coeliaci
Plexus coeliacus, Ganglia coeliaca
and Mesentericum superius
Plexus hepaticus

Plexus splenicus

Plexus suprarenalis

Plexus renalis

(Rr. intestinales)

Efferent (motor) fibres

Afferent (sensory) fibres Fig. 9.40 N. vagus [X], cores
Parasympathetic fibres and fibre qualities, highly sim-
plified diagram.

Clinical remarks mucosa of the throat area, Isthmus faucium, base of the tongue
and entrance of the larynx to the Nucleus spinalis nervi trigemi­
Manipulation in the external auditory canal, e.g. when the ni. The nerve cell bodies reside in the Ganglion nodosum (infe­
ear nose and throat (ENT) doctor removes ear wax, irritation of
the throat area is triggered via the sensory fibres of the N. va-
rius).
gus [X]. In excessive irritation of the throat, there may also be • N. laryngeus superior (SVE, GSA): the branch leaves the N. va­
vomiting. Also, the stimulation of the R. meningeus, e.g. in the gus [X] usually shortly after leaving the skull and passes between
case of meningitis in the area of the posterior cranial fossa A. carotis interna and pharyngeal wall caudally to the level of the
may trigger vomiting. larynx. Here it branches into:
– The R. externus innervates the M. cricothyroideus.
– The R. internus provides sensory innervation of the larynx
The main stem of the nerve runs together with the A. carotis inter­ epithelium above the glottis.
na and the V. jugularis interna within a common sheath (Vagina • Rr. cardiaci cervicales superiores and inferiores, Rr. cardiaci
carotica) as a vascular nerve cord caudally through the throat area. thoracici (GVE, GVA): the branches leave the N. vagus already
On its way, it emits the following branches: in the throat area and upper chest area and run to the heart. The
• R. pharyngeus (SVE, GSA): it forms together with the N. glos­ N. vagus continues its course through the upper thoracic aper­
sopharyngeus [IX] the Plexus pharyngeus and provides motor ture. The Rr. cardiaci form the Plexus cardiacus at the heart.
innervation to the pharyngeal muscles. Sensory information is They are switched to the 2nd neuron and then innervate the atri­
relayed via Rr. linguales and the Plexus pharyngeus from the um, the sinus nodes (right vagus part) and the AV nodes (left

456
 9.3 Cranial nerves

vagus part) parasympathetically. The chambers of the heart are sensory disturbances in the pharynx and the epiglottis (lack of
not innervated by the N. vagus. gag reflex, taste disturbances), hoarseness (via Nn. laryngei),
• N. laryngeus recurrens (SVE, GSA): it passes on the left side tachycardia, arrhythmia as well as respiratory and circulatory
from front to back around the aortic arch (and is wound around problems.
the Lig. arteriosum BOTALLI). On the right side, it extends
from front to back around the A. subclavia and passes as on the
left-hand side into the groove between trachea and oesophagus.
On both sides, it emits Rr. tracheales and oesophageales (para­ 9.3.11 N. accessorius [XI]
sympathetic) and continues cranially to the larynx, which it
reaches as the N. laryngeus inferior. Its fibres divide and inner­ By definition, the N. accessorius [XI] (SVE) is not actually a cranial
vate all other laryngeal muscles and the mucosa of the glottis nerve as its main section (Radix spinalis) does not originate from
and below the glottis (subglottis), with the exception of the M. cerebral core areas, but from the anterior horn (Nucleus nervi ac-
cricothyroideus which has already been innervated by the N. la­ cessorii) in the cervical spinal cord (up to C5). Hence the name
ryngeus superior. ‘accessorius’ = additional. Only a smaller part (Radix cranialis)
• In the thorax numerous fibres leave the N. vagus and form the leaves the brainstem together with the N. glossopharyngeus [IX]
Rr. bronchiales, the Plexus pulmonalis and the Plexus oe- (› Chap. 9.3.9) and the N. vagus [X] (› Chap. 9.3.10) in the Sul­
sophageus for the parasympathetic innervation of the corre­ cus retroolivaris. The neurons are in the Nucleus ambiguus. Within
sponding structures. the Foramen jugulare the two Radices merge to the N. accessorius
• Below the tracheal bifurcation the fibres which originally be­ [XI] (› Fig. 9.41). It is not conclusively clarified whether the fibres
longed to the left N. vagus [X] shift to the front and form the of the Radix cranialis pass over below the Foramen jugulare as R.
Truncus vagalis anterior, the fibres belonging to the right N. va­ internus to the N. vagus [X] or whether there is no connection to
gus [X] move dorsally and form the Truncus vagalis posterior. the N. vagus at all. The Radix cranialis participates in the innerva­
This shift is based on the gastric rotation during embryonic de­ tion of the pharyngeal and laryngeal muscles and, strictly speaking,
velopment. Both Trunci vagales pass together with the oesopha­ is not part of the N. accessorius [XI]. The fibres of the Radix spina­
gus through the Hiatus oesophageus of the diaphragm into the lis, with their neurons in the Nucleus nervi accessorii, pass as R.
abdominal cavity and then branch out with the vessels as part of externus via the M. levator scapulae caudally to the M. sternoclei­
the enteric nervous system in: R. hepaticus (Omentum minus), domastoideus and innervate it. One part then continues through
Plexus hepaticus, Rr. gastrici anteriores, Plexus coeliacus, Gan­ the lateral triangle of the neck to the anterior border of the M. tra­
glia coeliaca and Mesentericum superius, Plexus splenicus, Plex­ pezius, which it also innervates.
us suprarenalis, Plexus renalis and Rr. intestinales. They there­
fore parasympathetically innervate the viscera of the upper ab­
domen and gastrointestinal tract. The switch from preganglionic
Clinical remarks
to postganglionic occurs directly at the respective organ. Since the N. accessorius [XI] runs very superficially in the
The innervation area of the N. vagus [X] ends at the level of the throat area, it is at risk of injury (e.g. in the case of the removal
colic flexure (CANNON-BÖHM point). From there, the parasym­ of lymph nodes). In most cases the damage lies below the
pathetic innervation is guaranteed for all further distally located outlet for the M. sternocleidomastoideus in the lateral triangle
of the neck, so that the innervation of the M. trapezius fails.
sections from the sacral medulla. The two autonomic nervous parts
The consequences are dropping of the shoulder and difficul-
overlap extensively in this area, so that there can be no sharp bor­ ties in raising the arm above the horizontal plane (distorted
der between the cranial (N. vagus [X]) and the sacral parasympa­ elevation). If the damage is above the outlet to the M. sterno-
thetic nervous system. cleidomastoideus, it will also no longer be innervated and
apart from the difficulties in raising the arm the patient can
NOTE also no longer turn the head to the healthy side.
The course of the N. laryngeus recurrens is different on both sides
(left around the aortic arch, right around the A. subclavia). This can
be explained from the development. A thicker myelin sheath on the
left side ensures that despite the longer course both vocal folds can 9.3.12 N. hypoglossus [XII]
swing synchronously. In rare cases, the A. subclavia dextra originates
as the last branch from the aortic arch (so-called A. lusoria) and runs
behind or in front of the oesophagus or between the o ­ esophagus and The N. hypoglossus [XII] is a purely motor nerve with a quality
trachea on the right side of the body. In such a case, there is no N. (GSE). Its core area is the Nucleus nervi hypoglossi. It leaves the
laryngeus recurrens on the right side. The N. laryngeus inferior then brain as the only cranial nerve with multiple small fibres in the Sul-
originates either together or a few millimetres below the N. laryn- cus anterolateralis between olive and pyramid. After the merger of
geus superior from the N. vagus [X]. the fibres to the N. hypoglossus [XII] the nerve passes through the
Canalis nervi hypoglossi at the side of the Foramen magnum
through the skull base (› Fig. 9.42). Below this, fibres of the spinal
Clinical remarks nerves C1 and C2 (Plexus cervicalis) accumulate, which run to the
Damage to the N. vagus [X] is common in the context of skull Mm. geniohyoideus and thyrohyoideus and innervate them. After
fractures in the area of the Foramen jugulare; however, the passing through the skull base, it passes into the Spatium latero-
nerve can also be damaged due to tumours of the cerebello- pharyngeum between A. carotis interna and V. jugularis interna to
pontine angle or iatrogenically (from medical procedures), e.g. the front in the direction of the floor of the mouth. In doing so, the
biopsy incision of lymph nodes or a neck dissection (neck fibres from C1 and C2 also runs with them as Ansa cervicalis nervi
lymph node evacuation). Depending on the location of the hypoglossi. It passes between M. mylohyoideus and M. hyoglossus
damage, the following can be caused, difficulty in swallowing,
laterally into the tongue and provides motor innervation to the in­
ternal muscles (Mm. longitudinales superior and inferior linguae,

457
9 Head

N. accessorius [XI], N. vagus [X]

Radix spinalis
N. accessorius [XI],
Radix cranialis
Nucleus Foramen
ambiguus jugulare
N. vagus [X], Ganglion
superius jugulare

Truncus nervi accessorii

Nucleus nervi R. internus

accessorii
N. vagus [X], Ganglion
inferius (nodosum)
N. cervicalis [C1]
R. externus
N. cervicalis [C2] M. sternocleidomastoideus

N. cervicalis [C3]

N. cervicalis [C4]

M. trapezius

Connection to the
Plexus brachialis

Plexus brachialis, Truncus superior

Fig. 9.41 N. accessorius[XI],

Efferent (motor) fibres cores and fibre qualities. Ven-
Afferent (sensory) fibres tral view, vertebral canal and
skull are opened.

N. cervicalis [C1], (R. meningeus)

N. hypoglossus [XII]

Nucleus nervi hypoglossi

N. cervicalis [C1], R. anterior

N. cervicalis [C2], R. anterior

N. cervicalis [C3], R. anterior

Ansa cervicalis profunda,

radix superior

Ansa cervicalis profunda,

radix inferior

Truncus sympathicus

Ansa cervicalis profunda

Fig. 9.42 N. hypoglossus [XII],
Efferent (motor) fibres cores and fibre qualities. Sche-
Afferent (sensory) fibres matic median section, view from
left.

M. transversus linguae, M. verticalis linguae and the Mm. stylo­ Clinical remarks
glossus, hyoglossus and genioglossus). It is the only motor muscle
Skull base fractures or infarcts in the flow area of the A. verte-
for the tongue and therefore vital for eating, drinking, swallowing bralis may cause damage to the N. hypoglossus [XII]. Usually
and speaking. only one side is affected. The patients are conspicuous due to
articulation disorders (dysarthria) and swallowing difficulties

458
 9.4 Eye

(dysphagia). When prompted to stick out the tongue, it devi- Treatment

ates to the diseased side, as the muscles on the healthy side The immediate intravenous administration of a megadose of
are predominant. If the lesion persists longer, the result is an the anti-inflammatory glucocorticoid prednisolone does not
atrophy of the tongue muscles on the affected side. improve the vision loss on the right side.

Long-term diagnosis
After about 7 weeks an optical atrophy is detected. Due to the
side impact of the unprotected head (helmet on when cy-
9.4 Eye cling!) on the road, there was a rupture of the Nn. opticus [II]
Michael Scholz and/or the relevant vessels in the Canalis opticus.

Skills The eye (Organum visus) as the optical organ in humans consists
functionally of the eyeball (Bulbus oculi) with the actual optical
After processing this chapter, you should be able to: apparatus, the external eye muscles (Mm. bulbi), numerous blood
• understand the embryological development of the eye and vessels and nerves and various auxiliary structures such as the eye-
assess the resulting special features of the respective struc-
lids (Palpebrae), the conjunctiva (Tunica conjunctiva) and the
tures of the eye
• name the construction and the structures of the orbita lacrimal apparatus (Apparatus lacrimalis). With the exception of
• differentiate the auxiliary structures of the Orbita and ex- the eyelids, all auxiliary structures together with the eyeball and a
plain their functions filling fat body (Corpus adiposum orbitae), which is developed
• describe and distinguish between the structure and function around the Bulbus oculi as a connective tissue capsule (Vagina
of the extraocular muscles, their blood supply and the inner- bulbi; TENON's capsule) are accommodated in the bony orbit
vation of the Bulbus oculi and the Orbita (Orbita) (› Fig. 9.43).
• differentiate the components of the Bulbus oculi and assign
• Each eye has an upper (Palpebra superior) and a lower eyelid
their functions
(Palpebra inferior).
• The lacrimal apparatus is composed of the lacrimal gland
(Glandula lacrimalis), the accessory lacrimal gland (Glandulae
Clinical case lacrimales accessoriae) and the MEIBOM's glands (Glandulae
tarsales) in the eyelids, the upper and the lower tear ducts (Can­
Rupture of the N. opticus [II] aliculi lacrimales superior and inferior), the lacrimal sac (Saccus
Accident lacrimalis) and the nasolacrimal duct (Ductus nasolacrimalis).
A 32-year-old man falls from his racing bike in a light descent • In the orbit there are 6 muscles that move the eyeball, and the
and hits his right temple hard on the asphalt ground. Although (upper) lid elevator (M. levator palpebrae superioris). Of the 6
the man is not wearing a helmet, he does not become uncon-
muscles that move the eyeball, 4 run straight (M. rectus superior,
scious as a result of the fall. He notes a coruscation for a few
seconds in the right eye and by covering his left eye finds that M. rectus inferior, M. rectus medialis and M. rectus lateralis)
he can see nothing through the right eye. Apart from minor and 2 have an oblique course (M. obliquus superior and M.
abrasions a haematoma forms on the right temple. obliquus inferior).
• The eyeball (Bulbus oculi) resembles an onion in its layered
Diagnosis structure. On the outer optic membrane the layer looks like a
After admission to hospital an emergency computed tomogra-
husk (Tunica fibrosa bulbi), the middle eye membrane follows
phy (CT) is conducted to evaluate possible fractures. A frac-
ture cannot be detected, the optic nerve channel (Canalis opti- with sclera and cornea (Tunica vasculosa bulbi), which consists
cus) is also intact. The alternating light exposure test which of the choroid, the ciliary body and the iris. The inner eye mem­
was also conducted to determine pupil reaction shows a com- brane (Tunica interna bulbi) is the retina. On the inside of the
plete afferent disruption of light perception in the right eye. eyeball are the intraocular fluid, lens and vitreous body.

M. orbicularis oculi
Os frontale
N. frontalis
Capsula bulbi*
M. levator palpebrae superioris
Fornix conjunctivae superior

Palpebra superior M. rectus superior

Tarsus superior
N. opticus [II]
Cornea
M. rectus inferior
Palpebra inferior Fig. 9.43 Vertical section
Tarsus inferior through the middle area of the
Fornix conjunctivae inferior
Sclera Orbita. Medial view. All struc-
M. obliquus inferior tures within the Orbita are
Septum orbitale
embedded in a fat body, which
Corpus adiposum orbitae is similar to a filling or padding
Maxilla mass surrounding the content
structures. ∗TENON's capsule

459
9 Head

Optic cup
Lens
vescicles
Optic cup Lens
stalk vescicles
Optical
Fig. 9.44 Phases of ocular
ventricle Optic cup
development In the 5th and 6th
a b fissure with A. hyaloidea weeks (schematic diagram). a
5th week. B 6th week. [E838]

9.4.1 Embryology vessels are increasingly enclosed by the N. opticus [II] emerging in

the optic cup stalk. The distal branches of the vitreous body vessels
Tissue of origin subsequently degenerate, while the proximal branches remain as a.
The development of the organ of sight is principally controlled by a and V. centralis retinae in the N. opticus (› Fig. 9.44).
series of inductive signals, which initially take place within the
neuroectoderm of the diencephalon (diencephalon) and later in
mutual interaction between the respective portions of the eye sys­
Clinical remarks
tem. In principle, the later eye tissue originates from 3 different ar­ Because the eye development is very complex, there may be a
eas during embryonic development (› Table 9.21): whole range of congenital malformations of the eye. Usually
• The neuroectoderm of the diencephalon the malformations are caused by closure disorders of the op-
• The superficial ectoderm of the head tic cup fissure. Basically the type and severity of the respec-
tive anomalies depend on the embryonic stage of the devel-
• The head mesenchyme
opmental disorder. Apart from exogenous factors (e.g. envi-
ronmental toxins) disturbances in the expression of important
Development of the eye system molecular factors may have an influence which plays an im-
The development of the eye system is already visible at the begin­ portant role in the development of the eye (e.g. the transcrip-
ning of the 4th week. First of all, a trough-shaped dent of the neu­ tion factor Pax6 or secreted signal molecules, such as Shh
roectoderm is created on both sides (optical/farrow, Sulcus opticus). [sonic hedgehog]).
This creates eye vesicles by fusing the neural folds, which come into
contact with the surface ectoderm during the further course of de­
velopment. The surface ectoderm becomes thicker at the contact
points and each develops a lens placode as a unit of the subsequent Development of the retina
lens. The lens placodes then sink and merge finally to the spherical The retina develops from the layers of the optic cup. The outer, thin
lens vesicles, which subsequently lose their connection to the sur­ layer of of the optic cup becomes a single-layered pigment epitheli­
face ectoderm. The eye vesicles laterally surround the lens vesicles, um, while the inner layer thickens during the invagination of the
so that the lens vesicles can emerge from the optic cups. Via the optic cup and develops to the actual neuroretina (› Fig. 9.45). The
Sulcus opticus, the optic cup is still connected to the diencephalon. optic ventricle, which lies between the two units, disappears com­
As an oblong indentation on the ventral side of the optic cup, the pletely until birth due to the close approximation of both retinal
optic cup fissure (Fissura optica) develops along the optic cup stalk layers; however, as a result no defined cell contacts are developed
, through which mesenchymal cells can migrate along the entire between the two layers, which means that the connection is not
length of the eye unit into the inside of the optic cup but not into particularly resilient mechanically and clinically plays a key role
the optic ventricle located between the two layers of the optic cup. e.g. in the development of age-related retinal detachment (Ablatio
This optic fissure forms blood vessels, which are partly surrounded retinae).
by the first nerve fibres of the later N. opticus [II]. These blood ves­
sels supply as A. and V. hyaloidea (vitreous body vessels), the inner
5th week
layer of the optic cup, the lens vesicles as well as the optic cup mes­ Wall of the optic cup
enchyme. During the continuing development process the edges of stalk (continues
the optic cup fissure finally begin to merge distally. Due to the into the wall of the
prosencephalon) Surface ectoderm
proximal progressive extension of this merger zone, the vitreous
Lumen of the optic Lens pit
cup stalk (continues
Table 9.21 Tissue of origin of the eye system with the parts of the into the lumen of Inner sheet of the
eye developed during the course of the organ development. the prosencephalon) optic cup (primordium
of neural epithelium
Tissue of origin Resulting components of the eye of the retina)
Optical ventricle
Neuroectoderm (diencephalon) • Retina
Mesenchyme Outer sheet of the
• Inner layers of the ciliary body (primordium of optic cup (primordium
• Rear layers of the iris choroidea of pigment epithelium
• N. opticus and sclera) of the retina)
Surface ectoderm (head) • Ocular lens
• Corneal epithelium Fig. 9.45 Microscopic sagittal section; eye development; 5th week,
200x. The eye vesicle has already invaginated into the optic cup and
Head mesenchyme • Sclera
has close contact to the lens placode. The inner and outer layers of
• Cornea
the optic cup and the still existing optical ventricle can be clearly differ-
• Choroidea
entiated. [E581]

460
 9.4 Eye

Development of the inner eye tissue time of birth, which is why newborns cannot form tears when cry­
The exterior corneal epithelium develops from the surface ecto­ ing.
derm, while the stromal cells and the inner epithelium, which is
known as the endothelium, develop from neural crest cells. The
corneal curvature for normal visual acuity critical corneal curva­ 9.4.2 Protective and auxiliary structures of the eye
ture is formed in direct dependency on the intraocular pressure.
The mesenchyme surrounding the optic cup (from the neural crest The protective and auxiliary structures of the eye include the eye­
cells) is stimulated by the inducing effect of pigment epithelium to lids, the conjunctiva, the lacrimal apparatus and the extraocular
further differentiation and forms 2 layers: the internal, vessel-rich muscles. They also include the orbital fat body and the vascular,
and later also pigmented layer, which is referred to as the choroid lymphatic and nervous systems running in it.
(Choroidea) and an external, connective tissue and initially ves­
sel-poor layer, as the sclera. In the creation of the sclera the mesen­ Eyelids and conjunctiva
chyme thickens and passes seamlessly in a transition zone (Limbus The eyelids (Palpebrae) can be described as movable soft tissue
corneae) into the cornea. The Choroidea changes on the optic cup folds of the face, which in particular cover the cornea of the eyeball
edge and forms the core of the ciliary body process which is cov­ from the front and protect it against mechanical damage. At the
ered by the double layered ciliated epithelium. The iris develops same time, regular blinking (10–15 times per minute) ensures an
from the front edge (Pars caeca) of the optic cup, which bulges in­ even distribution of the tear fluid to the cornea and conjunctiva
wards and in this way partially covers the lens from the outside. In and protects the eye from drying out. The epidermis on the eyelids
the same way as the layers of the optic cup, the iris displays a bilay­ is relatively thin and fat free. Along the front edge of the eyelids are
ered epithelium, which continuously procedes proximally into the several dense rows of eyelashes (Cilia), which curve upwards and
epithelium of the ciliary body. Early in the development the pig­ are usually longer than on the lower eyelid. The excretory ducts of
mentation spreads in the iris up to the transition to the ciliary epi­ the large sebaceous glands (glands of ZEIS; Glandulae sebaceae
thelium from the outside and to the inner layer of the optic cup, flow in the hair funnel of the eyelashes). On the hair roots there are
rendering the iris fully impermeable to light and justifying the sub­ apocrine sweat glands (MOLL's glands, Glandulae ciliares). In the
sequent function as a screen for the eye against incidental light. upper eyelid there are small accessory lacrimal glands (KRAUSE's
glands, WOLFRING glands) in the vicinity of the Fornix conjunc­
Development of the eyelids and lacrimal glands tivae and on the top edge of the MEIBOM glands.
The eyelids develop during the 6th week from 2 skin folds growing The eyelid (upper and lower eyelid are basically structured the
successively over the cornea, which contain the cells of the head same) is divided into an outer and inner layer (› Fig. 9.46):
mesenchyme. Roughly from the beginning of the 10th week these • The outer layer of the eyelid contains the striated, facial M. orbi-
wrinkles fully cover the cornea and connect to each other up to the cularis oculi with its Pars palpebralis as a sphincter of the pal­
26th week. As long as the connection exists, the conjunctiva in pebral fissure. The opening of the eyelids is especially the func­
front of the cornea, which has previously differentiated, forms a tion of the M. levator palpebrae superioris, its tendon radiates
closed pouch. Through the keratinization of the epidermis system into the upper edge of the fibrous eyelid plate of the upper lid
on the eyelid edges the epithelium connection dissolves approxi­ (Tarsus). The section of the muscle near to the eyelid edge is
mately from the 7th month in this area and the eye can be opened. known as the RIOLAN muscle (see below). Both in the upper
The systems of the two lacrimal glands develop as bud-like consoli­ and the lower eyelid the smooth muscle fibres of the M. tarsalis
dations of the surface ectoderm. In adults the buds form branching begin at the tarsal edge which is innervated sympathetically and
in the mesenchyme, in which the duct system and gland end pieces ensures the retraction of the eyelids. Decreased activation of the
differentiate. The lacrimal glands are not yet fully functional at the muscle e.g. in the case of fatigue (parasympathetic nervous sys­

M. orbicularis oculi,
Pars palpebralis

Tunica conjunctiva palpebrarum

Tarsus superior

Glandulae tarsales

Facies posterior
Facies anterior palpebrae
palpebrae

Limbus posterior
Cilia palpebrae Fig. 9.46 Upper eyelid, Palpe-
brae superior. Photograph of a
M. orbicularis oculi, microscopic preparation; azan
Pars palpebralis stain; sagittal section, magni-
Limbus anterior palpebrae
fied. [M375]

461
9 Head

tem activation) causes in the truest sense of the word ‘the eyes to products are part of the lacrimal film. They also occur in the con­
fall closed’. junctiva lymph follicle which belong to the conjunctiva-associated
• The internal layer of the eyelid includes the eyelid plate (Tarsus) lymphatic tissue (CALT).
consisting of tough collagen connective tissue with the elongated
MEIBOM glands (Glandulae tarsales) stored in it, 25-35 (upper
eyelid) and 15-25 (lower eyelid), which as modified sebaceous
Clinical remarks
glands flow on the rear edge of the eyelid (› Fig. 9.47). In the area The hailstone (chalazion) is a pain-free swelling of the eyelid,
of the eyelid edge there are muscle fibres of the M. orbicularis ocu­ mostly due to clogging of the excretory duct of a MEIBOM
li (Pars palpebralis) grouped concentrically around the excretory gland, with subsequent non-bacterial inflammation. It is dif-
ducts of the MEIBOM glands, which radiates into the Tarsus and ferentiated from the painful infection of the eyelid edge
glands (ZEIS or MOLL's glands), which is referred to as a stye
are referred to as RIOLAN muscles or Fasciculi ciliares. Whether
(Hordeolum externum) and is mostly caused by bacteria
the muscle portion is for pressing out the oily secretion of the (Staphylococcus aureus). The Hordeolum internum is a bacte-
MEIBOM glands or the closure of the glands (e.g. during sleep), rial inflammation of a MEIBOM gland. In both cases, the clini-
has not been clarified to date. The eyelid conjunctiva (Tunica cal picture shows a significant redness of the eyelid edge with
conjunctiva palpebrarum) is the mucosa at the inner side of the oedematous swelling and possible pus formation.
eyelids.
The conjunctiva (Tunica conjunctiva) not only covers the inside
of the eyelids. In its course in the direction of the eyeball it changes
in the area of the orbital rim to the eyeball and thus forms reserve Lacrimal apparatus
wrinkles, which are important for eye movements (Fornix conjunc­ Lacrimal gland (Glandula lacrimalis)
tivae superior/inferior). In the further course the conjunctiva cov­ Within the Orbita lies the lacrimal gland (glandula lacrimalis)
ers - with the exception of the cornea – as eye connective tissue immediately below the periorbita in the Fossa glandulae lacrimalis
(Tunica conjunctiva bulbi) the entire front surface of the Bulbus of the os frontale, lateral above the temporal eyelid angle (› Fig.
oculi. Both units together form the conjunctival sac. This enables 9.48). Its front edge extends to the Septum orbitale that closes the
the movements of the eyelids and also provides protection for the orbita to the outside with connective tissue. It is separated by the
eye. In the nasal eye angle there is a third, small and slightly curved tendon of the M. levator palpebrae incompletely into a larger upper
mucosal fold (Plica semilunaris conjunctivae), which is considered part (Pars orbitalis) and a smaller lower part (Pars palpebralis),
in humans as rudiment of the nictitating membrane that is partially which in turn is divided into 2–3 lobes. In the rear lateral part of
well developed in animals (Membrana nictitans). In the multi-layered the gland both parts are connected. The approximately 10 excreto­
epithelium of the conjunctiva cup cells are stored, their secretion ry ducts of this branched, tubuloalveolar gland ultimately flow into

Tarsus superior

Glandulae tarsales

Angulus oculi Angulus Fig. 9.47 Eyelids, Palpebrae,

lateralis oculi medialis right. Rear view; glandular ducts
Commissura
Commissura of the Glandulae tarsales in a
medialis brightened preparation. Each
lateralis
palpebrarum eyelid contains approximately
palpebrarum
20–30 individual glands with
Rima Glandulae tarsales
palpebrarum Tarsus inferior
their own excretory duct open-
ing into the rim of the eyelid.

Septum orbitale
M. levator palpebrae
superioris, Tendo

Tarsus superior
Pars orbitalis

Glandula Pars palpebralis Lig. palpebrale

lacrimalis mediale

Ductuli excretorii

(Raphe palpebralis lateralis);

Lig. palpebrale laterale Maxilla,
Proc. frontalis
Fig. 9.48 Right orbital opening
Septum orbitale (Aditus orbitalis) with Septum
orbitale and the underlying lac-
rimal gland (Septum orbitale
Tarsus inferior
opened in the temporal upper
quadrant).

462
 9.4 Eye

the upper fornix (Fornix conjunctivae superior) behind the eyelid. Table 9.22 Highly simplified division of the lacrimal film built in 3
Their most important feature is the secretion of large parts of the physically different portions that continuously merge together.
aqueous component of the lacrimal film (› Table 9.22). Structure of the lacrimal film Secreting glands/cells
Lipid layer Mainly MEIBOM's glands
Clinical remarks Function: prevents a fast evaporation of the (Glandulae tarsales), with a
­lacrimal film small proportion of cell
In order to investigate the normal physiological lacrimal gland membrane lipids of desqua-
function, a SCHIRMER test is conducted. To this end, a filter mated epithelial cells
paper strip of standardised length is suspended in the con-
Aqueous component • Lacrimal gland (Glandula
junctival sac. The paper strip absorbs lacrimal liquid and grad-
• Isotonic electrolyte solution lacrimalis)
ually discolours it. At a normal rate of tear production, more
• Gel-forming mucins and cleavage products of • Cup cells of the conjuncti-
than two thirds of the paper strip should be coloured within 5
membrane-bound mucins va (Tunica conjunctiva)
minutes. If a lower proportion of the filter paper is dyed, this
• Antimicrobial substances (e.g. lysozyme, lacto- • Accessory lacrimal gland
suggests reduced tear production.
ferrin, lipocalin, defensins, surfactant proteins (KRAUSE's glands, WOL-
A and D) FRING's glands)
• IgA (by transcytosis)
Function: irrigation fluid, equilibrates surface
Lacrimal film irregularities, antimicrobial protection
Corneal and conjunctival epithelium are moistened with a lacri- Mucosal component • Corneal epithelial cells
mal film up to 40 µm thick. Its main component is the aqueous • Membrane-bound mucins in the cell membrane • Conjunctiva (Tunica con-
component derived from the lacrimal gland, an isotonic electrolyte of microplicae of the superficial epithelial cells junctiva)
solution, containing antimicrobial proteins and peptides and high of cornea and conjunctiva
molecular gel-forming mucins (main component of mucus) from Function: part of the glycocalyx represents the
connection between epithelium and aqueous
the cup cells of the conjunctiva and from the lacrimal gland. The
component of the lacrimal film and thus serves
accessory lacrimal glands of the eyelids also make a small part of adhesion of the lacrimal film
the aqueous component of the lacrimal film. The adhesion of the
lacrimal film is made possible by microplicae on the superficial ep­
ithelial cells and membrane mucins in the apical cell membrane of Vessel supply and innervation
the surface cells of the cornea and Tunica conjunctiva. Evaporation The lacrimal gland is supplied with blood via the A. lacrimalis
of the aqueous component is prevented by a superficial lipid layer (branch of the A. ophthalmica) (› Fig. 9.49). The venous blood
that lies on the aqueous component and originates mainly from flows via the V. ophthalmica superior to the Sinus cavernosus. The
MEIBOM's glands of the eyelids (› Table 9.22). The lacrimal film parasympathetic nervous system increases tear secretion, the sym­
protects and nourishes the ocular surface while forming the refrac­ pathetic nervous system inhibits it. Preganglionic fibres of the sym­
tive anterior aspect of the visual system. pathetic nervous system are switched in the Ganglion cervicale su­
perius of the sympathetic trunk to postganglionic fibres. These
reach the lacrimal gland by following the Aa. carotis interna, oph­
Clinical remarks thalmica and lacrimalis or they leave the plexus around the A.
The dry eye (sicca syndrome) is one of the most common carotis interna as N. petrosus profundus, the parasympathetic fi­
chronic eye diseases. Approximately 50 % of the patients who bres of which connect to its fibres in the Canalis pterygoideus as
visit an ophthalmologist, suffer from a form of dry eye. It is de- N. canalis pterygoidei, in order to reach the lacrimal gland. The pre­
fined as a multifactorial malfunction of the lacrimal film and ganglionic fibres of the parasympathetic nerve system (1st neuron
the surface of the eye, which leads to symptoms such as eye
in the Nucleus salivatorius superior) reach the Ganglion pterygo­
pain, visual disturbance and lacrimal film instability and is as-
sociated with possible damage to the surface of the eye. The palatinum via the intermediate part of the N. facialis [VII] as
disease is associated with increased lacrimal film osmolarity N. petrosus major and then as N. canalis pterygoidei (in conjunction
and inflammation of the ocular surface. The cause is often a with sympathetic fibres from the N. petrosus profundus). Here, the
change in the tear fluid with respect to the quantity produced switching of the parasympathetic fibres to postganglionic takes
(e.g. reduced blinking when working at a screen, Sjögren's place, which then reach the N. lacrimalis and ultimately the lacri­
syndrome) and the composition. In most cases there is a mal- mal gland with the N. zygomaticus (branch of the N. maxillaris
function of the MEIBOM's glands. Due to an insufficient lipid
[V/2]) via the R. communicans cum nervo zygomatico (› Fig. 9.49).
layer tear fluid can evaporate faster and there are ‘dry spots’
on the surface of the eye. There can be other causes for insuf-
ficient eyelid movement (e.g. facial paralysis) or systemic dis- Efferent lacrimal ducts
eases (e.g. Diabetes mellitus). Michael Scholz, Friedrich Paulsen
The beat of the eyelid runs in a time-shifted manner from temporal
to nasal (Pars palpebralis, M. orbicularis oculi) and wipes the tear
fluid in the direction of nasal eye angle. The efferent lacrimal ducts
Clinical remarks begin here with the upper and lower Puncta lacrimalia (Punctum
lacrimale), which are on the nasal eyelid edge of the upper or lower
In the surgical removal of the Pars palpebralis of the lacrimal
gland basically all excretory ducts of the lacrimal gland are eyelid, respectively, near the medial angle of eye (› Fig. 9.50a). The
removed; however, tear production does not end. The reason Puncta lacrimalia submerge in the Lacus lacrimalis when the eyelid
for this are the accessory lacrimal glands (Glandulae lacri- closes (Lacus lacrimalis). This is the ‘old’ used tear fluid that has col­
males accessoriae; KRAUSE's glands and WOLFRING's glands) lected at the eyelid angle at the nose. The lacrimal fluid reaches the
of the upper eyelid. They are responsible for the basic secre- upper and lower lacrimal canaliculi via the Puncta lacrimalia (Cana-
tion of the lacrimal film (approximately 5 %). liculi lacrimales superior and inferior), which either flow individu­
ally or combined in a short common tract into the lacrimal sac (Sac-

463
9 Head

Os frontale
N. lacrimalis

A. lacrimalis
Glandula lacrimalis,
Pars orbitalis
R. communicans cum
nervo zygomatico

Palpebra superior
M. rectus lateralis

N. opticus [II]

Palpebra inferior
Os sphenoidale, Ala major

R. communicans cum
nervo zygomatico
Fig. 9.49 Arterial blood supply
N. infraorbitalis and nervous innervation of the
Foramen zygomaticoorbitale lacrimal gland. Medial view,
N. zygomaticus
schematic drawing.

cus lacrimalis) (› Fig. 9.50a, b). Around the lacrimal canaliculi the Maxilla and the Os lacrimale and has a dorsal topographic relation­
Pars lacrimalis of the M. orbicularis oculi (HORNER's muscle), is ship to the maxillary sinus. Medially, an ethmoid bone cell (Agger
arranged which is essential for the tear transport through the cana­ nasi cell) can push between the wall of the bony canal and the lateral
liculi. This so-called tear pump function of the Pars lacrimalis is not nasal wall. The Ductus nasolacrimalis continues downwards into the
yet fully understood. The muscle fibres insert via small tendons on lower nasal duct (Meatus nasi inferior) below the lower nasal concha
the Septum lacrimale of the lateral lacrimal sac wall. (Concha nasalis inferior). The outlet area in the nasal cavity is below
The lacrimal sac, which lies in the Fossa lacrimalis and is separated the front portion of the inferior nasal concha and is very variably
lateral to the Orbita by the Septum lacrimale (› Fig. 9.51) extends formed. In many cases there is a mucosal fold (Plica lacrimalis,
cranially to the Fornix sacci lacrimalis and passes caudally in approx. HASNER's valve) at the outlet area. The lumen of the lacrimal sac
25 mm long nasolacrimal ducts (Ductus nasolacrimalis). The Duc­ and lacrimal nasal duct are surrounded by a strong vessel plexus,
tus nasolacrimalis is located in one of the bony canals formed by the which is functionally comparable with a cavernous body. Around

Papilla lacrimalis; Punctum lacrimale

Fornix conjunctivae superior
Plica semilunaris conjunctivae
Canaliculus lacrimalis superior
Glandula lacrimalis, M. orbicularis oculi
Ductuli excretorii
Fornix sacci lacrimalis
Caruncula lacrimalis
Saccus lacrimalis
Canaliculus lacrimalis inferior
Papilla lacrimalis;
Punctum lacrimale
Concha nasalis media
(Corpus cavernosum)
Fornix conjunctivae
inferior Ductus nasolacrimalis
Plica lacrimalis
N. infraorbitalis Meatus nasi inferior
Concha nasalis inferior
Sinus maxillaris,
a Tunica mucosa

Ampulla canaliculi Canaliculus

lacrimalis lacrimalis superior

Caruncula
lacrimalis Fig. 9.50 Structures of the lac-
Saccus lacrimalis rimal apparatus, Apparatus lac-
rimalis right. a View from the
Canaliculus front lateral. Upper and lower
lacrimalis inferior Maxilla, Proc. frontalis canaliculi, lacrimal sac and lac-
M. orbicularis rimal nasal passage. The lacri-
oculi mal nasal passage is open
before it flows into the Meatus
M. obliquus inferior nasi inferior (underneath the
Concha nasalis inferior). b Hori-
b Sinus maxillaris Ductus nasolacrimalis zontal section at the height of
the lacrimal sac.

464
 9.4 Eye

NOTE
Rostral
If the cavernous body tissue swells, the tear transport is reduced or
Periost no longer possible through the efferent lacrimal ducts. Then the
Maxilla, Crista lacrimalis tears flow down the cheeks and one ‘cries.’ Except for mechanical
anterior causes (foreign objects in the conjunctival sac; ‘reflex tears’) the
Lumen Saccus blood vessels of the cavernous body may fill even with strong
Vessel plexus lacrimalis
­emotions (e.g. great pleasure, anxiety or grief) (at the same time
Lig. palpebrale
the liquid lacrimal gland production considerably increases). In the
mediale course of life a person cries up to 80 litres of tear fluid. There are
different theories and opinions to the cause for the development of
Lateral 'emotional tears'. Without a doubt, crying has an important social
function between people. While crying in infancy and small chil-
M. orbicularis oculi,
Pars lacrimalis
dren is the only form of communication up to a certain degree, it is
usually an expression of different emotions in adults. In the animal
Sinus
Septum orbitale world the emotional tears of man are probably unique. Other mam-
maxillaris
Os lacrimale, mals and reptiles can weep with a corresponding lacrimal appara-
Crista lacrimalis posterior tus, but the so-called crocodile tears are actually reflectory tears
Occipital and are probably due to the fact that the reptiles open their mouth
wide when eating and thus mechanically increase the pressure on
Fig. 9.51 Lacrimal apparatus, Apparatus lacrimalis, right side. Hori- the lacrimal gland. Nevertheless: animals demonstrably also expe-
zontal section at the height of the lacrimal sac (diagram). [E402] rience the pain and grief sensation, even if there are no tears to ac-
company these feelings.
and between the vessels of the cavernous body connective tissue fi­
bres from the lacrimal sac run spirally to the lower nasal concha.
Due to the attachment in the area of the inferior nasal concha and
the spiral course of the connective tissue fibres, the lacrimal sac and 9.4.3 Orbita
lacrimal nasal duct are pulled cranially on contraction of the Pars
lacrimalis of the M. orbicularis oculi; in the process the lacrimal sys­ The orbit (Orbita) is a bony limited, conically constructed space. ‘It
tem is wrung out like a towel and the tear liquid drained distally. is formed by various bony parts of the neurocranium (skull) and
the viscerocranium Viscerocranium/facial skeleton (› Fig. 9.52,
also › Fig. 9.7). The parts of the neurocranium consist of:
Clinical remarks • the Facies orbitalis of the Os frontale (roof of the Orbita)
The most common pathological changes of the efferent lacrimal • the Lamina orbitalis of the Os ethmoidale (medial wall)
ducts include inflammation (dacryocystitis), constriction (da- • the Ala major and minor of the Os sphenoidale (rear limitation
cryostenosis) and stone formations (dacryolithiasis). The symp- of the Orbita)
toms are epiphora (Greek: ‘downflow’), an overflow of the tear The bony boundaries of the viscerocranium are formed by the
fluid through the eyelid margins. In the case of dacryostenosis it
• Proc. orbitalis of the Os palatinum
can also be a congenital defect, which e.g. can be attributed to
persistance of HASNER's valve, a thin fibrous membrane at the • Facies orbitalis of the Maxilla (floor of the Orbita)
transition to the lower nasal passage and prevents a normal • Os lacrimale (medial wall)
lacrimal drainage. In most cases it ruptures shortly after birth. If • Fascies orbitalis of the Os zygomaticum (lateral wall)
it persists longer than a year, it must be therapeutically pierced.

Foramina ethmoidalia Squama

anterius and posterius frontalis Squama frontalis
Os ethmoidale, Lamina orbitalis Pars Pars orbitalis Os frontale
Os frontale
orbitalis
Fissura orbitalis superior
Facies Facies orbitalis
Canalis opticus orbitalis

Os nasale
Foramen zygomaticoorbitale
Os lacrimale
Fissura orbitalis superior
Fissura orbitalis Maxilla Os zygomaticum,
inferior
Canalis nasolacrimalis Facies orbitalis

Ala major
Fossa Facies Os sphenoidale
Corpus
pterygopalatina orbitalis
Maxilla
Corpus
maxillae Fissura orbitalis inferior
Os sphenoidale,
Proc. pterygoideus Fissura pterygomaxillaris
Maxilla, Facies orbitalis
Proc. Sinus maxillaris
a Os palatinum pyramidalis b Sinus maxillaris
Proc. orbitalis Canalis infraorbitalis

Fig. 9.52 Bony structure of the Orbita. Os frontale (purple), Os ethmoidale (dark yellow), Os sphenoidale (green), Os palatinum (blue), Maxilla
(light yellow), Os lacrimale (dark red), Os zygomaticum (light red). a View of the medial wall of the Orbita. b View of the lateral wall of the Orbita.

465
9 Head

Clinical remarks be easily fractured by a trauma. Inflammatory processes can

then easily spread from the physiologically pathogen populat-
The bony structure of the Orbita requires very close topo- ed mucous membranes of the sinuses into the ‘sterile’ Orbita
graphic relationships to the directly adjacent neighbouring (e.g. as orbital phlegmon).
regions that are clinically of great importance (› Fig. 9.53).
The treatment of pathological changes within or in the area of
the Orbita may require the interdisciplinary cooperation of dif-
ferent disciplines. Inflammatory processes or tumour events Vessels and innervation of the Regio orbitalis
in the Orbita can, for example, spread very quickly to the Above the Septum orbitale the Orbita is surrounded by a circular
neighbouring regions and usually make a multidisciplinary arterial plexus of vessels (› Fig. 9.54). In this region the innerva-
approach to treatment necessary. In such cases, in addition to
tion areas of A. carotis interna overlap with its branches (A. su­
the ophthalmologist, ENT doctors, radiologists, maxillofacial
and brain surgeons or neurologists are involved in appropriate praorbitalis, Aa. palpebrales laterales [from A. lacrimalis] and Aa.
therapeutic management. palpebrales mediales) with those of the A. carotis externa (A. fa­
cialis, A. angularis, A. infraorbitalis, A. temporalis superficialis and
A. zygomaticoorbitalis). The veins of the same name accompany
The frontal opening of the orbita bordered by a bone edge (Margo the arteries. The N. supraorbitalis leaves the Orbita variably as a
orbitalis) is called the Aditus orbitalis. The bony Orbita is lined by branch of the N. ophthalmicus [V/1] via the Foramen supraorbit­
the periosteum which is known as the Periorbita. At the Canalis ale or the Incisura supraorbitalis of the same name. The N. infraor-
opticus and the Fissura orbitalis superior, the Periorbita is connect­ bitalis passes as a branch of the N. maxillaris [V/2] below the Or­
ed to the Dura mater of the brain and bridges as Membrana orbit- bita through the Foramen infraorbitale into the superficial facial
alis the Fissura orbitalis inferior. The fibres of the M. orbitalis run region. Both nerve exit points (N. supraorbitalis and N. infraorbit­
in this membrane, a smooth muscle innervated sympathetically alis) are used as pressure points in the context of the physical ex­
via the N. petrosus profundus, the tone of which regulates the flow amination of a patient to check the function of the top two nerve
of blood through the V. ophthalmica inferior. On the outside, the branches of the N. trigeminus [V] (trigeminal pressure points).
Orbita is closed according to the two eyelids by a thin connective
tissue plate, the Septum orbitale, (› Fig. 9.54). The Septum orbit­ NOTE
ale is attached at the top and bottom in the area of the Margo orbit­ The V. angularis connects the superficial facial region with the V.
alis and passes close behind the M. orbicularis oculi of the eyelids ophthalmica inferior, which in turn drains into the Sinus caverno-
to the outer edge of the tarsal plate. sus. By infections in the face (e.g. after squeezing a spot on the
cheek) pathogens can be relayed to the Sinus cavernosus. This
may create a thrombosis that can be associated with intracranial
Clinical remarks complications (e.g. damage to the cranial nerves running through
or on the edge of the Sinus cavernous with resulting deficits or
The bony boundaries between Orbita and sinuses (Sinus max- meningitis).
illaris; Cellulae ethmoidales) are extremely thin. So they can

II

VI

III

IV

I Fossa cranii anterior (anterior fossa)

II Sinus frontalis (frontal sinus)
III Cellulae ethmoidales (ethmoidal cells)
IV Cavitas nasi (nasal cavity) Fig. 9.53 Localisation and pre-
V Sinus maxillaris (maxillary sinus)
VI Fossa temporalis (temporal fossa) sentation of the directly neigh-
bouring regions of the Orbita.

466
 9.4 Eye

A.; V.; N. supraorbitalis

A.; V.; N. supratrochlearis
M. levator palpebrae
superioris, Tendo (A.); (V.); N. infratrochlearis
Tarsus superior Arcus palpebralis superior
A. palpebralis lateralis A. palpebralis medialis
(A. lacrimalis)
N. lacrimalis Lig. palpebrale mediale
A. lacrimalis
Arcus palpebralis
Lig. palpebrale laterale inferior
A. palpebralis lateralis
A.; V. temporalis
superficialis

Septum orbitale A.; V. angularis

Tarsus inferior

A. transversa faciei
Fig. 9.54 Arteries, veins and
A.; N. infraorbitalis
nerves of the Regio orbitalis, on
the right. Anterior view. [E460]

Content of the Orbita Clinical remarks

In the Orbita embedded in the surrounding fat body (Corpus adi­
The orbital apex syndrome (TOLOSA-HUNT syndrome) is a
posum orbitae), the M. levator palpebrae and the 6 extraocular
painful paralysis of the extraocular muscles (ophthalmople-
muscles are situated. Vessels and nerves enter and exit the Orbita gia). The causes are chronical inflammatory processes, rarely
through bony openings (› Table 9.23). malignancies in the area of the orbit tip. For certain clarifica-
tion of the findings appropriate diagnostic imaging is usually
Extraocular muscles required.
At the tip of the orbital bowl a tendon ring begins formed by the
Periorbita (Anulus tendineus communis; anulus of ZINN) which
forms the origin of most extraocular muscles. The cranial nerves II The Bulbus oculi can move around all 3 axes of the eyeball, similar
(N. opticus), III (N. oculomotorius) and VI (N. abducens) run to the rotating movements of a ball joint. There are 3 pairs of antag­
through its central opening and as a branch of the N. ophthalmicus onistically acting muscles responsible for this: the 4 straight Mm.
[V/1], the N. nasociliaris and the A. ophthalmica (› Fig. 9.55). recti and the 2 oblique Mm. obliqui. The M. levator palpebrae supe­
rioris serves to raise the eyelid and is not involved in the movement
of the eyeball. The 4 straight ocular muscles (M. rectus superior, M.
Table 9.23 Overview of the points of penetration of the Orbita with rectus inferior, M. rectus lateralis, M. rectus medialis) have their or­
the respective associated vascular, lymphatic and nervous systems. igin at the Anulus tendineus communis (ZINN's tendon ring) and
attach before the equator of the Bulbus oculi at the sclera. The ori­
Points of penetration Vascular, lymphatic and nervous systems gin of the two oblique eye muscles is in contrast to the straight ocu­
of the Orbita
lar muscles not at the Anulus tendineus communis. Its end tendons
Canalis opticus • N. opticus [II] radiate as the straight extraocular muscles into the sclera of the Bul­
• A. ophthalmica bus; however, behind the equator (› Fig. 9.56). Particularly worth
• Meninges; Vaginae nervi optici
mentioning here is the course of the attachment tendon of the M.
Fissura orbitalis superior • N. frontalis (N. ophthalmicus [V/1]) obliquus superior, which passes during its forward-facing course
(lateral section) • N. lacrimalis (N. ophthalmicus [V/1])
• N. trochlearis [IV]
• R. orbitalis (A. meningea media) N. ophthalmicus [V/1], N. frontalis N. trochlearis [IV]
• V. ophthalmica superior N. ophthalmicus [V/1], N. lacrimalis N. opticus [II]
Irregular: A. ophthalmica
A. ophthalmica,
• Anastomoses between the A. meningea media
R. meningeus recurrens
and the A. lacrimalis
V. ophthalmica superior
Fissura orbitalis superior • N. nasociliaris (N. ophthalmicus [V/1])
(annular section) • N. oculomotorius [III] with R. superior and R. infe- N. oculomotorius [III],
R. superior
rior
• N. abducens [VI] N. ophthalmicus [V/1],
N. nasociliaris
Fissura orbitalis superior • Rr. venae ophthalmicae inferioris through to the
(medial section) Sinus cavernosus N. abducens [VI]

Fissura orbitalis inferior • V. ophthalmica inferior Anulus tendineus

communis
• N. zygomaticus (N. maxillaris [V/2])
• A., V., N. infraorbitalis (N. maxillaris [V/2]) N. oculomotorius [III], V. ophthalmica inferior
• M. orbitalis R. inferior
Foramina ethmoidalia • A., N. ethmoidalis anterior/posterior (N. ophthal-
anterius/posterius micus [V/1]) Fig. 9.55 Points of penetration of vascular, lymphatic and nervous
systems into the Orbita through the Fissurae orbitales superior and
Foramen zygomaticum • N. zygomaticus (N. maxillaris [V/2]) with R. zygo-
inferior and within the Anulus tendineus communis (ZINN's tendon
maticotemporalis and R. zygomaticofacialis
ring). [E460]

467
9 Head

Axis of the Orbita Optical axis

23°

M. rectus medialis

M. obliquus superior

M. obliquus inferior

M. rectus superior
M. rectus inferior Fig. 9.56 Course of the extraoc-
M. rectus lateralis ular muscles and their position
Anulus tendineus relative to the Bulbus oculi (dia-
communis gram). The optical axis and the
axis of the Orbita differ by 23°.

through a trochlea (fibrous connective tissue loop) serving as a hy­ is directed downwards. If, at the same time, the innervation of
pomochlion, and is deflected back laterally to the rear before it radi­ the M. levator palpebrae superioris is affected, there is also
ates behind the equator of the bulbus into the sclera. ptosis, the drooping eyelid over the optical axis, so that the
The axis of each Orbita is slightly laterally aligned viewed from the patient has no double vision, in spite of the deformity of the
Bulbus. If the eyelid of the affected patient is manually pulled
rear to the front. The Bulbus oculi with the optical axis is in con­
upwards, this will result in diplopia (double vision). In an
trast aligned exactly to the front (› Fig. 9.56). As a result, the in­ ­internal oculomotor paralysis the parasympathetic innervation
teraction of the 6 extraocular muscles leads to various movements of the M. sphincter pupillae and M. ciliaris is stopped. This is
of the eyeball in a 3-dimensional space (› Table 9.24). characterised by a wide, light rigid pupil and a reduced ability
of accommodation.
Clinical remarks
In the case of an outer oculomotor paralysis there is a highly
complex impairment of eye movement, since the N. oculom­ Vascular, lymphatic and nervous systems of the Orbita
otoris [III] innervates all extraocular muscles, with the excep- Arteries
tion of the Mm. rectus laterales (N. abducens [VI]) and the As a general rule, all structures within the Orbita including the
obliquus superior (N. trochlearis [IV]). Because of the prepon-
Bulbus oculi are supplied with blood via the A. ophthalmica, the
derance of the two unaffected muscles the gaze of the eye
first branch from the Pars cerebralis of the A. carotis interna imme­
diately after penetration through the dura mater (› Fig. 9.57). The

Table 9.24 Extraocular muscles of the eyeball with respective origin and attachment as well as function and innervation of the muscle.

Innervation Origins Attachment Function

M. rectus superior
N. oculomotorius [III], Upper section of the Anulus tendineus com- Above, ventral of the equator at Elevation of the optical axis, adduction and inward rotation
R. superior munis the bulbus of the eyeball
M. rectus inferior
N. oculomotorius [III], Lower section of the Anulus tendineus com- Below, ventral of the equator at Lowering of the optical axis, adduction and inward rotation
R. inferior munis the bulbus of the bulbus
M. rectus lateralis
N. abducens [VI] Lateral section of the Anulus tendineus com- Lateral, ventral of the equator at Abduction of the bulbus
munis the bulbus
M. rectus medialis
N. oculomotorius [III], Medial section of the Anulus tendineus com- Medial, ventral of the equator at Adduction of the bulbus
R. inferior munis the bulbus
M. obliquus inferior
N. oculomotorius [III], Medial section of the orbital base behind the Lateral rear quadrant of the Bul- Elevation of the optical axis, adduction and outward rotation
R. inferior orbital edge; on the Maxilla lateral of the bus oculi of the bulbus
­Sulcus lacrimalis
M. obliquus superior
N. trochlearis [IV] Corpus ossis sphenoidalis, above and medial Lateral rear quadrant of the Bul- Lowering of the optical axis, adduction and inward rotation
of the Canalis opticus bus oculi of the bulbus
M. levator palpebrae superioris
N. oculomotorius [III], Ala minor ossis sphenoidalis, in front of the Front surface of the tarsus in the Elevation of the upper eyelid
R. superior Canalis opticus upper lid; fibres for skin and
Fornix conjunctivae

468
 9.4 Eye

A. ophthalmica, enters the Orbita together with the N. opticus [II]. M. rectus superior V. supratrochlearis

There, it divides into: M. obliquus superior

• The A. lacrimalis exits lateral of the N. opticus from the A. oph­ V. ophthalmica
thalmica and runs temporally to supply the lacrimal gland, the superior V. supra-
orbitalis
extraocular muscles in this area, the Bulbus (as Aa. ciliares ante­ Vv. vorticosae V. nasofrontalis
riores) and the lateral portion of the upper and lower eyelids (as V. angularis
A. palpebralis lateralis) with blood. M. obliquus
• The A. centralis retinae passes centrally in the N. opticus [II] up Sinus superior
to the Papilla nervi optici and divides there into several branch­ caver- M. rectus
lateralis
es. It is responsible within the Bulbus as a terminal artery (risk of nosus

blindness in closure of this vessel!) for the supply of the inner M. obliquus
inferior
layers of the retina.
• The Aa. ciliares posteriores longae and breves emerge from V. facialis
dorsal through the sclera into the Bulbus and supply structures
Plexus venosus
within the Bulbus. pterygoideus
• After the A. ophthalmica has crossed the N. opticus [II] in its M. rectus inferior (V. infraorbitalis)
course, it emits the A. supraorbitalis. It runs together with the V. ophthalmica inferior
N. supraorbitalis through the Foramen supraorbitale of the Os
frontale and brings blood to the forehead and scalp. Fig. 9.58 Lateral view of the venous blood vessels of the Orbita in
• The A. ethmoidalis anterior runs through the Foramen ethmoid­ their course from rostral to occipital. The lateral wall of the Orbita
ale anterius from the Orbita and on to the nasal cavity. Here it sup­ has been removed. [E460]
plies the side wall of the nasal cavity, the upper section of the nasal
septum and the Cellulae ethmoidales (› Chap. 9.6.5). Finally it (→ V. ophthalmica superior) and V. facialis (→ V. ophthalmica infe­
flows into the Aa. dorsalis nasi that supplies the surface anatomy of rior). In principle, the V. ophthalmica superior runs through the
the nose as one of the 2 terminal branches of the A. ophthalmica. upper part and the V. ophthalmica inferior through the lower part
• The A. ethmoidalis posterior leaves the orbita through the Fo­ of the Orbita. Both veins receive corresponding inflows from the
ramen ethmoidale posterius and provides the upper rear of the muscles and the veins that run in the respective part of the Orbita
nasal cavity and also in part the Cellulae ethmoidales with blood with the arteries. The V. ophthalmica superior leaves the Orbita
(› Chap. 9.6.5). dorsally via the Fissura orbitalis superior, and then flows into the
• The second terminal branch of the A. ophthalmica is the A. su- Sinus cavernosus. The V. ophthalmic inferior combines in its dorsal
pratrochlearis, which leaves the Orbita together with the N. su­ section with the Vv. ophthalmica superior, but can also occur as an
pratrochlearis and in its course supplies parts of the forehead independent vessel through the Fissura orbitalis superior, to then
with arterial blood (› Fig. 9.57). flow as an independent vessel into the Sinus cavernous. A further
dorsal vessel branch combines with the V. infraorbitalis, passes
Veins through the Fissura orbitalis inferior and drains into the Plexus
The venous blood leaves the Orbita via 2 large vessels, the Vv. oph- pterygoideus which lies in the Fossa infratemporalis.
thalmicae superior and inferior (› Fig. 9.58). Both Vv. ophthal­
micae receive inflow from venous vessels of the superficial and Innervation
deep facial regions: V. supraorbitalis, V. nasofrontalis, V. angularis The innervation of the eyeball as well as the orbital structures takes
place via the cranial nerves II–VI and sympathetic fibres from the
thoracic medulla. In › Fig. 9.59the view from the top of the
A. dorsalis nasi opened orbital cavity is shown, after the dura mater, the roof of the
A. supratrochlearis Orbita and finally the Periorbita with parts of the Corpus adipo­
sum orbitae have been removed. At the same time, the dura mater
A. supraorbitalis
was removed above the Ganglion trigeminale (Ganglion semi­
A. ethmoidalis anterior lunare, GASSER's ganglion).
Glandula lacrimalis
N. opticus [II]
A. ethmoidalis posterior
Within the retina of the eyeball are the first three projection neu­
A. ciliaris posterior brevis rons of the optic tract. The processes of the ganglion cells merge
A. lacrimalis
with the optic nerve papillae (Discus nervi optici) to the N. opticus
[II] that leaves the Bulbus to the rear. The nerve runs through the
A. ciliaris posterior longa retrobulbar adipose tissue towards the Anulus tendineus commu­
nis (ZINN's tendon ring), passes through it and continues via the
A. centralis retinae Canalis opticus into the anterior cranial fossa (› Fig. 9.55; the
A. ophthalmica runs in the opposite direction through the Canalis
R. meningeus recurrens opticus and then through the Anulus tendineus communis to con­
tinue to branch in the Orbita). Within the Orbita the N. opticus
A. ophthalmica
[II] generally forms a slightly outwardly convex arch during dissec­
N. opticus [II] A. carotis interna
tion. This is the reserve length for the various eye movements. As a
diverticulum of the diencephalon, the N. opticus [II] is not an ac­
Fig. 9.57 View from above on the opened right Orbita with Bulbus ocu- tual cranial nerve, but is completely surrounded by the three me­
li and the arterial vessel exit points from the A. carotis interna. [E460] ninges. At the Bulbus oculi the dura mater passes into the sclera;

469
9 Head

A. supraorbitalis
N. supraorbitalis, R. lateralis
M. levator palpebrae
superioris
N. supraorbitalis,
R. medialis
Glandula lacrimalis,
N. supratrochlearis Pars orbitalis
Corpus adiposum orbitae
M. rectus superior

A. ethmoidalis anterior A. lacrimalis

M. obliquus superior
N. lacrimalis
N. nasociliaris

A. ophthalmica M. rectus lateralis

N. frontalis N. abducens [VI]

N. trochlearis [IV]

N. ophthalmicus [V/1]
Fig. 9.59 Contents of the Orbita
N. maxillaris [V/2]
opened cranially with Ganglion
N. opticus [II]
trigeminale. The course of the
N. ophthalmicus [V/1] and its
A. ophthalmica A. meningea media branches can be determined
A. carotis interna through the opened Fissura
N. mandibularis [V/3],
N. oculomotorius [III] R. meningeus
orbitalis superior. In addition,
the entries into the Orbita from
N. trochlearis [IV]
N. mandibularis [V/3] the cranial nerves III, IV and VI,
N. abducens [VI] which innervate the extraocular
Ganglion trigeminale
R. tentorius muscles and the penetration of
N. trigeminus [V] the N. opticus [II] are represent-
ed by the Canalis opticus.

portions of the soft meninges (leptomeninx) are continued by the the preganglionic parasympathetic fibres from the R. inferior nervi
Choroidea. oculomotorii (Radix oculomotoria) are switched. As with all crani­
al ganglia, there is also an additional sensory root in the Ganglion
ciliare (Radix sensoria) of the N. trigeminus [V] (N. nasociliaris)
Clinical remarks and a sympathetic root (Radix sympathica) with postganglionic
Due to its course, the N. opticus [II] has a close topographic re- fibres from the Plexus caroticus internus. The fibres of the two lat­
lationship to the sphenoidal sinus (Sinus sphenoidalis). Patho- ter roots pass unswitched through the Ganglion ciliare. The senso­
logical processes within the Sinus sphenoidalis (inflammation, ry fibres originate for the most part from the surface of the eye
tumours) can spread through the paper thin bony wall of the (cornea and conjunctiva). They leave the Bulbus via the Nn. ciliaris
sphenoidal sinus to the optic nerve. In the case of surgical pro-
breves. The sympathetic fibres take the opposite way and pass with­
cedures in the sphenoidal sinus, this point represents a risk.
in the Bulbus mainly to the M. dilatator pupillae (› Fig. 9.34).

N. trochlearis [IV]
N. oculomotorius [III] The N. trochlearis [IV] runs like the N. oculomotorius [III] intra­
Shortly before or after passing through the Fissura orbitalis superi­ durally in the lateral wall of the Sinus cavernosus (› Fig. 9.59,
or into the Orbita the N. oculomotorius [III] branches into an up­ › Fig. 9.60). Shortly before it reaches the Orbita, it runs upwards,
per and a lower branch (› Fig. 9.60, › Fig. 9.34) which pass crosses the N. oculomotorius (› Fig. 9.60) and enters the Orbita
through the Anulus tendineus communis when entering the Orbita above the Anulus tendineus communis (ZINN's tendon ring)
(› Fig. 9.55). In the Orbita the R. superior runs lateral to the N. through the Fissura orbitalis superior. In its relatively short intraor­
opticus [II] upwards and innervates the Mm. rectus superior and bital course, it runs medially over the M. levator palpebrae superio­
levator palpebrae superioris (› Fig. 9.60). The larger R. inferior in ris and provides motor innervation radiating from above into the
its course is divided into 3 other branches which supply the motor M. obliquus superior(› Fig. 9.34).
innervation to the Mm. rectus medialis, rectus inferior and
obliquus inferior (› Fig. 9.61). On the way to the M. obliquus in­ N. trigeminus [V]
ferior the 3rd branch of the R. inferior emits another branch to the N. ophthalmicus [V/1]
Ganglion ciliare (see below). These preganglionic fibres form the Also after an intradural course in the lateral wall of the Sinus cav­
parasympathetic root of the Ganglion ciliare. After switching to ernous, the N. ophthalmicus [V/1] enters the Orbita as the most
postganglionic (within the Ganglion ciliare) the parasympathetic cranial main branch of the N. trigeminus [V], through the Fissura
fibres pass via the Nn. ciliares breves into the bulbus and innervate orbitalis superior (› Fig. 9.59). Shortly before the purely sensory
the M. sphincter pupillae and the M. ciliaris. nerve divides into three branches:
• N. nasociliaris
Ganglion ciliare • N. frontalis
The uppermost of the 4 parasympathetic cranial ganglia lies lateral • N. lacrimalis
to the N. opticus [II] (› Fig. 9.60, › Fig. 9.61, › Fig. 9.34). Here,

470
 9.4 Eye

N. supratrochlearis N. supraorbitalis,
R. medialis
A. supraorbitalis

N. supraorbitalis,
R. lateralis
M. levator palpebrae
superioris
Glandula lacrimalis,
Pars orbitalis

A. ophthalmica M. rectus superior

A. lacrimalis
M. obliquus superior N. lacrimalis
Ganglion
ciliare
N. abducens [VI]
N. oculomotorius [III], M. rectus lateralis
R. superior Fig. 9.60 Orbita from above
N. nasociliaris after folding away the M. leva-
tor palpebrae superioris and the
M. rectus superior. The nerve
N. ophthalmicus [V/1]
branches of the cranial nerves
N. opticus [II] N. maxillaris [V/2] III, IV and VI can be clearly rec-
ognized in the respective mus-
A. ophthalmica
cles. After removing the orbital
A. carotis interna N. mandibularis [V/3]
fat tissue, the approximately 2
mm in size Ganglion ciliare is
Ganglion trigeminale
N. oculomotorius [III] visible, which is located approx-
N. trigeminus [V] imately 2 cm behind the Bulbus
N. trochlearis [IV] N. abducens [VI] oculi, lateral of the N. opticus
[II].

A. supraorbitalis
M. levator palpebrae superioris

M. obliquus superior,
Tendo
M. obliquus superior

M. rectus superior
A. supratrochlearis
Bulbus oculi
A. dorsalis nasi

M. rectus medialis N. opticus [II]

N. infratrochlearis N. lacrimalis
A. ethmoidalis anterior
A. lacrimalis
N. ethmoidalis anterior
N. nasociliaris M. rectus lateralis

A. ethmoidalis posterior Nn. ciliares breves

N. ethmoidalis posterior Aa. ciliares
N. ciliaris longus
N. abducens [VI]
M. obliquus superior
N. oculomotorius [III], R. inferior
N. oculomotorius [III],
R. superior Ganglion ciliare
N. trochlearis [IV] Radix parasympathica Fig. 9.61 View of the Orbita
M. levator palpebrae [oculomotoria] (III)
from above after separation and
superioris
Radix sensoria (V/1) folding up of the Mm. levator
M. rectus superior
Radix sympathica palpebrae superioris, rectus
N. opticus [II]
(N. caroticus internus) superior and obliquus superior.
A. ophthalmica In addition to the Ganglion cili-
N. ophthalmicus [V/1]
A. carotis interna are and branches of the A. oph-
N. oculomotorius [III] N. trigeminus [V], Radix sensoria thalmica, the N. opticus [II] and
N. trochlearis [IV] N. abducens [VI] the branches of the N. nasocilia-
ris are visible.

471
9 Head

The N. frontalis and N. lacrimalis run outside around the Anulus communis (ZINN's tendon ring) into the Orbita (› Fig. 9.55,
tendineus communis (ZINN's tendon ring), the N. nasociliaris › Fig. 9.34). There it runs laterally to the M. rectus lateralis and
usually penetrates through the ring. provides motor innervation.
The purely sensory N. nasociliaris is the most caudal in the Orbita.
It crosses in its course the N. opticus [II] (› Fig. 9.61) and passes
below the M. rectus superior medially. Its branches are listed in
Clinical remarks
› Table 9.18. In the case of damage to the N. trochlearis [IV] (trochlear pare-
The N. frontalis runs between the M. levator palpebrae superioris sis) the M. obliquus superior can no longer be moved. In these
and periorbita ventrally after penetrating through the Fissura or­ patients the optic axis is therefore displaced medially. Due to
bitalis superior. It divides in the centre of the Orbita into its 2 ter­ its central course through the Sinus cavernous the N. abdu-
cens [VI] is particularly frequent in a thrombosis of the Sinus
minal branches:
cavernosus and is often the first cranial nerve affected (abdu-
• N. supraorbitalis cens palsy). The patient can no longer abduct the affected eye
• N. supratrochlearis (› Fig. 9.60). laterally.
The thicker N. supraorbitalis leaves the Orbita via the Foramen In order to find suitable surgical access the following classifi-
supraorbitale or the Incisura supraorbitalis. Both nerves innervate cation of the Orbita is used according to various clinical as-
the forehead and part of the scalp. pects:
The N. lacrimalis runs ventrally as the smallest branch of the N. • Bulbar/retrobulbar section
• Central or intraconal part/peripheral or extraconal part
ophthalmicus [V/1] on the upper edge of the M. rectus lateralis. In
– The intraconal part is the part of the Orbita which is bor-
its course it takes up fibres from the R. zygomaticotemporalis nervi dered by the cone-shaped (conal) straight extraocular
zygomatici which contributes both parasympathetic postganglionic muscles
(Ganglion pterygopalatinum) as well as postganglionic sympathet­ • Upper/middle/lower level of the Orbita
ic fibres (Ganglion cervicale superius) to the innervation of the lac­ – The upper level extends from the Orbita roof to the M. rec-
rimal gland. In addition, the N. lacrimalis sensitively innervates tus superior and includes the M. levator palpebrae superi-
parts of the conjunctiva as well as the lateral area of the upper eye­ oris, the Nn. frontalis, trochlearis [IV] and lacrimalis as
lid. well as the Aa. supraorbitalis, supratrochlearis, the A. and
V. lacrimalis and the V. ophthalmica superior (› Fig.
9.43; › Fig. 9.59)
N. maxillaris [V/2] – The middle level is the same as with the above-mentioned
The N. zygomaticus is a branch of the N. maxillaris [V/2] and in intraconal space between the straight extraocular muscles
its course separates in the fossa pterygopalatina from the N. maxil­ and includes the Nn. opticus [II], oculomotorius [III], naso-
laris. After taking up postganglionic parasympathetic fibres from ciliaris, abducens [VI] and zygomaticus, the Ganglion cili-
the Ganglion pterygopalatinum it runs through the Fissura orbital­ are, the A. ophthalmica, the V. ophthalmica superior and
is inferior into the Orbita and divides there into 2 sensory skin in­ the Aa. ciliares posteriores breves and longae (› Fig. 9.61)
– The lower level extends from the M. rectus inferior to the
nervating branches: Orbita floor and includes the N. infraorbitalis as well as
• R. zygomaticofacialis the A. infraorbitalis and the V. ophthalmica inferior
• R. zygomaticotemporalis (› Fig. 9.43; › Fig. 9.58).
The parasympathetic (visceroefferent) fibres are conveyed by the R.
communicans cum nervo zygomatico and the N. lacrimalis to the
lacrimal gland and innervate it (› Fig. 9.62).

N. abducens [VI] 9.4.4 Bulbus oculi

After leaving the brain stem The N. abducens [VI] runs through
the Sinus cavernosus lateral of the A. carotis interna and then goes The eyeball (Bulbus oculi) is almost spherical and in adults has a
via the Fissura orbitalis superior through the Anulus tendineus diameter of about 2.5 cm. It weighs between 8 and 10 g and fills the

R. communicans cum nervo zygomatico

N. lacrimalis
Ganglion ciliare

Glandula
lacrimalis

N. maxillaris [V/2]
N. infraorbitalis

Ganglion
pterygopalatinum

N. zygomaticus
Fig. 9.62 Nerve pathways in the
Orbita. Lateral view after remov-
al of the temporal wall and the
orbital fat body.

472
 9.4 Eye

front section of the orbit. The largest part of the eyeball is sur­ Clinical remarks
rounded by the sclera. It consists of strong connective tissue which
The endocrine orbitopathy is a disease that is one of the or-
contains collagen and elastic fibres. The Vagina bulbi (TENON's
gan-specific autoimmune diseases and occurs mostly in the
capsule) is a connective tissue sheath and covers the entire surface context of BASEDOW's disease. It is believed that the immune
anatomy of the bulbus from the point of entry of the N. opticus [II] system forms faulty antibodies against specific tissue in the
to the Limbus corneae where the sclera transforms into the cornea. Orbita (e.g. eye muscles, fatty tissue) and leads to inflamma-
Between the sclera and Vagina bulbi there is a thin gap (Spatium tory reactions. Clinically, this type of disease is manifested as
episclerale). protruding of the eyes (exophthalmus), an enlargement of the
Penetrating the Vagina bulbi, the tendons of the external ocular palpebral fissure with eyelid retraction and movement disor-
ders of the eye.
muscles attach at the sclera. At the front, the round shape of the
bulbus is interrupted by the swelling of the transparent cornea
(› Fig. 9.63). It passes into the sclera and the conjunctiva covering Inside the eyeball is hollow. The anterior chamber of the eyeball
it (Tunica conjunctiva) in the area of the Limbus corneae. The cor­ connects behind the cornea in the direction of the optic nerve that
nea has no vessels and remains so up to the transition into the vas­ is stretched between the cornea and the front side of the iris. The
cularised Tunica conjunctiva, so that the superficial epithelial lay­ anterior chamber of the eyeball is connected to the posterior eye
ers of the cornea have to be supplied with nutrients and oxygen via chamber through the pupil opening of the iris. Here the aqueous
the tear fluid. humour circulates from the back of the eye chamber into the anterior
chamber of the eye. The aqueous humour (Humor aquosus) is
­secreted by the ciliary epithelium of the ciliary body (Pars plicata)
into the posterior eye chamber and flows between the lens and the

Axis externus bulbi

Epithelium anterius
Polus anterior lentis
Camera anterior bulbi
Iris
Facies anterior Limbus corneae
Iris
Facies posterior Angulus iridocornealis
Cornea Sinus venosus sclerae*
Reticulum trabeculare
Tunica conjunctiva
Tunica conjunctiva bulbi Fibrae circulares
Fibrae M. ciliaris
Camera posterior bulbi meridionales

Orbiculus ciliaris Facies anterior

Zonula ciliaris Pars ciliaris retinae
M. sphincter pupillae
Corpus ciliare Polus posterior
lentis Ora serrata
Lens

Pars optica retinae

Camera postrema [vitrea] bulbi;

Aequator Corpus vitreum Aequator

Axis opticus Corpus vitreum

Axis internus bulbi
Retina, Stratum
Pars pigmentosum
optica Discus nervi
retinae Stratum nervosum optici Choroidea

Spatium perichoroideum

Sclera

Excavatio disci

Lamina cribrosa sclerae Macula lutea, Fovea centralis

Vagina externa nervi optici

Spatium intervaginale subarachnoidale

Fig. 9.63 Right Bulbus oculi in middle horizontal cut with section of the N. opticus [II] at the height of the pupil opening. Below the sclera is
the uvea (vessel skin), which at the front area of the eye consists of the iris (Iris) and the ciliary body (Corpus ciliare) and at the rear area of the
choroid (Choroidea). The Ora serrata marks the transition from the ciliary body into the choroid. This is important for the nutrition of the inner
overlying retina but at the same time for the temperature regulation of the Bulbus oculi. The retina with its visual sense cells forms the inner-
most layer of the Bulbus oculi. In the front part of the eye the pigment epithelium of the ciliary body and the epithelium of the iris also belong
to this layer.

473
9 Head

back of the iris through the pupil into the anterior chamber of the be seen as a special form of primary open-angle glaucoma,
eye. In the iridocorneal angle (Angulus iridocornealis), which is there is damage of the optic nerve, even though the intraocu-
bordered by the iris root, the ciliary body and the cornea, lies the lar pressure is not increased in these patients.
trabecular meshwork (Trabeculum corneosclerale), and the
aqueous humour drains into the annular Sinus venosus sclerae
(SCHLEMM's canal) through its connective tissue fissure spaces The posterior chamber borders on the back of the eye lens. This
and is then diverted via the intrascleral and episcleral veins into the consists of a lens core (Nucleus lentis) and the lens cortex (Cortex
venous system (› Fig. 9.64). The continuous production and lentis) and is surrounded by a dense fibre capsule (Capsula lentis).
draining of the aqueous humour (approximately 6–7 ml per day) is In the equator region new cells are formed below the lens capsule
important for the nutrition of the inner layers of the cornea and the in a growth zone (Zona germinativa) for a lifetime. These then re­
lens and for maintaining the physiological intraocular pressure shape into long fibres, store transparent crystalline proteins and
(normal range from 10 to 21 mmHg), which guarantees the stable then lose their cell organelles. The transparent, biconvex formed
spherical shape of the Bulbus oculi and the stable spacing of the resilient lens loses elasticity during the continuous growth process
optical media inside the eye to each other. with increasing age, which at around the age of 40-45 years leads to
presbyopia. The ciliary zonules (Zonula ciliaris) insert in the lens
capsule, which emerge from the ciliary processes of the ciliary
Clinical remarks body (Corpus ciliare) (› Fig. 9.63). As a result of the contraction
If draining of the aqueous humour is impaired, the result may of the M. ciliaris the ciliary body moves towards the lens, which
be a glaucoma ('green star'). The increased intraocular pres- reduces the tension of the ciliary zonules. This rounds off the lens
sure often causes neuronal damage in the area of the retina and the eye focuses on the close proximity (near accommodation).
and optic disc, as the sclera is constructed from connective In the non-contracted condition of the ciliary muscle the tension
tissue and is not very elastic. Glaucoma diseases are among
of the ciliary zonules prevails and the lens flattens out. In this way
the most common causes of blindness worldwide. The cause
of a decreased outflow of aqueous humour is, for example, the eye focuses on far-sightedness. Behind the lens and its holding
the shift of the iridocorneal angle by adhesion of the iris to the apparatus the eye is filled up to the retina with the transparent vit-
cornea (synechia), which may lead to closed-angle glaucoma. reous body (Corpus vitreum)constructed from a gel-like sub­
When the chamber angle is open the outflow of aqueous stance, which consists almost to 98 % of water. It assumes almost
­humour through the trabecular meshwork of SCHLEMM's four fifths of the total volume of the Bulbus (› Fig. 9.63). Cornea,
­canal can also be disrupted due to other causes (open-angle aqueous humour in the eyes chambers, iris, lens and vitreous body
glaucoma). In the case of normal pressure glaucoma that can
form the optical apparatus of the eye.

Sinus venosus sclerae*

Circulus arteriosus iridis major
V. conjunctivalis anterior
A. conjunctivalis anterior

A. ciliaris anterior
Circulus arteriosus
iridis minor

Ora serrata
V. ciliaris
anterior

A. ciliaris
posterior longa
Retina
Vasa sanguinea retinae

Choroidea V. vorticosa

Lamina choroidocapillaris
Lamina vasculosa**
Sclera
V. centralis retinae
V. episcleralis
A. centralis retinae A. episcleralis
A. ciliaris posterior longa Fig. 9.64 Blood vessels of the
right Bulbus oculi (diagram).
Aa. ciliares posteriores breves ∗
clinically: SCHLEMM's canal
∗∗
clinically: uvea

474
 9.4 Eye

Vessel supply (high-risk keratoplasty). To minimise this risk, a tissue typing

The eyeball is supplied with blood from different arterial inflows, is conducted on the recipient using a blood sample (HLA typ-
all of which come from the A. ophthalmica (› Fig. 9.64): ing) before the operation, to find suitable transplants con-
• A. centralis retinae: it originates from the A. ophthalmica forming to the recipient’s tissue type (via corneal banks).
(› Fig. 9.50) and runs after its entry centrally in the N. opticus
[II], enters into the Bulbus at the Discus nervi optici and supplies
the innermost layer of the retina. Tunica vasculosa bulbi
• Aa. ciliares anteriores: they supply all internal eye muscles and In the Tunica vasculosa bulbi (Tunica media bulbi, Uvea) there are
form anastomoses with the Aa. ciliares posteriores longae. many blood and lymph vessels. It includes all the inner eye mus­
• Aa. ciliares posteriores longae: they penetrate the sclera medial cles, which are necessary for regulation of incident light in the eye
and lateral of the N. opticus [II] and run forwards inside the and are necessary to control the lens shape and is responsible for
choroid (Choroidea). the secretion of the aqueous humour. The iris, the ciliary body and
• Aa. ciliares posteriores breves: these branches penetrate the the Choroidea belong to it (› Fig. 9.65).
sclera immediately around the N. opticus [II] and pass into the
Choroidea. Choroidea
The venous blood flow from the Bulbus oculi takes place primarily The Choroidea forms the rear part of the Tunica vasculosa bulbi
via the vortex veins (Vv. vorticosae), 4 vessels which come from and makes up around two thirds of the entire vessel layer. Oxygen
the Choroidea and run in one of the four quadrants of the rear bul­ and nutrients reach the outer portions of the retina via its capillary
bus through the sclera and then flow into the V. ophthalmica supe­ system. The Choroidea is pigmented and internally firmly connect­
rior or the V. ophthalmica inferior. The venous blood of the inner ed to the outer retina and on the exterior loosely connected to the
retina is diverted through the V. centralis retinae which in its sclera.
course flows into the V. ophthalmica superior or directly into the
Sinus cavernosus. Corpus ciliare
The ciliary body (Corpus ciliare) is connected at the front to the
Choroidea. It extends at the front to the transition of cornea and
Clinical remarks sclera and at the back up to the Ora serrata. It is formed mainly
Central venous thrombosis is a relatively frequent vascular from the M. ciliaris which consists of smooth muscle fibres ar­
disease of the V. centralis retinae. Patients initially perceive a ranged in a circular, radial and longitudinal fashion. Thus the cili­
painless deterioration of vision. Except for general risk factors ary muscle protrudes into the inside of the eye and contraction
for the development of thrombosis, the cause of a central ve- leads to a loosening of the ciliary zonules of the holding apparatus
nous thrombosis has not yet been sufficiently clarified.
of the lens and thus to close accommodation. The ciliary zonules
originate from the Procc. ciliares of the ciliary body and are visible
as lengthwise aligned folds on its inner surface (› Fig. 9.65). The
Wall structure of the bulbus totality of the connective tissue fibres is called the Lig. suspensori­
The content of the Bulbus oculi is surrounded by a wall, which can um lentis. The ciliary body is divided into an evenly running part
be divided into three layers (› Table 9.25). (Pars plana) and into a folded part (Pars plicata). Approximately
70 ciliary processes (Proc. ciliares), originate from the Pars plica­
Tunica fibrosa bulbi ta from which the ciliary zonules of the lens holding apparatus ra­
The Tunica fibrosa bulbi consists of 2 units, the sclera and cornea: diate. The ciliary epithelium in the area of the Pars plicata also se­
• The sclera, the so-called white of the eyes, forms the rear and cretes the aqueous humour.
side portion of the Bulbus and is traversed by numerous vessels.
• The cornea is constructed from 5 layers: Table 9.25 Wall layers of the eyeball with their parts.
– Epithelial layer,
Tunica fibrosa bulbi Tunica vasculosa bulbi Tunica interna bulbi
– BOWMAN's membrane (a thick basal membrane),
– Stroma (makes up around 90 % of corneal thickness), • Sclera • Choroidea • Retina
– DESCEMET's membrane (a thick basal membrane) and • Cornea • Corpus ciliare – Pars caeca retinae
• Iris – Pars optica retinae
– Endothelial layer (it is involved specifically in the metabolic
control between aqueous humour and stroma)
M. sphincter pupillae Cornea

Clinical remarks M. dilatator pupillae

Iris

After injury of the cornea regeneration is only limited. After un- Sinus venosus sclerae
treated damage there is often scarring that can lead to severe Camera posterior bulbi
vision loss. To restore the vision after scarring or a deteriora- Proc. ciliaris
Corpus Camera
tion of the cornea, a corneal transplantation (keratoplasty) is anterior bulbi
ciliare M. ciliaris
usually necessary. This procedure is the most frequently car-
ried out tissue transplantation in Germany. The healing ten-
dency in this procedure is good to very good (clear healing of Zona ciliaris
Choroidea
the graft is achieved in approximately 90 % of operations),
since the cornea is an avascular tissue (it is one of the im- Sclera Lens
mune privileged organs). Rejection of the donor tissue is rare (
<5 %); however, if vessels have already immigrated in the re-
ceptor cornea, the risk of rejection significantly increases
Fig. 9.65 Structures of the iridocorneal angle (diagram). [E460]

475
9 Head

Iris Arteriola temporalis Venula temporalis

The Tunica vasculosa bulbi is closed at the front through the iris. retinae superior retinae superior
The iris represents the adjustable aperture of the eye and is visible Venula macularis Venula nasalis
through the cornea as the coloured part of the eye. At the back it is superior retinae superior

covered by a pigment sheet (› Fig. 9.66). It has a central opening, Arteriola nasalis
retinae superior
the pupil (Pupilla). The size of the pupil opening (variable be­ Arteriola
Discus nervi
tween approximately 1.5 and 8 mm) can be changed by smooth macularis
optici
muscle fibre traction, which are positioned in the connective tissue superior
(Venula
of the iris stroma. Extending annularly around the pupil opening, Fovea medialis
muscle fibres form the M. sphincter pupillae and leads by contrac­ centralis, retinae)
Foveola
tion to a reduction in pupil diameter (miosis; › Fig. 9.66). They (Arteriola
are innervated by postganglionic parasympathetic nerve fibres Arteriola medialis
macularis retinae)
from the Ganglion ciliare (Nn. ciliares breves). In the course fan- inferior Arteriola nasalis
shaped and radially outwards extending smooth muscle fibres are retinae inferior
Venula macularis
attached, which form the M. dilator pupillae. On contraction this inferior Venula nasalis retinae inferior
leads to a widening of the pupil opening (mydriasis). Its muscle fi­
Arteriola temporalis retinae inferior Venula temporalis retinae inferior
bres are located directly on the pigment sheet of the iris and are in­
nervated by postganglionic sympathetic nerve fibres from the Gan­ Fig. 9.67 Branching of the blood vessels of the retina with localiza-
glion cervicale superius, which also reach the Bulbus via the Gan­ tion of the Discus nervi optici and the Fovea centralis (diagram).
glion ciliare but are not switched. The blood supply of the iris is via
2 arterial rings, the outer Circulus arteriosus iridis major and the
incomplete inner Circulus arteriosus iridis minor (› Fig. 9.66). photo receptors (rods and cones), which are unevenly distributed
Both artery rings are connected to one another by anastomoses. over the retina and in which the signal transduction of a light stim­
The back of the iris has a radiating-like structure which is created ulus (photon) takes place in a physiological nerve impulse (pho­
by the serrated edge of the retina (Pars ciliaris retinae) and by the totransduction). The photo receptors form synaptic connections to
arrangement of the ciliary body processes (Plicae iridis). the inner retinal neurons (bipolar cells, horizontal cells, amac-
rine cells), which in turn are synaptically connected to the inner­
Tunica interna bulbi most retinal neurons, the ganglion cells. A photon must therefore
The Tunica interna bulbi (retina) consists of two portions: first penetrate all retinal layers before it can come to a signal trans­
• The Pars caeca retinae covers the inner surface of the Corpus duction in the outer segments of the photoreceptors. The ganglion
ciliare (Pars ciliaris retinae) and the iris (Pars iridica retinae) by cells are the only neurons of the retina which send visual sense
their two parts in front of the Ora serrata. stimuli to the brain via the joint course of their axons. The axons of
• Dorsally and laterally in the eye up to the Ora serrata there is the the retinal ganglion cells converge for this in the optic disc (Discus
Pars optica, the actual light sensitive part of the retina. It con­ nervi optici) and run as the N. opticus [II] and after the Chiasma
sists of two layers: opticum as Tractus opticus in the direction of the thalamus (Cor­
– The outer retinal pigment epithelium (Stratum pigmento- pus geniculatum laterale) of the diencephalon (› Chap. 9.3.2). In
sum), which is firmly connected to the Choroidea and contin­ the area of the papillae, except for the axons of the ganglion cells
ues to the front as a pigment layer in the area of the Pars caeca there are no retinal structures. For this reason, this area of the
retinae, retina is referred to as the blind spot. This is where the A. centralis
– The inner neuronal retina (Stratum neuroepitheliale), retinae enters into the inside of the eye and divides into various
which is only directly connected with the Stratum pigmento­ branches to supply blood to the inner retina (› Fig. 9.67). The
sum around the N. opticus [II] and on the Ora serrata corresponding vein (V. centralis retinae) leaves the eye above the
The neuronal retina, in turn, is divided into several layers. The out­ optic disc. Lateral to the Discus nervi optici is the yellow spot, the
er layer that rests directly on the pigment epithelium, contains the Macula lutea. It is characterised by a depression (Fovea centralis)
which represents both the thinnest part of the retina as well as the
area of sharpest vision. Here the highest visual sensitivity within
Pupilla the retina is based on the large density of cone cells without the
Anulus iridis presence of rod cells. When directly focusing on an object the
Plicae iridis minor ­picture falls into this area of the retina and can thus be sharply
seen.
Anulus iridis
Margo major
pupillaris Clinical remarks
Pathological changes of the retina in the area of the Macula
Reticulum lutea are referred to as macular degeneration . The most com-
Circulus trabeculare mon form of this disease which gradually lead to a progressive
arteriosus iridis
vision loss is the age-related or senile macular degeneration
major Margo ciliaris
(AMD). In industrialised countries it most often results in
Circulus arteriosus blindness for people over 50 years, followed by glaucoma dis-
iridis minor Lens, Facies anterior eases and diabetic retinopathy. Apart from a genetic predis-
M. dilatator pupillae position the main risk factors for AMD are smoking and high
M. sphincter pupillae blood pressure.

Fig. 9.66 Iris with lens from the front (diagram). [L127]

476
 9.5 Ear

Clinical remarks ing. The auricle hurt for a short period then the pain disap-
peared quickly; however, the auricle became swollen relatively
The retinal pigment epithelium supplies the outer parts of the quickly and the trainer sent him immediately to the ENT clinic.
retina. In the case of a retinal detachment (Ablatio retinae)
the connection between the neuronal retina and pigment epi- Initial examination
thelium becomes detached for various reasons. If the photore- The doctor examines the auricle, the external auditory canal
ceptors are no longer sufficiently nourished due to the loss of and the eardrum in detail. The bluish swelling of the auricle is
contact, depending on the duration and location of the abla- soft and fluctuating. The ENT doctor diagnoses an auricular
tion a massive loss of function in the affected areas may oc- haematoma, i.e. a serous bloody effusion between the peri-
cur. A retinal detachment is treated depending on the cause, chondrium and cartilage. The box kick led to a tangential,
location and extent. After repositioning of the retina a func- shearing force impact on the auricle, causing the perichondri-
tional regeneration can be achieved. um to be pushed off the cartilage. A gap is formed, which has
secondarily filled with liquid.

Treatment
The ENT doctor incises the swelling under sterile conditions in
9.5 Ear order to prevent an auricular perichondritis. A serous bloody
Friedrich Paulsen secretion drains out in the process. In order to optimally reat-
tach the perichondrium to the cartilage, he makes 2 mattress
sutures. In addition, he prescribes an antibiotic. He then ex-
plains to the patient that this type of injury is quite frequent in
Skills boxing and advises him in the future to regularly wear head
protection because in the long-term recurrent auricular hae-
After processing this chapter, you should be able to: matoma can cause a ‘cauliflower ear’. A connective tissue or-
• describe the anatomical construction of the auricle, middle ganisation of the haematoma occurs with restrictions of the
ear and inner ear and name its content structure nutrient supply of the ear cartilage and with loss of cartilage,
• correctly describe the various regions of the ear, clearly de- which ultimately leads to deformity of the auricle.
fine their limits and to place them into a topographical and
clinical context with neighbouring structures
• describe the structure of the Tuba auditiva, the muscles in- The ear (Auris) includes the hearing organ and the equilibrium or­
volved in the tube function and the relationship to the mid- gan. It is divided into the external ear, middle ear and internal
dle ear ear.(› Fig. 9.68):
• describe the course of the vascular, lymphatic and nervous • The external ear includes the auricle, the external auditory canal
systems in the Pars petrosa and understand the arrange-
and the eardrum.
ment of their different supply or innervation areas
• describe the embryological development of the auricle, the • The middle ear consists of the tympanic cavity, which lies cen­
middle ear and the inner ear and explain the structure and trally in the temporal bone (Pars petrosa of the Os temporale). It
function is separated from the external auditory canal through the tym­
panic membrane, accommodates 3 ossicles and is connected via
the Eustachian tube with the nasopharynx as well as via the An­
trum mastoideum with the mastoid process.
Clinical case • Also referred to as the labyrinth the internal ear also lies in the
temporal bone. It consists of various cavities, which border later­
Auricular haematoma
ally on the middle ear and medially on the Meatus acusticus in­
Case study
ternus.
A young man consults the ENT doctor in charge late at night
with a severely swollen auricle on the front. He is a kick boxer The hearing organ in the internal ear (Organum vestibulocochleare)
and states that he had received a kick to the head when train- converts the sounds and noises received via the auricle, which are
forwarded and amplified by the middle ear as mechanical informa­

Os temporale
Ossicula auditus
Cavitas tympani

Labyrinthus
vestibularis
Auricula
Labyrinthus
cochlearis
Meatus acusticus
externus Membrana
tympanica

Tuba auditiva
[auditoria]
Proc. mastoideus

Fig. 9.68 Parts of the ear, Auris,

Proc. styloideus right. Longitudinal section
through ear canal, middle ear
and Eustachian tube; frontal
view.

477
9 Head

tion, into electrical impulses in such as way that the information • The stirrup as a derivative of REICHERT's cartilage and the M.
can be forwarded to the brain. In addition there are specialised re­ stapedius in the 2nd pharyngeal arch (innervation therefore by
ceptor cells in the internal ear to determine movements and posi­ the N. facialis [VII], the 2nd pharyngeal arch nerve)
tions in space (organ of equilibrium).
Development of the internal ear
On approximately the 22nd day the otic placode forms in the sur-
9.5.1 Embryology face ectoderm on both sides of the position of the rhombencepha­
lon as a thickening of the epithelium; it soon bulges out to form an
Development of the auricle auditory pit and constricts the ear vesicle. Each vesicle is divided
The auricle which has the function of receiving sound develops into a front (rostral) part, to form the Sacculus and Ductus co­
from the 1st pharyngeal groove, between the 1st and 2nd pharyn­ chlearis and in a rear (occipital) part, to form the Utriculus, semi­
geal arches. circular canals and Ductus endolymphaticus; rostral and occipital
parts remain connected through a narrow path and form, in total
Development of the auricle from the six auricular hillocks the membranous labyrinth.
At the dorsocranial end of the 1st pharyngeal groove, at the begin­
ning of the 6th week there are 2 rows each of 3 auricular hillocks
that grow at different speeds and fuse quickly to the auricle. With 9.5.2 External ear
the extension of the mandibular branch in the 1st pharyngeal arch,
the auricles are indirectly shifted cranially and finally lie at the level The external ear is divided into the externally visible auricle (Auricu­
of the eye. la) as well as the external auditory canal (Meatus acusticus exter­
nus), which leads to the inside and the eardrum (Membrana tym­
panica). It is used for sound transmission and improvement of the
Clinical remarks directional location.
Excessive or inadequate fusing of the auricular hillocks is not
uncommon and spontaneous (auricle malformations); au­ Auricle
ricles that are positioned too deep are often associated with The auricle (› Fig. 9.69) consists of a basic framework made up of
chromosome-related malformations. elastic cartilage. The skin on the lateral surface is immovable and
fixed to the perichondrium without folds; on the rear side the skin
is movable. No subcutaneous fatty tissue. The ear lobe (Lobulus
Development of the external acoustic meatus from the first auriculae) has no cartilage, is variably formed and consists of sub­
pharyngeal groove cutaneous adipose tissue with skin coating. The outer edge of the
The external auditory canal develops from the ectoderm in the auricle, the helix, is rolled together, the antihelix is the inner auric­
depth of the 1st pharyngeal cleft that grows inwards as a fun­ ular fold, tragus and antitragus are prominent cartilage parts that
nel-shaped tube until it reaches the entodermal lining of the tym­ limit the central depression (Cavitas conchae) at the entrance of
panic cavity (Recessus tubotympanicus, from the 1st pharyngeal the auditory canal. The tragus continues in the cartilaginous part of
pouch) and at the start of the 9th week forms a solid auditory canal the external auditory canal. Other names are commonly used for
plate on the auditory canal floor. the auricle, but are negligible for understanding.

Muscles
Clinical remarks On the auricle rudimentary muscles are often present, such as the
If the auditory canal plate does not dissolve after the 7th Mm. auriculares anterior, superior and posterior or the M. tragicus
month, congenital deafness occurs. (some people can waggle their ears but only in conjunction with
the M. epicranius). These are mimic muscles (innervated by the
N. auricularis posterior of the N. facialis [VII]) which belong to a
rudimentary sphincter system (M. orbicularis conchae) that is still
Middle ear development well pronounced in many animals. Hence horses, for example, can
The entodermal lining of the 1st pharyngeal pouch grows from the turn the outer ears towards the direction of sound. Hedgehogs and
5th week as a lateral bulge of the pharyngeal skin and becomes the
middle ear. It meets with ectodermal tissue at the bottom of the 1st
pharyngeal cleft. At the point of contact, only a thin membrane re­ Helix Scapha
mains, the tympanic membrane. Now the distal portion of the 1st Crura antihelicis
Fossa triangularis
pharyngeal pouch extends, Recessus tubotympanicus, and be­
Cymba conchae
comes the primitive tympanic cavity. The proximal part remains (Tuberculum
auriculare) Crus helicis
narrow and becomes the auditory tube (Tuba auditiva [auditoria],
EUSTACHIAN tube). Antihelix Incisura anterior

Helix Cavitas conchae

Development of the auditory ossicles Concha auriculae Tragus
Also at the start of the 5th week the ossicles begin to differentiate Incisura
in the mesenchyme of the 1st and 2nd pharyngeal arches : Helix intertragica
• Hammer and anvil as derivatives of MECKEL's cartilage as well Antitragus
as the M. tensor tympani in the 1st pharyngeal arch (innervation Lobulus auriculae Cavitas conchae
therefore by the N. mandibularis [V/3], the 1st pharyngeal arch
nerve) Fig. 9.69 Auricle, Auricula, right. Lateral view.

478
 9.5 Ear

bears can close the external auditory canal so as not to be disturbed [V/3]), behind and below the ear from the Plexus cervicalis (N. au-
by noise during hibernation. ricularis magnus, N. occipitalis minor). The auricle itself is inner­
vated via the N. facialis [VII] (which part of the N. facialis [VII] is
Vascular, lymphatic and nervous systems exactly supplied, is not conclusively clarified) and at the entrance
Arteries to the external auditory canal via the N. vagus [X].
The auricle has an abundant blood supply by virtue of its exposed
position (protection against cold, heat loss). The arteries are External auditory canal
branches of the A. carotis externa. The A. temporalis superficialis The external auditory canal in adults is approximately 25-35 mm
with Rr. auriculares anteriores reaches the front of the auricle; Rr. long and generally in the horizontal and vertical plane bent slightly
auriculares of the A. auricularis posterior supply the back. forward in an S-shape (in neonates it is still straight) (› Fig. 9.71).
It stretches from the depth of the Cavitas conchae to the tympanic
Veins membrane and consists of two parts:
Corresponding Vv. auriculares anteriores drain into the Plexus • A longer cartilaginous (elastic cartilage) externally located Pars
pterygoideus; the V. auricularis posterior flows into the V. jugu­ fibrocartilaginea (up to 20 mm)
laris externa and the Vv. temporales superficiales into the V. jugu­ • A bony Pars ossea
laris interna. The Pars ossea belongs to the Pars tympanica of the Os temporale,
which borders the Meatus acusticus externus from the front, below
Lymph vessels and behind. In its superior aspect, the bony ring is interrupted by
Lymph is drained from the auricle forwards into the Nodi lym- the Incisura tympanica (attachment point for the Pars flaccida of
phoidei parotidei and backwards into the Nodi lymphoidei mas- the tympanic membrane, see below). The end of the external audi­
toidei, In some cases also into the upper Nodi lymphoidei cervi- tory canal is formed by the Sulcus tympanicus and the Incisura
cales profundi. tympanica, the eardrum is attached here. Functionally the auditory
canal is a sound funnel (approx. 8 mm diameter at the entrance, in
Innervation the Pars ossea only 6–7 mm, narrowest point at the transition from
Innervation of the auricle (› Fig. 9.70) takes place in front of the cartilage into the bony part). The auditory canal cartilage is con­
ear via the N. auriculotemporalis (from the N. mandibularis nected to the tragus of the auricle. The cartilaginous part is covered
by skin on the inside on its entire course, which contains hair, spe­
cialised free sebaceous glands and apocrine tubulous olfactory
glands (ceruminous glands, Glandulae ceruminosae). The secre­
N. auriculotemporalis tion of the glands forms the earwax (cerumen), which contains
from the N. mandibularis (V/3) shed epithelial cells, lipids and protein pigments (brown colour) as
well as bitter substances (unpleaseant for all types of insects).

N. occipitalis Vascular, lymphatic and nervous systems

minor (C2) Arteries
The external auditory canal is arterially supplied by Rr. auriculares
anteriores of the A. temporalis superficialis and the R. auricularis
posterior of the A. carotis externa.

Veins
The venous drainage occurs via Vv. auriculares anteriores into the
Vv. temporales superficiales and from here into the V. jugularis in­
terna, as well as via the V. auricularis posterior in both the V.
N. auricularis magnus jugularis interna as well as the V. jugularis externa.
N. vagus [X] (C2, C3)
N. facialis [VII]

Fig. 9.70 Sensory innervation of the auricle, Auricula, right. Lateral

view. [E402]

Pars ossea
Caput mandibulae
Cavitas tympani (Recessus meatus
Auricula
acustici inferior)
Auricula Membrana tympanica
Membrana tympanica
(Recessus meatus Pars fibro-
acustici inferior) Cavitas tympani cartilaginea
Pars fibro-
cartilaginea Pars ossea

Glandula parotidea
a b

Fig. 9.71 External ear canal, Meatus acusticus externus, right (diagram). The arrows indicate the pulling direction of the examiner on the auri-
cle, to stretch the ear canal in order gain a view of the tympanic membrane. a Frontal section. b Horizontal section.

479
9 Head

Lymph vessels In order to be able to inspect the tympanic membrane with an

Regional lymph node stations are the Nodi lymphoidei parotidei ear mirror or a microscope (otoscopy), the auricle has to be
superficiales and profundi and Nodi lymphoidei infraauricu- pulled back and upwards. This stretches the cartilaginous por-
lares, which drain into the Nodi lymphoidei cervicales profundi. tion of the auditory canal and the tympanic membrane can be
seen (at least partially) (› Fig. 9.71).
Zoster oticus is the secondary manifestation of infection with
Innervation varicella zoster virus in the area of the ear, resulting in blister-
The front and upper wall are innervated by the N. meatus acustici ing of the auricle and/or on the external auditory canal. Severe
externi from the N. auriculotemporalis (from the N. mandibu­ pain is typical for zoster. The infection can also spread to the
laris [V/3]); the posterior and partially the lower wall are reached internal ear and cause hearing loss up to deafness (N. cochle-
by the R. auricularis of the N. vagus [X]. The rear wall and the ex­ aris) or equilibrium disorders (N. vestibularis).
ternal side of the tympanic membrane are innervated by the Rr. au­
riculares of the N. facialis [VII] and of the N. glossopharyngeus
[IX].
Tympanic membrane
Topography Each medium has a distinctive sound wave resistance, which is re­
The external auditory canal is directly adjacent to the Glandula pa­ ferred to as the impedance. The impedance of air and one of the
rotidea, to the Proc. mastoideus, the middle cranial fossa and the fluids (perilymph) located in the inner ear are so different that 98
mandibular joint. When opening the mouth the head of the tem­ % of the incident sound waves would be reflected in direct trans­
poromandibular joint glides on the slope of the Tuberculum artic­ mission from the air to the inner ear. The remaining 2 % would be
ulare ossis temporalis, which slightly extends the cartilaginous too little to provide sufficient cortical perception. Tympanic mem­
­portion of the external auditory canal. brane (Membrana tympanica) and auditory ossicles of the middle
ear, however, serve as a kind of impedance converter and reduce
the reflection of the noise, so that on average 60 % of the sound en­
Clinical remarks ergy can be transferred to the oval window of the inner ear.
An inflammation of the elastic cartilage may occur (auricular The tympanic membrane (› Fig. 9.72a, › Fig. 9.73) forms the
perichondritis) as a result of injuries or insect bites to the au- border between the external ear and the middle ear and closes both
ricle. The ear lobe is unaffected because it contains no carti- spaces against each other in an airtight closure (the middle ear is
lage. therefore solely ventilated by the Tuba auditiva in the case of an in­
Since the ear lobe is well supplied with blood, is very easily
tact eardrum). The eardrum is grey, with a mother-of-pearl-like
accessible and has no elastic cartilage, it is often used for taking
a blood sample, e.g. in diabetic patients for the determination gloss, elliptically rounded in shape and has a diameter of approxi­
of blood glucose levels. Through the exposed location and the mately 9 mm with an area of 85 mm2. Structures lying in the mid­
lack of a fat layer, frostbite and sunburn, however, are not un- dle ear close behind the tympanic membrane shimmer through. A
usual. distinction is made between 2 areas:
Abnormalities of the auricle often require plastic reconstruc- • The very much smaller, thinner and slacker Pars flaccida located
tive surgery. Mechanical manipulation (e.g. cleaning the exter- in the cranial section (SHRAPNELL's membrane, approx. 25
nal auditory canal with a cotton bud) or damage often result in
mm2), which does not vibrate on sound (› Fig. 9.72a)
an inflammation of the auricle and the external auditory canal
(Otitis externa). • The large, thicker (approx. 0.1 mm) and tighter Pars tensa,
Excessive formation of cerumen (ear wax) often results in a which is used for sound transmission to the hammer head.
ceruminal plug that may close the external auditory canal (Ce- The eardrum has a thickened edge (Limbus membranae tympani-
rumen obturans) and leads to conductive hearing loss. cae), which is attached in the area of the Pars tensa via a connective
Due to the sensory innervation of the external auditory canal tissue ring (Anulus fibrocartilagineus) in the bony Sulcus tym­
through the N. vagus [X] during manipulations in the auditory panicus of the temporal bone and the Incisura tympanica, a recess
canal (e.g. when removing earwax or when foreign bodies are
of the Sulcus at the upper front. It sits obliquely to the auditory ca­
trapped in the auditory canal) a throat irritation is almost al-
ways triggered. In a worst case scenario the manipulation can
nal axis. The position of eardrums can be imagined if the out­
cause vomiting or collapse. stretched palms of the hand are placed together like the bows of a
ship so that only the tips of the 3rd–5th fingers touch: the backs of

Plica mallearis posterior Plica mallearis posterior

Recessus epitympanicus
Meatus acusticus externus
Pars flaccida* Stapes
(Paries posterior) Plica mallearis Manubrium mallei Incus, Crus longum
anterior Plica mallearis superior
Prominentia Recessus superior
mallearis membranae tympanicae ***
Pars tensa
4 Recessus anterior
Edge of the
tympanic membrane 3 membranae tympanicae
1
2 Plica mallearis anterior
Anulus fibro- Umbo membranae
cartilagineus tympanicae M. tensor tympani
** Tuba auditiva [auditoria]
a b

Fig. 9.72 Tympanic membrane, Membrana tympanica, right. Lateral view. a Mirror image of the ear. b Schematic representation with Recessus
of the tympanic cavity, Cavitas tympani and division into 4 quadrants. ∗ clinically: SHRAPNELL's membrane, ∗∗ typically positioned light reflex,
∗∗∗
clinically: PRUSSAK's space.

480
 9.5 Ear

Lymph vessels
Regional lymph nodes are the Nodi lymphoidei parotidei superfi-
ciales and profundi and the Nodi lymphoidei infraauriculares
and from here the Nodi lymphoidei cervicales profundi.
Epitympanon
Innervation
The eardrum is extremely well sensory innervated. On the outside
via the Rr. auriculares of the N. vagus [X] and the N. auriculotem-
poralis (from the N. mandibularis [V/3]); on the inside via the
Plexus tympanicus from fibres of the N. facialis [VII] and the N.
Mesotympanon glossopharyngeus [IX].

Clinical remarks
Hypotympanon
In the anterior lower quadrant one can see when inspecting
the eardrum through the otoscope a bright pyramid-shaped
light reflex, which is referred to as a mirror or tympanic mem-
Fig. 9.73 Levels of the tympanic cavity, Cavitas tympani, right. Ante- brane reflex. It can be used to draw conclusions about the ten-
rior view. [L126] sion of the tympanic membrane. The base of the light reflex
pyramid is directed to the Anulus fibrocartilagineus.
The Pars flaccida of the eardrum is thinner than the Pars tensa
hand point to the auditory canals, the palms in the direction of the and therefore in the case of suppurating middle ear infections
cranial cavity. In the case of small children and infants the eardrum (Otitis media) is the preferred location for a spontaneous per-
is even more inclined than in adults. The eardrum is drawn inside foration.
like a funnel. The eccentrically lying tip corresponds to the lowest Hydromyrinx can be seen and drained through the tympanic
point on the auditory canal side or Umbilicus of the tympanic membrane. To ensure that the middle ear structures during a
paracentesis are not put at risk (incision through the tympanic
membrane (Umbo membranae tympanicae); the tip of the ham­
membrane) it is performed in the anterior lower or posterior
mer grip (Manubrium mallei) is attached at this point, on the mid­ lower quadrant. A tympanostomy tube can then be inserted
dle ear side, which continues obliquely towards the upper front. At through the incision for long-term aeration of the middle ear.
the most cranially located attachment point of the hammer the
short hammer process protrudes (Proc. lateralis mallei) as the
Prominentia mallearis in the direction of the auditory canal. From
this bulge the Plicae malleares anterior and posterior run on the
inner surface of the tympanic membrane and separate the Pars 9.5.3 Middle ear
flaccida from the Pars tensa of the tympanic membrane.
If one creates an imaginary line through the Manubrium mallei The middle ear (Auris media) includes the tympanic cavity (Cavi­
and a line perpendicular to it that leads exactly through the Umbo, tas tympani) with the 3 ossicles. Connections are present via the
one can divide the eardrum into 4 quadrants: Antrum mastoideum with the air-containing cells of the mastoid
• An anterior upper process, as well as the Eustachian tube (Tuba auditiva [auditoria],
• A posterior upper ‘tube’, EUSTACHIAN tube) with the nasopharynx.
• An anterior lower
• A posterior lower Tympanic cavity
The division into quadrants (› Fig. 9.72b) is of practical clinical The tympanic cavity (Cavitas tympani) is separated from the ex­
significance. The auditory ossicles are located behind the upper ternal auditory canal by the eardrum which is airtight and thus
quadrants. In addition, the Chorda tympani (branch of the N. fa­ represents a closed space which must be ventilated. This ventilation
cialis [VII]) and the attachment tendon of the M. tensor tympani of the tympanic cavity (and the air-containing cells of the mastoid
(see below) run here. The basis of the tympanic membrane is a lay­ process) only takes place during the swallowing process in which
er of connective tissue (Stratum fibrosum), which forms a network the tube, which is otherwise sealed, opens briefly and enables the
from radial and circular fibres and provides the stiffness of the air exchange between nasopharynx and middle ear.
tympanic membrane. On the auditory canal side, the connective The tympanic cavity is anatomically and clinically divided (› Fig.
tissue is covered by squamous epithelium, in the middle ear by a 9.73) into:
Stratum mucosum (single layered cuboidal epithelium). • The Epitympanum (dome recess, tympanic dome, attic) contains
the suspension device and the largest part of the auditory ossicles
Vascular, lymphatic and nervous systems and is connected to the mastoid cells (retrotympanal spaces) via
Arteries the Antrum mastoideum. Below the Antrum the semicircular ca­
The external side of the tympanic membrane is fed arterially by the nals of the labyrinth bone bulge out. The area between Pars flacci­
A. stylomastoidea which comes via the A. auricularis profunda da of the tympanic membrane (lateral) and hammer head and an­
from the A. maxillaris; the internal side receives its blood supply vil body (medial) is the Recessus epitympanicus. An even smaller
from the A. tympanica anterior, a branch of the A. carotis externa. space between Pars flaccida and hammer neck is the Recessus
superior membranae tympanicae (PRUSSAK's space).
Veins • The Mesotympanum (tympanic space) includes the Manubrium
The venous drainage occurs on the outside and the inside via the mallei, the Proc. lenticularis of the anvil, and the tendon of the
Vv. perforantes into the V. stylomastoidea and from here into the M. tensor tympani and lies directly behind the tympanic mem­
Plexus pterygoideus. brane.

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9 Head

• The Hypotympanon which merges into the Tuba auditiva (tym­ petrosa, through which the Chorda tympani, the A. tympanica
panic cellar, Recessus hypotympanicus) is the lowest point of the anterior and the Lig. mallei anterior enter and exit. The auditory
tympanic cavity and is located below the tympanic membrane tube (Tuba auditiva [auditoria]) flows into the tympanic cavity
level. in the lower wall section.
The distance between the Epitympanum and the Hypotympanum • The rear panel (Paries mastoideus) borders on the mastoid pro­
is 12–15 mm at a depth of 3–7 mm. The internal volume of the cess (Proc. mastoideus,› Fig. 9.75). At the upper rear there is a
tympanic cavity is only about 1 cm3. direct connection to the normally pneumatic spaces (Cellulae
The tympanic cavity is lined by a single layer of isoprismatic epi­ mastoideae) of the mastoid (Aditus ad antrum). In the upper
thelium; individual goblet cells and ciliated epithelium are also part of the rear wall the Eminentia pyramidalis forms an eleva­
present. The auditory ossicles are covered by multilayered squa­ tion. At this point, the tendon of the M. stapedius exits. Just be­
mous epithelium. In the Lamina propria there are tubulous glands low flows the Canaliculus chordae tympani, through which the
(Glandulae tympanicae), which are innervated by the Plexus tym­ Chorda tympani enters the tympanic cavity.
panicus. • The lower wall of the tympanic cavity (Paries jugularis) is part
of the Hypotympanum. It demarcates the tympanic cavity from
Delineations the V. jugularis interna. The bone is very thin at this section (ap­
The tympanic cavity has 6 walls (› Fig. 9.74, › Table 9.26): a rear, prox. 0.5 mm) and partially pneumatised. Here, the N. tympani­
a front, a roof, a floor and a medial and a lateral wall: cus together with the A. tympanica inferior enter through the
• A thin bony plate (Tegmen tympani, Paries tegmentalis) sepa­ Canaliculus tympanicus into the tympanic cavity.
rates the Epitympanum above from the middle cranial fossa. • The medial wall (Paries labyrinthicus) separates the cochlea
• The paper thin front wall of the Mesotympanum (Paries caroti- from the tympanic cavity and therefore forms the border to the
cus) has a connection to the A. carotis interna. inner ear (labyrinth). It has two openings (› Fig. 9.75): the oval
• The lateral wall (Paries membranaceus) is almost exclusively window (Fenestra vestibuli), in which the stirrup foot plate lies,
formed by the eardrum. At the top edge lies the Fissura spheno­ which is attached in the oval window via the Lig. anulare stape­

Upper wall (Paries tegmentalis)

A. carotis interna
Fossa cranii media

Posterior wall
(Paries mastoideus)

Anterior wall V. jugularis interna

(Paries caroticus)

Cavitas tympani

Medial wall
Lateral wall (Paries labyrinthicus)
(Paries membranaceus) = Fenestra vestibuli
= Membrane tympani
Proc. mastoideus

a Proc. styloideus Lower wall (Paries jugularis)

Prominentia Upper wall

canalis facialis (Paries tegmentalis)

Prominentia canalis Medial wall

semicircularis lateralis (Paries labyrinthicus)

Aditus ad Antrum
mastoideum M. tensor tympani
Tuba auditiva
Posterior wall [auditoria]
(Paries mastoideus)
Anterior wall
Fenestra vestibuli (Paries caroticus)
Promontorium
M. stapedius

N. facialis [VII]

Fenestra Plexus Fig. 9.74 Topographical rela-

cochleae sympathicus tionships of the tympanic cavi-
ty, Cavitas tympani, to the adja-
A. carotis interna cent structures. a Right side;
Chorda lateral view exterior; schematic
tympani representation (› Table 9.26).
Plexus Lower wall b Right side; view from lateral
b tympanicus (Paries jugularis) into the tympanic cavity sche-
matically shown as a box.

482
 9.5 Ear

Table 9.26 Walls of the tympanic cavity. Clinical remarks

Wall Relationship Openings/connections An acute inflammation of the middle ear (Otitis media) is one
of the most common diseases during childhood. It is common-
Posterior, rear Mastoid wall Aditus to Antrum mastoideum (transition to
wall (Proc. (Paries mastoi- the mastoid cells); Eminentia pyramidalis
ly caused by bacteria and viruses entering the middle ear
mastoideus) deus) (passage of the tendon of the M. stapedius);
through the pharyngotympanic tube (Tuba auditiva [audito-
opening of the Canaliculus chordae tympani
ria]) during or after an infection of the nasopharynx. The in-
flammation is characterised by a reddening of the mucous lin-
Anterior, fron- A. carotis Canaliculi caroticotympanici (passage sym- ings, oedema, granulocytic infiltration and formation of pus.
tal wall (carot- interna (Paries pathetic nerve fibres); Semicanalis tubae Since the pus cannot exit via the inflamed and therefore
id canal) caroticus) auditivae (bony connection in the direction of blocked tubes, the inflammation can spread to the surround-
the nasopharynx) ing area and cause severe complications such as:
Superior, Middle cranial Opening of the Semicanalis musculi tensoris • Tympanic membrane perforation (most common, via Paries
upper wall fossa (Paries tympani and passage of its tendon; Fissura membranaceus)
(middle cranial tegmentalis) petrosquamosa (passage of the A. tympanica • Mastoiditis (via Paries mastoideus, Antrum mastoideum)
fossa) superior); Canaliculus nervi petrosi minoris • Thrombophlebitis and jugular vein thrombosis (via Paries
(contains preganglionic parasympathetic jugularis)
fibres of the N. glossopharyngeus [IX], which • Sepsis (pathogen spreading into the blood via Paries caroti-
run to the Ganglion oticum) cus)
Inferior, lower V. jugularis Canaliculus tympanicus (passage of N. tym- • Brain abscess and/or meningitis (via Paries tegmentalis)
wall (Fossa (Paries jugu- panicus and A. tympanica inferior) • Peripheral facial palsy (via Paries labyrinthicus)
jugularis) laris) • Labyrinthitis (so-called tympanogenic labyrinthitis with ver-
tigo and hearing impairment via Paries labyrinthicus
Medial, medial Oval window Fenestra vestibuli (above the Promontorium, A distinction should be made between this type of tympano-
wall (labyrinth) (Paries labyrin- contains stirrup base plate); Fenestra cochle-
genic labyrinthitis and meningogenic labyrinthitis. The latter
thicus) ae (below and behind Promontorium; closed
is due to the fact that bacteria (pneumococcal and meningo-
from Membrana tympanica secundaria)
coccal) in the context of an infection of the meninges (menin-
Lateral, lateral Tympanic Fissura sphenopetrosa (passage of the Chor- gitis) come through the Aqueductus cochleae (see below) into
wall (tympanic membrane da tympani) the inner ear and lead to labyrinth failure.
membrane) (Paries mem- Defects in the chain of transmission (tympanic membrane, au-
branaceus) ditory ossicles) result in conductive hearing loss. If the sound
pressure transformation fails completely, the hearing loss lies
at approximately 20 dB. A typical disorder that leads to such
diale, and the round window (Fenestra cochleae) located fur­ an impairment is otosclerosis. In this localised disease of the
ther below which is closed by the Membrana tympanica secund­ temporal bone the Lig. anulare stapediale ossifies and holds
the stirrup foot plate in the oval window. The result is a slowly
aria. Between the oval and the round window, the medial tym­ increasing conductive hearing loss. Inflammatory foci in the
panic cavity wall bulges out towards the Promontorium area of the cochlea may also cause inner ear hearing loss.
through the basal cochlear coil. Above the oval window, the me­ Women aged 20–40 years are affected twice as often as men.
dial wall protrudes outward through the lateral semicircular ca­ In 70% of cases, otosclerosis affects both ears.
nal towards the Prominentia canalis semicircularis lateralis.
The N. facialis [VII] runs through the medial wall in the Canalis
nervi facialis. The canal bulges the medial wall towards the hor­
izontally running Prominentia canalis nervi facialis. Vascular, lymphatic and nervous systems
The Tuba auditiva [auditoria] commences at the Ostium tympani­ Arteries
cum tubae auditivae and is demarcated at the top by the Septum The middle ear including the ossicles and the Cellulae mastoideae
canalis musculotubarii from the Semicanalis musculi tensoris tym­ are supplied by 10 arteries (› Table 9.27). They are listed here for
pani. the sake of completeness but exact knowledge is superfluous infor­

Prominentia canalis semicircularis lateralis

Antrum mastoideum Prominentia canalis facialis
Fenestra vestibuli
Canalis nervi facialis
Proc. cochleariformis
Semicanalis musculi
Cellulae
tensoris tympani
mastoideae
Impressio trigeminalis
Canalis caroticus
Septum canalis
musculotubarii
Paries
mastoideus Ostium tympanicum
tubae auditivae

Promontorium
Meatus acusticus Fig. 9.75 Medial wall, Paries
externus Fossula fenestrae cochleae
labyrinthicus, the tympanic cav-
Sinus tympani Sulcus tympanicus ity, Cavitas tympani, right. Ver-
Proc. mastoideus Proc. styloideus
tical section in the longitudinal
axis of the temporal bone; fron-
tal lateral view.

483
9 Head

Table 9.27 Arteries of the tympanic cavity. the tympanic cavity and form a movable chain from the eardrum
to the oval window (Fenestra vestibuli):
Artery Entry site Supply area
(original vessel) • The Malleus consists of head (Caput mallei), neck (Collum mal­
lei), handle of Malleus (Manubrium mallei), a long (Proc. anteri-
Aa. caroticotympani- Canaliculi caroticotym- Promontorium
or) and a short (Proc. lateralis) process. Manubrium mallei and
cae (A. carotis interna) panici
Proc. lateralis are fused with the tympanic membrane. The tendon
A. tympanica superior Canalis nervi petrosi M. tensor tympani, Epitym- of the M. tensor tympani is also attached at the Manubrium mallei.
(A. meningea media) minoris panum, Stapes
• The anvil consists of a body (Corpus incudis) and 2 legs (Crus
R. petrosus (A. menin- Hiatus canalis nervi N. facialis [VII], Stapes longum and Crus breve incudis). On the front of the Corpus is
gea media) petrosi minoris
the articular surface for articulation with the Malleus. The Crus
A. tympanica anterior Fissura sphenopetrosa Epitympanum, hammer, longum runs parallel to the Manubrium mallei. At the end, there
(A. maxillaris) anvil, Antrum mastoideum, is the Proc. lenticularis, which bends at a right angle and bears
tympanic membrane
the joint surface for articulation with the stirrup.
A. tympanica posterior Canaliculus chordae Chorda tympani, hammer, • The stirrup consists of a head (Caput stapedis), 2 legs (Crus an-
(A. stylomastoidea) tympani tympanic membrane
terius and Crus posterior stapedis) as well as the base of the
A. tympanica inferior Canaliculus tympani- Stapes, Promontorium, stirrup (Basis stapedis). The base plate is movably fixed in the
(A. pharyngea ascen- cus Hypotympanum, Pars carti- oval window via a connective tissue ring ligament (Lig anulare
dens) laginea of the Tuba auditiva
stapediale) and transmits the sound vibrations to the perilymph
A. auricularis profunda Basis partis petrosae outer ear canal, tympanic of the inner ear.
(A. maxillaris) ossis temporalis membrane, Hypotympanum
The 3 bones are connected in a series and linked by true joints (Ar-
A. stylomastoidea Canalis nervi facialis Cellulae mastoideae, Antrum ticulatio incudomallearis, a saddle joint, and Articulo incudosta-
(A. auricularis posteri- mastoideum, Paries mastoi- pedialis, a ball joint). In the tympanic cavity the bones are fixed
or) deus, Stapes, M. stapedius
with ligaments:
R. mastoideus Foramen mastoideum Cellulae mastoideae • Ligg. mallei superius, anterius (remnants of the MECKEL's car­
(A. occipitalis)
tilage) and posterius (Ligg. mallei anterius and posterius togeth­
A. subarcuata Below the front semi- Cellulae mastoideae er form the ‘axis ligament’, which acts as a lever of the hammer)
(A. labyrinthi) circular canal • Ligg. incudis superius and posterius
The ligaments are listed just for the sake of completeness.
mation and not necessary to understand the middle ear. If necessary
it can be looked up. With the exception of the Aa. caroticotympani­ NOTE
cae all vessels are branches of the A. carotis externa. Most of the The auditory ossicles form a flexible chain for the transmission of
arteries form an anastomosis system in the area of the Promontori­ sound waves conducted by the tympanic membrane to the peri-
um. lymph of the inner ear. Low air impedance has to be transferred to
the significantly higher inner ear fluid impedance. This requires the
amplification of the sound waves (impedance matching), which is
Veins accomplished by the size difference between the tympanic mem-
The veins of the same name drain into the Sinus petrosi superior brane (55 mm2) and the oval window (3.2 mm2; 17 times) and the
and inferior, the Sinus sigmoideus, the Bulbus superior venae jugu­ lever action of the auditory ossicles (1.3-times). This boosts acous-
laris, the V. meningea media and the Plexus pharyngeus tic pressure 22-fold.

Lymph vessels
Regional lymph nodes are the Nodi lymphoidei parotidei profun- Muscles
di and the Nodi lymphoidei retropharyngeales, which drain to The sound transmission is influenced by 2 striated muscles (Mm.
the nodi lymphoidei cervicales profundi. ossiculorum auditus) (› Fig. 9.77), the M. tensor tympani and the
M. stapedius. Its contraction leads to a reduction of high sound in­
Innervation tensities and the volume range is adjusted dynamically. They also
The tympanic cavity, the ossicles and the Cellulae mastoideae are weaken the transfer of one's own voice.
innervated sensitively from the N. tympanicus of the N. glossopha- The M. tensor tympani originates in the Semicanalis musculi ten­
ryngeus[IX]. Preganglionic parasympathetic fibres of the N. facial­ soris tympani of the temporal bone. Its tendon enters at the Proc.
is [VII] and the N. glossopharyngeus [IX] form the Plexus tympan­
icus below the tympanic cavity mucosa. A part of the fibres is
switched here in small groups of multipolar ganglion cells to post­ Corpus incudis
Caput mallei
ganglionic neurons and innervates the tympanic cavity mucosa. Crus breve
The other part leaves the tympanic cavity and forms the N. petro-
Proc. lateralis
sus minor (innervation of the Glandula parotidea, JACOBSON's Articulatio
incudomallearis
anastomosis). Apart from parasympathetic fibres, sympathetic fi­
Crus longum
bres also occur in the Plexus tympanicus (sometimes referred to as
Proc. anterior
R. communicans cum plexu tympanico), which reach it as Nn. Articulatio
caroticotympanici (passage through the Paries caroticus) coming incudostapedialis
from the Plexus nervosus of the A. carotis interna. Manubrium mallei
Crus posterius

Auditory ossicles Crus anterius Basis stapedis

The 3 ossicles coated by mucous membranes (› Fig. 9.76), ham­
mer (Malleus), anvil (Incus) and stirrup (Stapes) are suspended in Fig. 9.76 Ossicles, Ossicula auditus, right. View from medial above.

484
 9.5 Ear

Ganglion geniculi N. facialis [VII]

M. stapedius, Tendo
Stapes
M. tensor tympani, Tendo
Incus M. stapedius
N. petrosus minor
N. stapedius
Malleus
N. petrosus major Proc.
pyramidalis
M. tensor tympani
Semicanalis musculi N. facialis
tensoris tympani [VII]
Tuba auditiva Chorda
[auditoria], tympani
Pars ossea

A. carotis interna
Proc.
Tuba auditiva [auditoria], mastoideus
A. carotis
Pars cartilaginea
interna
Fissura sphenopetrosa Foramen
Membrana
stylomastoideum
tympanica
Chorda tympani

R. stylohyoideus N. auricularis posterior

R. digastricus
M. stylohyoideus Fig. 9.77 Tympanic cavity with
ossicles, ossicular muscles,
course of the N. facialis [VII] and
M. digastricus, Venter posterior some of its branches. Vertical
section through the Canalis
facialis; view from the left side.

cochleariformis through the Paries tegmentalis into the tympanic mastoideum (› Fig. 9.75), are lined with mucous membrane and
cavity and is deflected almost at right angles. It inserts after a short must be ventilated. Blood supply and innervation in the tympanic
course at the top edge of the hammer handle. The A. tympanica cavity were already discussed.
superior supplies it with blood, the N. pterygoideus medialis of
the N. mandibularis [V/3] innervates the muscle. Functionally the
M. tensor tympani tenses the eardrum by tension at the hammer
Clinical remarks
handle and stiffening of the ossicular chain. It is used for a better An inflammation of the Cellulae mastoideae (mastoiditis) is
transmission of high sound frequencies. often an inflammation transferred from the tympanic cavity. It
The M. stapedius originates in the Cavum musculi stapedii. Its is one of the most common complications of a middle ear in-
tendon enters at the tip of the Proc. pyramidalis in the Paries mas­ flammation. The inflammation can spread from the mastoid to
the soft tissue parts behind and in front of the ear, the M. ster-
toideus into the tympanic cavity and passes to the Caput stapedis.
nocleidomastoideus, the inner ear, the Sinus sigmoideus, the
The A. stylomastoidea supplies it with blood, the N. facialis [VII] meninges, the cerebellum and the N. facialis [VII].
innervates the muscle. A contraction tips the stirrup foot plate in
the oval window and reduces energy transfer. Very loud noises are
thus weakened, the inner ear is protected.
Topography of the N. facialis [VII] and its branches
Vascular, lymphatic and nervous systems Course
The blood supply for the tympanic cavity was already discussed The N. facialis [VII] runs in its peripheral section over a long dis­
above. The ossicles are sensitively innervated from the N. mandibu- tance through the Os temporale (› Fig. 9.77). It is composed of
laris [V/3], vegetatively innervated via the N. tympanicus and Nn. two branches, the actual N. facialis and the N. intermedius. Both
caroticotympanici, exactly in the same way as the tympanic cavity branches combine in the depth of the facial canal (Canalis nervi
mucosa. facialis) to the N. intermediofacialis (generally referred to as N.­facialis
[VII]) (› Fig. 9.81). After it leaves the cerebellopontine angle, it
Mastoid process passes together with the N. vestibulocochlearis [VIII] through the
In neonates, only the tympanic cavity and the Antrum mastoide­ Meatus acusticus internus of the temporal pyramid (meatal and
um are filled with air. First in young children (finishing approxi­ labyrinthine distance) up to the Ganglion geniculi (outer facial
mately in the 6th year of life) air-filled cells are formed in the mas­ bend), flexes here to the rear and continues in the m ­ edial tympanic
toid process starting from the anvil. The degree of pneumatisation wall (Paries labyrinthicus) in a thin bony canal between Epitympa­
differs greatly according to the individual case. Zygomatic and num and Mesotympanum (tympanal distance). Its bony channel
temporal bone pyramids can be almost completely pneumatised bulges the bones above the oval window. Shortly afterwards, the N.
(extensive pneumatisation); the pneumatisation can also be com­ facialis [VII] bends to caudal and passes through the front section
pletely missing (compact mastoid bone) or only slightly formed of the mastoid (mastoidal distance). Between the mastoid and
(partially pneumatised). All pneumatised spaces (Cellulae mas­ Proc. styloideus it leaves the skull base at the Foramen stylomastoi­
toideae) are in contact with the tympanic cavity via the Antrum deumi.

485
9 Head

Branches Ostium pharyngeum tubae auditivae, which protrudes at the side

On the way through the petrous bone, the N. facialis [VII] emits to the rear in the nasopharynx (the Ostia of both sides protrude as
the N. petrosi major and stapedius and the Chorda tympani (also Torus tubarius). In its mucosa lies the Tonsilla tubaria as part of the
› Chap. 9.3.7). lymphatic tonsillar ring (WALDEYER's tonsillar ring). A distinc­
At the Ganglion geniculi the first branch to be emitted is the N. tion is made between a bony section (Pars ossea) and an almost
petrosus major (› Fig. 9.77). It runs in the Os temporale to the twice as long cartilaginous section (Pars cartilaginea) (› Fig.
front medially and exits at the Hiatus nervi petrosi majoris on the 9.68, › Fig. 9.78a). The latter consists of a groove made of flexible
Facies anterior of the Pars petrosa ossis temporalis below the dura. cartilage (Cartilago tubae auditivae). The upside-down cartilage
The nerve carries preganglionic parasympathetic fibres to the groove is medially enclosed by connective tissue (Lamina membra­
­Ganglion pterygopalatinum for the innervation of lacrimal, nasal, nacea) to form a slit-shaped canal. The Tuba auditiva [auditoria] is
palatine and pharyngeal glands and taste fibres from the palate. opened by the contraction of the Mm. tensor and levator veli pala­
Since the N. facialis [VII] runs directly passed the Proc. pyramida­ tini as part of the swallowing action (› Fig. 9.78b, c).
lis ossis temporalis in whose cavity the M. stapedius lies, the N. sta- The bony section of the Tuba auditiva [auditoria] is inside a trian­
pedius is a very short nerve, which originates directly from the N. gular bony canal (Semicanalis tubae auditivae of the Canalis mus­
facialis [VII] (› Fig. 9.77). culotubarius) of the Pars petrosa ossis temporalis. Separated by a
The Chorda tympani, which exits shortly before the end of the Ca­ thin bony layer the M. tensor tympani lies in the Semicanalis mus-
nalis nervi facialis and regresses through its own bone canal goes culi tensoris tympani of the Canalis musculotubarius (› Fig.
back into the tympanic cavity and runs embedded in mucosa, be­ 9.77).
tween hammer and Crus longum of the anvil right through the
tympanic cavity, to leave the skull base via the Fissura sphenope­
trosa (or Fissura petrotympanica) (› Fig. 9.77).
Clinical remarks
The Tuba auditiva [auditoria] is lined by respiratory ciliated
epithelium with goblet cells; mixed Glandulae tubariae occur
Clinical remarks in the subepithelium. The ciliary beat is aimed in the direction
The N. facialis [VII] can be damaged due to fractures of the pe- of the nasopharynx. Failure of the protective mechanism in the
trous bone and inflammation of the middle ear or mastoid tube can lead to an ascending inflammation with formation of
process, as well as surgical interventions because of these a tube catarrh up to otitis media. By injection of air via the
conditions. For facial diagnostics (the amount of the damage) nose, adhesions and closures inside the tubes can be dis-
and the follow-up after facial paralysis, various test proce- solved (e.g. swallowing for pressure problems).
dures are used: SCHIRMER's test (lacrimal gland function), One of the most common causes of conductive hearing loss in
Stapedius reflex test, taste test and sometimes a sialometry childhood is the relocation of the tube opening (tube occlu-
(test of the salivary gland function) for testing the Chorda tym- sion) due to tube catarrh or restricted nasal breathing due to
pani and electromyography (EMG) and electroneuronography enlarged pharyngeal tonsils (adenoids). If the tube function dis-
(ENoG) to test the facial muscles; however, these methods are order persists over a longer period of time, restructuring of the
increasingly being replaced by modern high-resolution imag- middle ear mucosa takes place. As a result, an actively secret-
ing methods. ing epithelium develops, with fluid retention formation in the
The course of the Chorda tympani renders it susceptible to in- tympanic cavity (secretory otitis media).
jury in surgery conducted on the middle ear. During middle ear
infections there is often an isolated functional loss of the
Chorda tympani with dry mouth and loss of taste sensation on
the affected side. Muscles
If the N. stapedius is involved, and thus the M. stapedius is The opening of the Tuba auditiva and thus the pressure compensa­
paralysed, the result is impaired hearing on the affected side. tion between tympanic cavity and nasopharynx takes place using
Loud sounds are perceived as uncomfortably loud (hyperacu- the Mm. tensor and levator veli palatini and the M. salpingopha­
sis), because of insufficient attenuation (due to a tilting of the
ryngeus (› Fig. 9.78, › Table 9.28).
base of the stirrup foot plate in the oval window).
The N. facialis [VII] can be exposed surgically via the Proc.
The swallowing action involves contraction of the Mm. tensor and
mastoideus to provide relief, for example, in the context of an the levator veli palatini. The contraction of the M. tensor veli pa-
inflammatory swelling of the nerve. In the process the bony latini causes the tubal lumen to expand by pulling on the Pars
canal is opened or removed from behind. membranacea and the upper edge of the tubal cartilage (› Fig.
9.78b, c). Contraction of the M. levator veli palatini causes the
muscle to bulge out and this muscle belly pushes against the carti­
laginous part of the tube from below. In the process, the groove is
Auditory tube bent open and the tube lumen expanded. The M. salpingopharyn­
The Eustachian tube (Tuba auditiva [auditoria], EUSTACHIAN geus is involved in occluding the tube (› Fig. 9.78a).
tube, Tuba EUSTACHII) is about 3.5 cm long and runs obliquely
from the rear lateral above to medial at the front below. It connects
the tympanic cavity with the nasopharynx and its function is pres­
Clinical remarks
sure compensation (› Fig. 9.78). The requirement for optimal Cleft palate is associated with a non-functioning Mm. tensor
transmission of sound waves is equal air pressure in both the tym­ and levator veli palatini, because the Punctum fixum of the
panic cavity and the external auditory canal. If this is not the case, muscles is missing and they contract into a void. This renders
e.g. during the ascent or descent in an aeroplane or when diving, the tubular function redundant. If left untreated, an adhesive
process occurs in the middle ear due to the absence of middle
there is hearing loss.
ear ventilation. Such children are hard of hearing and often do
The Tuba auditiva [auditoria] connects to the Hypotympanum and not learn to speak.
starts in the front wall of the tympanic cavity (Paries caroticus)
with the Ostium tympanicum tubae auditivae. It converges at the

486
 9.5 Ear

Semicanalis M. tensor
tubae auditivae tympani
Sinus sphenoidalis A. carotis interna Umbo mallei

Tonsilla
pharyngea

Cellulae
mastoideae

V. jugularis interna
Palatum M. levator
durum veli palatini A. carotis interna
Cartilago tubae
auditivae
Lamina membranacea
tubae auditivae
M. constrictor pharyngis
M. tensor veli palatini
a M. palatoglossus M. uvulae Uvula M. salpingopharyngeus

Dura mater cranialis

Ganglion trigeminale
A. carotis interna
Cartilago tubae
auditivae [auditoriae], Canalis caroticus
Lamina lateralis Fissura
sphenopetrosa

Fig. 9.78 Eustachian tube, Tuba

auditiva [auditoria], right.
a Medial view, connection
N. mandi- between the tympanic cavity
Plexus venosus bularis [V/3] Tuba auditiva and nasopharynx and location
caroticus internus [auditoria] of muscles. [L238]
M. tensor veli palatini
Recessus pharyngeus M. tensor
b, c Cross-sections at the level
Tuba auditiva [auditoria] veli palatini of the lateral portion of the Pars
Cartilago tubae auditivae
M. levator cartilaginea, closed (b) and
[auditoriae], Lamina medialis
M. levator veli palatini veli palatini open (c) tube, the effect of the
b c muscles on the tube is illustrat-
ed by arrows.

Table 9.28 Muscles of the Eustachian tube.

Innervation Origins Attachment Function

M. tensor veli palatini
N. musculi tensoris veli Fossa scaphoidea at the Proc. pterygoideus, Aponeurosis palatina Extends the lumen of the Eustachian tube, tenses the
palatini of the N. mandibu- membrane part of the Tuba auditiva soft palate
laris [V/3]
M. levator veli palatini
Plexus pharyngeus from Lower surface of the Pars petrosa ossis tem- Aponeurosis palatina Extends the lumen of the Eustachian tube, elevates the
N. glossopharyngeus [IX] poralis, Cartilago tubae auditivae soft palate
and N. vagus [X]
M. salpingopharyngeus
Plexus pharyngeus mainly Lower portion of tube cartilage in the area of Cartilago thyroidea, side wall of Closes the tube, raises the pharynx
from the N. vagus [X] the nasopharyngeal space the pharynx

487
9 Head

Vascular, lymphatic and nervous systems [IX]. Autonomic parasympathetic fibres also go through the Plexus
Arteries tympanicus to the Pars ossea. The Pars cartilaginea is parasympa­
The Pars ossea receives blood from the Aa. caroticotympanicae thetically supplied by the Plexus pharyngeus. Sympathetic fibres
(from the A. carotis interna); the Pars cartilaginea is fed via the A. originate in the nerve plexus around the A. carotis interna. The Os­
tympanica inferior from the A. pharyngea ascendens (› Table 9.27). tium pharyngeum tubae auditivae is innervated with parasympa­
thetic fibres of the R. tubarius from the N. glossopharyngeus [IX].
Veins
The venous drainage occurs in the Plexus pterygoideus.
9.5.4 Internal ear
Lymph vessels
Regional lymph nodes are the Nodi lymphoidei retropharyn- The internal ear (Auris interna) is a complex of bony canals and
geales, which drain into the Nodi lymphoidei cervicales anteriores, ­extensions inside the Pars petrosa of the Os temporale (osseous
as well as the Nodi lymphoidei parotidei profundi, which drain labyrinth, Labyrinthus osseus, › Fig. 9.79). Inside is a system of
into the nodi lymphoidei jugulares interni. membranous tubes and vesicles called the membranous labyrinth
(Labyrinthus membranaceus) (› Fig. 9.80). It houses the organ
Innervation for balance and hearing (Organum vestibulocochleare). The tip of
The Eustachian tube is sensitively innervated via the Plexus (nervo- the cochlea is pointed in an anterolateral direction. The semicircu­
sus) tympanicus of the R. tubarius from the N. glossopharyngeus lar canals (Canales semicirculares) are positioned at a 45° angle in

Cochlea

N. cochlearis

Canalis semicircularis
anterior
N. vestibularis
Canalis semicircularis
lateralis

N. vestibulo-
45°
cochlearis [VIII] Canalis semicircularis Fig. 9.79 Inner ear, Auris inter-
posterior na, and N. vestibulocochlearis
[VIII]. View from above, internal
Porus acusticus internus
ear projected in its natural posi-
tion on the temporal bone.

Canalis; Ductus Crista

semicircularis lateralis ampullaris Canalis; Ductus semicircularis anterior
Canalis; Ductus
semicircularis posterior Saccus endolymphaticus;
Ductus endolymphaticus

Macula utriculi

Ampulla
Dura mater

Macula sacculi
Crista ampullaris

Sacculus
Utriculus

Helicotrema

Stapes

Scala vestibuli

Ductus
Ductus cochlearis
utriculosaccularis Fig. 9.80 Membranous laby-
rinth, Labyrinthus membrana-
Fenestra cochleae Scala tympani ceus, right. Longitudinal section
through the temporal bone;
Ductus reuniens Organum spirale [CORTI] frontal view, schematic drawing.
[E402]

488
 9.5 Ear

relation to the main planes of the skull (frontal, sagittal, and hori­ posteromedial and its peak (Apex cochleae) anterolaterally. Thus,
zontal planes)(› Fig. 9.79). the base of the Modiolus lies near the Meatus acusticus internus. In
the Canales spiralis and longitudinalis modioli sits the Ganglion
Osseous labyrinth spirale cochleae with the perikarya of bipolar nerve cells of the N.
The bony labyrinth consists of (› Fig. 9.80): cochlearis (› Fig. 9.81). The Lamina spiralis ossea originates from
• Atrium (Vestibulum) the Modiolus into the cochlear canal. The Ductus cochlearis (part
• 3 bony semicircular canals of the membranous labyrinth) winds around the Modiolus, which
• The bony cochlea is attached to the Lamina spiralis and laterally on the outer wall of
• The internal auditory canal (Meatus acusticus internus) the cochlea. Through this arrangement 2 channels are created (one
The Vestibulum is the starting point for the cochlea and semicir­ above, the Scala vestibuli and one below, the Scala tympani of the
cular canals. It is connected to the tympanic cavity via the oval Ductus cochlearis), which pass through the entire cochlea and
window. connect at the apex via the Helicotrema. The Scala vestibuli starts
The semicircular canals (Canales semicirculares ossei) are divided at the Vestibulum; the Scala tympani leads to the round window
into front/top (Ductus semicircularis anterior), rear (Ductus (Fenestra cochleae) and is separated by a connective tissue mem­
semicircularis posterior) and side (Ductus semicircularis latera- brane from the middle ear. A small channel (Canaliculus cochleae)
lis) semicircular canals. They stretch from the Vestibulum in a pos­ begins close to the round window, passes through the Os tempora­
terosuperior direction. The canals account for approximately two le and opens on the Facies posterior into the posterior cranial fos­
thirds of a circle with one end each beginning at the vestibule and sa. This is a link between the perilymphatic space and subarach­
the other end extended to an Ampulla. Each canal is always per­ noid space (Spatium subarachnoideum).
pendicular to the other two. The internal auditory canal starts at the Porus acusticus internus
The cochlea consists of a canal (Canalis spiralis cochleae), which and continues laterally for around 1 cm. Here it ends in a perforat­
is wound in 2 ½ turns around the cochlear spindle (Modiolus ed bony plate. In the 1 cm long segment the N. facialis [VII] and
­cochleae). It is arranged so that its base (Basis cochleae) is aimed N. vestibulocochlearis [VIII] run (› Fig. 9.79).

N. petrosus major [Radix parasympathica N. facialis [VII], Geniculum

ganglii pterygopalatini] Canalis facialis
Cavitas tympani
Ganglion spirale cochleae
Caput mallei
N. vestibularis
N. cochlearis Chorda tympani
Incus
N. vestibulo-
cochlearis [VIII]
Medulla
oblongata Ampulla
membranacea
anterior

Ampulla
membranacea
lateralis

Utriculus

Ampulla
Sacculus membranacea
N. facialis posterior
Pedunculus [VII] Pars superior
cerebellaris inferior N. vestibularis
N. inter- Meatus Pars inferior
medius acusticus
a Ganglion
internus
vestibulare

Helicotrema

Modiolus cochleae

Scala vestibuli

Ductus cochlearis

Fig. 9.81 Cochlea. [E402]

Scala tympani
a Cochlea together with organ of
equilibrium, N. vestibulocochle-
aris [VIII] and N. facialis [VII],
course into the Pars petrosa of
Lamina spiralis ossea N. cochlearis the Os temporale; view from
b above; Pars petrosa opened. b
Cross-section (diagram). [E402]

489
9 Head

Membranous labyrinth to the Facies posterior of the Pars petrosa, and flows here with the
The membranous labyrinth is a coherent system of canals and bursae Saccus endolymphaticus into the posterior cranial fossa.
within the bony labyrinth and includes (› Fig. 9.80, › Fig. 9.81):
• Ductus cochlearis NOTE
• Sacculus The Saccus endolymphaticus is an epidural enlargement located in
• Utriculus the rear surface of the petrous bone, in which the endolymph
• 3 membranous semicircular canals (Ductus semicirculares) drains into the lymph fissures of the hard meninges.
The 3 membranous semicircular canals are in contact with the
Utriculus. Each semicircular canal forms an extension at the cross­
ing to the Utriculus (Ampulla membranenacea). The upper and Clinical remarks
posterior semicircular canals unite to form a common limb (Crus The triad of seizure-like dizziness attacks, unilateral hearing
commune). Each ampulla contains sensory epithelium (Crista am- loss and unilateral tinnitus is referred to as MENIÈRE's syn-
pullaris, › Fig. 9.82). drome. A reabsorption defect in the endolymph, with disten-
The membranous labyrinth is filled with sodium-poor and potassi­ sion of the membranous labyrinth (Hydrops cochleae) is dis-
um-rich endolymph, (mainly formed in the Stria vascularis of the cussed as the cause. Pathological changes to the sensory
cells are the result.
the Ductus cochlearis) and separated from the periosteum of the
walls of the bony labyrinth by perilymph. It is not directly adjacent
to the bony labyrinth, but is separated from it by the perilymphatic
space filled with perilymph (Spatium perilymphaticum). It is Sensory cells
thought that the perilymphatic space is formed by epithelial-like The sensory cells of the vestibular labyrinth filled with endolymph
cells, which are adjacent to the bone and the membranous laby­ sit as Macula sacculi in the Sacculus (registration of vertical linear
rinth. The perilymph originates as a exudate of perilymphatic cap­ acceleration), as Macula utriculi in the Utriculus (registration of
illaries and is probably reabsorbed in the region of postcapilliary horizontal linear acceleration) and as Cupulae in the Cristae ampul­
venules of the perilymphatic space or reaches the Liquor cerebro­ lares of the three semicircular canals (registration of rotational accel­
spinalis (CSF) via the Aqueductus cochleae, a tube located in the eration) (› Fig. 9.80). The sensory cells of the vestibular organ each
bony Canaliculus cochleae. The membranous labyrinth is func­ possess a long kinocilium and stereocilia which extend into a gelati­
tionally divided into a vestibular and a cochlear section. nous substance (Cupula) (› Fig. 9.82). Movements of the Cupula
lead to bending of the sensory cell processes. This stimulus leads to
Organ of equilibrium the synaptic activation of afferent fibres of the N. vestibularis.
Structure
The vestibular labyrinth includes the Sacculus and Utriculus Hearing organ
structures positioned in the Vestibulum, the Ductus utriculosaccu­ Structure
laris, the three semicircular canals and the Ductus endolymphati­ The cochlear labyrinth is formed from the Ductus cochlearis. The
cus (› Fig. 9.80). The Utriculus is larger than the Sacculus. It is vestibular and cochlear labyrinths communicate via the Ductus
located in the back of the upper part of the Vestibulum. All 3 semi­ reuniens (› Fig. 9.80).
circular canals lead into it with both their initial as well as their The Ductus cochlearis winds around the Modiolus. It is attached to
ampullar part. The Sacculus lies at the lower front in the Vestibu­ the Lamina spiralis and lateral to the outer wall of the cochlea and
lum. The Ductus cochlearis flows into it. The Ductus utriculosac- divides the Canalis spiralis cochleae into 3 spaces (› Fig. 9.81):
cularis connects the Sacculus and Utriculus. The Ductus endo- • the Scala vestibuli is filled with perilymph (vestibular canal),
lymphaticus, originates approximately in the middle which after a which extends from the Vestibulum to the Helicotrema, lies
short course through the Vestibulum enters the Aqueductus ves­ completely at the top and is separated at the bottom by the
tibuli (part of the bony labyrinth), passes through the Os temporale Membrana vestibularis from

Perilymphatic space Inner hair cell Ductus cochlearis

Inner phalangeal
Interdental cells
Endolymphatic space Outer hair cells
cells Inner NUEL's space
External tunnel
limit cell Membrana
Cupula tectoria
External border cell
Ampoulla HENSEN's
of the semi- cells
Sulcus
circular Limbus
spiralis
spiralis TUNNEL OF CORTI
canal internus Basal lamina
Sensory cell
(hair cell)
Lig. spirale
CLAUDIUS's
cells
Support cells
Nerve Inner Vas BOETTCHER's
Tympanal
a b column cell spirale cells
sheet layer
Lamina Outer Outer
Epithelium of the
Nerve spiralis column cell phalangeal Membrana Scala tympani
fibre ossea cells basilaris
Scala tympani

Fig. 9.82 Structure of the sensory cell-bearing organs (diagram). a Structure of the Crista ampullaris. b Structure of the Organum spirale
(organ of CORTI). [L141]

490
 9.6 Nose

• the Ductus cochlearis, filled with endolymph, which is delimit­ (N. vestibularis). The N. cochlearis comes in a slightly curved course
ed by the basilar membrane from from the cochlea. The ganglion cells (Ganglion spirale) and fibres
• the Scala tympani filled with perilymph (tympanic stairs), of the N. cochlearis lie in cavities of the bony Modiolus. They join
which extends from the Helicotrema to the round window in the at the base of the Modiolus to the N. cochlearis. The N. vestibu-
medial wall of the tympanic cavity. laris consists of a Pars superior from the front and lateral semicircu­
The Scala vestibuli and Scala tympani interconnect at the Helico­ lar canals as well as Sacculus and a Pars inferior from the Utriculus
trema. and rear semicircular canal. The perikarya of the neurons of both
sections are combined into the Ganglion vestibulare. The N. ves­
Sensory cells tibularis and N. cochlearis join together in the temporal bone. Be­
The floor of the Ductus cochlearis is the basilar membrane (Lami­ fore leaving the Porus acusticus internus, the N. facialis [VII] and
na basilaris), which carries the auditory organ (Organum spirale, its intermediate part lie on it. As N. vestibulocochlearis [VIII] they
organ of CORTI). The organ of CORTI (› Fig. 9.82b) is the actual pass through the posterior cranial fossa and enter between Pons
auditory organ. Auditory sensory cells (internal and external hair and Medulla oblongata into the lateral surface of the brain stem.
cells) are located here strictly organised together with supporting
cells on the basilar membrane and are covered by a gelatinous
membrane (Membrana tectoria). The organ of CORTI extends
Clinical remarks
over the whole length of the Ductus cochlearis. The hair cells are The acoustic neurino (Vestibularis schwannoma) is a benign
very complexly innervated afferently and efferently. tumour of the SCHWANN cells (› Chap. 9.3.8).

Clinical remarks
Hair cell damage, e.g. if the music heard was too loud or after Sound conduction
an explosion (acoustic shock), are very commonly associated Sound waves enter via the external ear (auricle and external acous­
with tinnitus . The term Tinnitus aurium (ringing of the ears) or tic canal) and are transmitted via the tympanic membrane and the
tinnitus for short, refers to a symptom in which the affected auditory ossicular chain via the stirrup foot plate to the perilymph.
person perceives sounds that have no perceptible external
This produces wave movements that migrate along the walls of the
cause to other persons. In industrialised countries tinnitus is
the most frequent common illness after obesity with 22 % Ductus cochlearis (especially the basilar membrane) (migrating
­affected in its acute form (up to 3 months) and with 4 % af- waves). This results in shearing movements of the organ of CONTI.
fected in its chronic form. The stereocilia of the inner hair cells are bent (deflexion). These
An acute hearing loss is a sudden hearing loss (up to deaf- biomechanical events are converted by the sensory cells into recep­
ness) with no identified cause. It is delimited from hearing tor potentials (mechanoelectrical transduction).
disorders with an identifiable cause. The diagnosis is a senso-
rineural hearing loss. The course of the hearing loss is very
variable, but a high spontaneous resolution rate is known. Clinical remarks
There are a number of therapies for conductive hearing loss;
the most common is an infusion therapy. A cholesteatoma (syn.: pearl tumour in the ear; expanding
growth of multi layered keratinizing squamous epithelium into
the middle ear with chronic putrid inflammation of the middle
ear), acute otitis media, mastoiditis, and trauma to the skull
can result in a labyrinthitis with dizziness, stimulus or nystag-
Vascular, lymphatic and nervous systems
mus (trembling of the eyes, uncontrolled rhythmic movements
Arteries of the eyes). Entry ports for infectious agents are the round
The bony labyrinth is supplied via the A. tympanica anterior from and oval windows, gaps in the bony labyrinth (after injury and
the A. maxilliaris, the A. stylomastoidea from the A. auricularis bone erosion by infected pneumatic areas), or inflammation
posterior and the R. petrosus from the A. meningea media. The ascending via nerves and vessels, Canaliculus cochleae or
complete blood supply to the membranous labyrinth takes place Canaliculus vestibuli to the meninges. Consequences range
from the branches of the A. labyrinthi, which divide into a R. co­ from sensorineural hearing loss to deafness and destruction
of the vestibular organ.
chlearis and 1 or 2 Rr. vestibulares; the Vv. labyrinthini drains the
blood into the Sinus petrosus inferior or Sinus sigmoideus. The A.
and V. inferior anterior cerebelli often project a few millimetres
into the internal auditory duct and emit here the A. and Vv. laby­ Stimulus processing
rinthi supplying the labyrinth with blood (Cave: terminal artery). The stimulus processing is presented in › Chap. 13.4.
Rarely does the A. labyrinthini come directly from the A. basilaris.

Clinical remarks 9.6 Nose

Friedrich Paulsen
Thrombotic closure of the A. labyrinthi or its afferent branch-
es is associated with balance disorders and hearing loss, be-
cause the A. labyrinth is a terminal artery. Skills
After processing this chapter, you should be able to:
Innervation • name the structures of the external nose, the bony and carti-
laginous structure of the nasal skeleton, the boundaries of
The innervation takes place via the N. vestibulocochlearis [VIII]
the nasal cavities and their distension
(often clinically referred to as N. statoacusticus) (› Fig. 9.81a). It
bears sensory fibres for the ears (N. cochlearis) and the balance

491
9 Head

• name the location, bony limits, openings and topographic 9.6.1 Overview

relation of the nasal sinuses to other structures
• know and be able to demonstrate the blood supply and in- Respiratory organs
nervation of the entire nose with respect to its clinical rele- The respiratory tract serves as gas transport and exchange between
vance
the air and blood. It is divided into respiratory organs that conduct
• describe the regional lymph flow
• describe the general development of the nose and nasal si- air and exchange air. The air conducting respiratory organs are di­
nuses vided into the upper respiratory tract (nose, throat) and lower re­
spiratory tract (larynx, trachea, bronchial tree); the junction be­
tween the two is formed by the entrance to the larynx. The gas ex­
change (external breathing) is carried out in the lungs (Pulmones).
Clinical case • Respiratory tract
• Air conducting respiratory organs
Case study
– Upper respiratory tract
A 22-year-old man is brought to the emergency surgery depart- – Nose (nose)
ment of a large hospital at 3 o'clock in the morning by 5 pass-
ers-by. People say that they saw how the young man was beat-
– Throat (pharynx)
en by 3 other men. In the process, he received a fist blow to – Lower respiratory tract
the head. He was also allegedly kicked several times when on – Larynx
the ground. Only the shouts of the passers-by and their com- – Trachea
mitted intervention caused the 3 men to leave him and flee. – Bronchial tree (Bronchi)
As the emergency department was nearby, they quickly linked • Gas exchange respiratory organs
arms with him and brought him in themselves. – Lungs (pulmones)
Initial examination
Upper respiratory tract
The young man is in a state of shock and appears slightly dis-
orientated when first questioned, but is responsive. His nose The upper respiratory tract includes the nose (Nasus) and throat
appears sunken and unnaturally broadened. The nose is (pharynx). The throat belongs to the aerodigestive tract, which
somewhat askew. There is also dried blood under the nose means that it is used both for the transport of gas and food. Its up­
and chin. His white t-shirt is stained with blood. On the right per section (nasopharynx) connects to the nose, transports respira­
side the eye is severely swollen and protruding, the eyelids tory gas, so it is purely an airway, the middle portion (oropharynx)
can no longer be closed properly and are under tension. The has a dual function of gas and food transport. At the entrance to
initial investigation shows a nasal fracture and a pronounced
the larynx the respiratory and gastric tracts divide again. The air is
Protrusio bulbi on the right side. The patient can no longer
properly close and open his eye on the affected side. In addi- fed to the lower respiratory tract, starting with the larynx, liquids
tion, the man displays abrasions on the right temple and has and food components are forwarded in the lower section of the
several bruises on the left arm and on the back. pharynx (laryngopharynx).

Further diagnostics Nose

An emergency so-called trauma spiral (a full-body CT) is con- The nose is the entrance to the respiratory tract. It is divided into
ducted, which includes a CT scan of the head (CCT). With the the externally visible external nose (Nasus externus) and the nasal
exception of the bruising there are no injuries to the internal
cavities (internal nose, Cavitates nasi). The two nasal cavities are
body or neck organs. The CCT shows a nasal framework fracture
and air inclusions in the area of the orbita tip as well as bone openly connected to the paranasal sinuses (Sinus paranasales) as
fragments of the Lamina orbitalis in the cavities of two rear eth- well as the upper portion of the pharynx (nasopharynx).
moidal cells. Air is passing in this way from the ethmoidal cells Function of the nose is, apart from air conduction (aerodynamics)
into the orbita tip and has evoked the Protrusio bulbi. An injury mechanical cleaning, warming and saturation (climatisation) of the
of the dura mater is not detectable. The attending eye doctor respiratory air and the immune defence of pathogens. On the roof
establishes a significant vision reduction of 10 %. of the nose is the olfactory field, which controls the inhalated air
Treatment (ability to smell). Nose-specific reflexes (e.g. sneezing) serve to
protect the respiratory organs. In addition, the nasal cavities are
Following diagnosis, the patient is relocated in the same night
to the ENT clinic. Due to the extensive Protrusio bulbi, the involved in phonation as a resonance space and formation site for
­attending ENT doctor conducts a lateral canthotomy on the right consonants.
eye edge with the patient under local anaesthesia. In doing
so, all structures in the lateral eye angle (skin, Lig. palpebrale
laterale, Septum orbitale) are cut with scissors (cantholysis) 9.6.2 Development
while protecting the eyeball. This results in a pressure relief in
the posterior compartment of the Orbita, which relieves the
Nose
structures (especially the N. opticus). In the same session, the
nasal framework fracture is reconstructed. The patient is ad- The nasal development belongs to the facial development and is
ministered antibiotics intravenously and also receives a corti- closely associated with the palate and oral cavity development. Be­
sone bolus. tween the 4th and 5th embryonic weeks the ectoderm consolidates
on the supraorbital ridge near the Stomatodeum to the olfactory
Course placodes. They submerge into the depth and become olfactory pits
The next day the Protrusio bulbi begins to recede, the air pock- and olfactory tubes, from which the nasal cavities later form. The
ets in the Orbita tip are rapidly rebsorbed over a short period edges of the pits are raised to a medial and a lateral nasal bulge. The
of time (hours to days), the vision of the patient increases
two medial nasal bulges, which are separated by the Area interna­
again and on day 3 after surgery reaches 100 %.
salis, grow out and down until they come in contact with the upper
jaw bulge. Here they form the middle part of the upper lip, the

492
 9.6 Nose

philtrum, the membranous part of the nasal septum and the pri­ concha (Concha nasalis suprema) is also possible. Initially, the
mary palate. The two lateral nasal bulges differentiate into the na­ skeleton of the nasal conchae is still cartilageous and is replaced in
sal wings. Right and left olfactory tubes grow on the roof of the pri­ the 5th fetal month by bone.
mary oral cavity, stay for a short time separated by an epithelial
plate (HOCHSTETTER's epithelial wall, epithelial choanal mem­ NOTE
brane, Membrana bucconasalis) and then gain connection by dis­ In the context of nasal development a tube-like connection forms
solution of the membrane in the 7th week to the primary oral cavi­ between the nasal septum and nasal floor, which sometimes ap-
ty. The two connections are referred to as primary choanae; the pears as a blind sack, Ductus incisivus. This is the tube around the
remaining area between external and internal openings are re­ vomeronasal organ (JACOBSON's organ, Organum vomeronasale),
which appears in humans as a rudimentary sensory organ. It be-
ferred to as primary palates; however, it is not identical with the longs to the olfactory system in many animals and has key features,
expansion of the later premaxillary segment. The further develop­ e.g. when looking for a partner, for food, for individual recognition
ment of the nasal cavities is linked to the development of the sec­ or the identification of territorial markings. Pheromones play a
ondary palate. On the roof of the primary oral cavity behind the ­crucial role in the function. Remnants of the vomeronasal organ are
primary palate the nasal septum is formed. It grows as a sagittal detectable in humans until after birth.
plate vertically downwards, and meets the two palatal processes in
the transverse level from left and right from the side wall of the pri­
mary oral cavity growing to the centre line, with which it fuses Paranasal sinuses
forming a seam (Raphe palatini). The abutting palatal processes The paranasal sinuses grow as early as the foetal period as small ep­
become secondary palates. At the point where the palatal process­ ithelial buds of the nasal cavities in the mesenchyme of the sur­
es and nasal septum meet on the V-shaped tapered primary palate, rounding cranial bone. They reach their full development only af­
a canal (Ductus nasopalatinus) forms. The Canales incisivi and ter completion of growth and can expand even further in the
the Foramen incisivum result later in the upper jaw from the canal. course of life. Their individual varying development is extremely
closely linked to the development of the dentition and is associated
NOTE with the formation of the face. An exception is the Sinus sphenoi­
The primary palate becomes a premaxilliary section of the defini- dalis. It develops as a detachment from the nasal cavity by creating
tive palate. The incisive bone (Os incisivum, ‘GOETHE's bone’) a Concha sphenoidalis. Around the 4th year of age the Sinus sphe­
emerges from it with the incisors. noidalis grows into the sphenoidal body. The expansion is just as
variable as for other sinuses.
The development of the secondary palate leads to the separation of
nasal and oral cavity; the development of the nasal septum sepa­
rates the inner nose in 2 separate cavities, which run dorsally via a 9.6.3 External nose
Meatus nasopharyngeus (secondary or definitive choane) into the
nasopharynx. On the external nose (Nasus externus, › Fig. 9.83) a distinction is
made between:
• The nasal root lying above the philtrum (Sulcus nasolabialis)
Clinical remarks (Radix nasi)
Cleft formation of the palate, upper jaw and face can be at- • The bridge of the nose ( Dorsum nasi)
tributed to inadequate mesenchymal proliferation and thus • The left and right ala of the nose (Alae nasi dextra and sinistra)
non-fusion of nose and jaw bulges and can be very differently
pronounced. In the case of mild forms (‘cleft lip’) only the up-
per lip is affected on one or two sides. Severe forms continue Linea
occipitally as cleft lip and palate (frequency 1:2,500 births). frontomentalis
Isolated cleft palates are the result of a non-fusion of the pala-
tal process (rear cleft palate) or between palatal processes
Glabella
and primary palate (front cleft palate). Combinations are pos-
sible. The mildest form of a rear cleft palate is an uvula bifida Nasion (125°)
(cleaved uvula). The causes of the palate, jaw and maxillofa- Dorsum nasi
cial clefts are manifold. (bone)

Dorsum nasi
The Vestibulum nasi emerges from the material of the nasal tubes, (cartilage)
a part of the Cavitas nasi and the Regio olfactoria. The residual part Apex nasi Ala nasi
originates from the material of the primary oral cavity. The mesen­ Columella Sulcus alaris
chyme that surrounds the secondary nasal cavity, differentiates to
Nasolabial fold
the cartilaginous nasal capsule. It ossifies partly enchondrially, par­ Nasolabial angle
tially desmally. The Cartilago septi nasi remain unossified with the (90–115°)
Proc. posterior as well as the cartilage of the outer nose. While the
nasal septum persists as a smooth wall, the surface of each lateral
nasal wall increases by developing the nasal conchae (Conchae
nasi), which protrude as epithelial bulges (Turbinalia) into the nasal
cavity lumen. Usually 3 nasal conchae each differentiate, which are
referred to as maxilloturbinal (Concha nasalis inferior, inferior na­
sal concha), ethmoturbinal I (Concha nasalis media, middle nasal
concha) and ethmoturbinal II (Concha nasalis superior, upper na­ Fig. 9.83 External nose with aesthetic nose angles and points of ref-
sal concha). As in the animal world the development of a 4th nasal erence. [L126]

493
9 Head

• The tip of nose (Apex nasi) Clinical remarks

• The membranous portion of the nasal septum (Pars membrana­
The skeleton of the nose is of great significance in nasal plastic
cea septi nasi, Columella, Pars mobilis septi)
surgery. Here, special names have prevailed (› Table 9.29).
• The nasal orifices (Nares)
The external nose has a great impact on the shape of the face.

Skeleton Musculature
Mechanical resilience is achieved through a skeletal system of hya­ The external nose is moved by multiple facial muscles (› Table 9.30,
line cartilage and connective tissue, which is attached to the bony › Fig. 9.23), allowing for control of the width of the nose opening.
nose pyramid (nasal scaffold consisting of the Os frontale, Os na­ For the innervation of the muscles › Table 9.10, for the attach­
sale and Proc. frontalis of the Maxilla). The Ossa nasalia are con­ ment › Table 9.8.
nected via the Sutura internasalis and together form with the Inci­
sura nasalis and the Proc. palatinus of the Maxilla, the outer bony
nasal aperture (Apertura piriformis).
Clinical remarks
The movable cartilaginous proportion (› Fig. 9.84) consists on Nothing characterises the physiognomy of the face as much as
each side of: the nose. Nose deformities (e, g. hump nose, saddle nose,
• The triangular cartilage (Cartilago triangularis, Cartilago nasi nasal tilted position) are therefore not only noticeable, but
lateralis, lateral cartilage) can also refer to acute or chronic diseases and injuries.
Through its exposed location, benign tumours may occur on
• The nose tip cartilage (Cartilago alaris major, wing cartilage)
the external nose (e.g. rhinophyma) and malignant tumours
• Small cartilage plates (Cartilagines alares minores and Cartilag­ (e.g. basal cell carcinoma, spinocellular carcinoma).
ines nasi accessoriae)
The wing cartilage forms with a narrow Crus mediale (nose bridge)
and a varyingly broad Crus laterale (nostrils) the shape of the nos­
tril. The cartilaginous nasal septum begins between the wing carti­
Table 9.29 Descriptions in nasal plastic surgery.
lages (Cartilago septi nasi, › Fig. 9.85). The cartilage-free areas are
filled with solid connective tissue, which connects the cartilage to Term Explanation
each other and to the bone. Supra-tip area The bridge of the nose just above the nose tip
Weak triangle The region of the dorsum of the nose just above the nose tip is
formed only by the nasal septum
Sutura frontonasalis
Keystone area Overlap of the lateral cartilage through the Os nasale
Sutura Soft triangle Skin area at the top edge of the nostril, close to which the Crus
nasomaxillaris Sutura internasalis mediale bends into the Crus laterale (the cartilage-free field
consists only of a skin duplicature)
Os nasale Columella The front section of the nasal septum between nose tip and
philtrum
(Cartilagines
nasi laterales)
Maxilla,
Proc. frontalis Table 9.30 Muscles of the external nose.
Cartilago alaris
major, Crus laterale Muscle Function
M. nasalis, Pars alaris (M. dilatator) Extends the nostrils
Cartilagines
alares minores M. nasalis, Pars transversa Narrows the nostrils
Cartilago alaris (M. compressor)
major, Crus mediale
Cartilago septi nasi M. depressor septi nasi Moves the nose downwards
M. levator labii superioris alaeque nasi Raises the nasal wing
Fig. 9.84 External nasal skeleton. Right frontal view.

Sinus frontalis
Lamina and Foramina cribrosa
Sinus sphenoidalis Os ethmoidale,
Lamina perpendicularis

Cartilago septi nasi

Cartilago septi nasi,

Proc. posterior

Cartilago alaris major,

Crus mediale
Vomer
Spina nasalis anterior
Fossa pterygoidea
Maxilla, Proc. palatinus
Hamulus pterygoideus

Sutura palatina transversa Fig. 9.85 Nasal septum (Sep-

tum nasi). View from the right

494
 9.6 Nose

9.6.4 Nasal cavities • from the oral cavity by the hard palate

• from the base of the skull bones by parts of the Ossa frontalia,
The paired nasal cavities with the pharynx belong to the upper re­ ethmoidalia and the Os sphenoidale
spiratory tract and contain the olfactory fields. Each nasal cavity • each other by the nasal septum (Septum nasi)
(Cavitas nasi) is a conical space, its base forms the nasal floor and • latteraly from the Orbitae and the paranasal sinuses
its tip forms the nasal cavity roof. The front and narrower sections At the rear they continue via a choane into the nasopharynx (epi­
of each nasal cavity are enveloped by the skeleton of the outer nose, pharynx).
the wider, rear parts are located centrally in the skull. The inhalated
air flows through the nasal orifices (Nares) into the nasal atrium Floor of the nasal cavity
(Vestibulum nasi). The border to the respective nasal cavity is the The nasal cavity floor (› Fig. 9.85, › Fig. 9.86, › Fig. 9.87) is
Limen nasi which is raised by the Crus laterale of the wing carti­ slightly concavely curved, smooth and much wider than the nasal
lage. The Limen nasi shapes together with the Crus mediale of the cavity roof. It is created:
wing cartilage and a floor bar of the Maxilla, the inner nasal valve • at the front by the cartilaginous nasal skeleton of the outer nose
(narrowest point of the nose for the air flow). Here, the inhalated • from the surface anatomy of the Proc. palatinus of the Maxilla
air is swirled and distributed in the respective nasal cavity – im­ (including the Os incisivum [intermaxillary bone])
proving the contact between air and mucosa (diffusor effect). Each • the Lamina horizontalis of the Os palatinum
nasal cavity has 4 walls: a floor, roof and a medial and a lateral na­ The nasal septum which lies in the midline at the base of the nose,
sal cavity wall (› Fig. 9.85, › Fig. 9.86, › Fig. 9.87). The nasal is attached over the protruded Spina nasalis anterior and the Crista
cavities are separated: nasalis anterior. The nasal orifices open at the front on the floor.

Sinus frontalis Hiatus maxillaris

Apertura sinus frontalis

Apertura sinus sphenoidalis
Concha nasalis superior
Sinus sphenoidalis
Os lacrimale
Foramen
Proc. uncinatus sphenopalatinum

Hiatus semilunaris Os palatinum,

Crista ethmoidalis
Meatus nasi
medius Concha nasalis inferior,
Proc. ethmoidalis
Meatus nasi Os palatinum,
inferior Lamina perpendicularis

Spina nasalis anterior Spina nasalis posterior

Os palatinum,
Canalis incisivus Lamina horizontalis
Fig. 9.86 Lateral nasal wall
without middle nasal concha.

Sinus frontalis Cellulae ethmoidales

Crista galli

Sinus frontalis
Ala minor
Cellulae ethmoidales
Os sphe-
anteriores
noidale
Ala major,
Facies orbitalis
Bulla ethmoidalis

Concha nasalis media

Os palatinum
Sinus maxillaris

Sinus maxillaris
Concha nasalis inferior
Vomer

Maxilla, Proc. alveolaris Maxilla,

Dens molaris Proc. palatinus

Fig. 9.87 Frontal section through the viscerocranium/facial skeleton. Right: representation of the bony topography, left: orifice of the parana-
sal sinuses: green = frontal sinus, purple = anterior ethmoidal sinuses, blue = maxillary sinus (arrows).

495
9 Head

Concha nasalis superior

(4th basal lamella)

Hiatus semilunaris
Bulla ethmoidalis
Proc. uncinatus (2nd basal lamella)

Attachment and position of the Concha

Concha nasalis inferior nasalis media (3rd basal lamella; red)
(1st basal lamella)

Fig. 9.88 Lateral nasal wall with

contour of the middle nasal con-
cha (red).

The openings of the Canales incisivi are located near the nasal sep­ Clinical remarks
tum right behind the nasal atrium at the start of the nasal cavities.
The Canales incisivi flow together in the unpaired Foramen inci­ Slight variations of the nasal septum wall from the median oc-
sivum in the oral cavity. cur regularly and are without functional importance. You can
usually already tell whether the nasal septum is somewhat
crooked by feeling the nasal bridge of the external nose. A
Roof of the nasal cavity more pronounced nasal septum deviation can hinder nasal
The nasal cavity roof (› Fig. 9.85, › Fig. 9.86, › Fig. 9.87) is breathing and restrict the ability to smell.
narrow and stands in the centre, which is formed by the Lamina After traumatic effects on the external nose or in the case of
cribrosa of the Os ethmoidale at the highest point. In front of the coagulation disorders there may be a nasal septum haemato-
Lamina cribrosa the roof drops off in the direction of the nasal ori­ ma, which requires immediate relief by puncture and, if neces-
fices and is formed here from: sary, incision and nasal packing, otherwise the septal carti-
lage is in danger of sinking.
• the Spina nasalis of the Os frontale
Rhinitis (inflammation of the nose, nasal catarrh, rhinitis, co-
• the Ossa nasalia ryza) is an acute or chronic nasal inflammation by infectious,
• the Procc. laterales of the Cartilago septi nasi allergic or vascular mechanisms. It is most common in the
• the Cartilagines alares of the external nose context of a common cold.
At the rear the roof lowers over the Recessus sphenoethmoidalis to
the respective choane and is formed by the front surface of the
Corpus ossis sphenoidalis. The olfactory fields lie directly below
the Lamina cribrosa on the nasal cavity roof. Lateral nasal cavity wall
The lateral nasal cavity wall of each nasal cavity is complexly
Medial nasal cavity wall structured (› Fig. 9.86, › Fig. 9.87, › Fig. 9.88). It consists, like
The basis of the medial nasal cavity wall is the nasal septum (Sep­ the nasal septum of bone, of cartilage and connective tissue. Only
tum nasi) (› Fig. 9.85, › Fig. 9.87), a Lamella standing vertically the general structure is described here. Deviations are common.
in the midsagittal plane made of connective tissue, cartilage and The bones involved in the development are:
bone that separates the two nasal cavities from each other. The na­
sal septum consists of
• Pars membranacea – in the nasal atrium mainly of dense con­ Plexus
nective tissue (nose bridge, Columella) cavernosus

• Pars cartilaginea – from the frontal Cartilago septi nasi and the
variable Proc. posterior of the Cartilago septi nasi continuing
from septum cartilage dorsally between Lamina perpendicularis
Meatus nasi inferior
ossis ethmoidalis and vomer, which slowly ossifies from dorsal
to rostral with increasing age Concha nasalis inferior
• Pars ossea – from vomer and Lamina perpendicularis ossis eth­
moidalis as well as a small part from the Ossa nasalia, the Spina
Glandulae nasales
nasalis superior ossis frontalis, the Spina nasalis anterior, the
Crista incisiva maxillae, the Crista nasalis maxillae, the Crista
nasalis ossis palatini and the Crista sphenoidalis

Fig. 9.89 Cavernous body tissue at the nasal septum (left) and on
the lower nasal muscle (Concha nasalis inferior).

496
 9.6 Nose

Sinus frontalis Recessus

sphenoethmoidalis
Concha nasalis
superior Opening of a rear
ethmoid bone cell
Hiatus semilunaris
Sinus
Proc. uncinatus sphenoidalis
Fig. 9.90 Confluence of the
paranasal sinuses and the Duc-
tus nasolacrimalis at the lateral
Bulla ethmoidalis nasal wall. Brown = Ductus
Sinus maxillaris, nasolacrimalis; green = frontal
the openings are usually covered sinus; purple = anterior eth-
by mucous membranes moidal cells; blue = maxillary
Concha nasalis
inferior sinus; orange = posterior eth-
moidal cells; red = sphenoid
sinus (arrows).

• At the front: concha lies above the lower nasal concha, the head is located ap­
– The Os nasale proximately 1 cm further dorsal, the tail also ends at the level of the
– The Facies nasalis maxillae respective choane. The upper nasal concha is in relation to the
– The Os lacrimale middle and lower conchae significantly smaller. Its head begins ap­
• In the middle: proximately at the height of the middle area of the Lamina cribro­
– The Corpus maxillae with its Hiatus maxillaris sa. Its tail falls caudally before the bony front wall of the Sinus
– The Os ethmoidale (with the thin Proc. uncinatus, the wall to sphenoidalis and extends to the upper section of the respective
the anterior and posterior ethmoidal cells [Cellulae ethmoid­ choane. Above the choanae the inspired breath extends into the
ales anteriores and posteriores]) as well as the top and the Meatus nasopharyngeus.
middle nasal concha (Conchae nasales superior and media) The most complex structure of the lateral nasal wall (osteomeatal
protruding into the nasal cavity complex,› Table 9.31) is the Hiatus maxillaris lying beneath the
– The inferior nasal concha (Concha nasalis inferior) as an in­ middle nasal concha (› Fig. 9.86, › Fig. 9.88, also › Fig. 9.91).
dependent bone. It is only partially closed by 3 structures:
• At the rear:
– The Lamina perpendicularis of the Os palatinum
– The Lamina medialis of the Proc. pterygoideus ossis sphenoi­
dalis
In the area of the outer nose, the lateral wall (Proc. lateralis of the
Ductus nasolacrimalis in Cavitas nasi
cartilago septi nasi, Crus mediale of the ala major and Cartilagines Canalis nasolacrimalis
minores) is formed from cartilage as well as from connective tissue. Cartilago
The nasal conchae, per nasal cavity a Concha nasalis superior, me­ septi nasi
dia and inferior, protrude from their attachment to the lateral nasal
wall in the respective nasal cavity. They divide the nasal cavity into Proc. uncinatus
4 air ducts. The upper canal is located directly below the olfactory Concha nasalis
field, the other 3 form the nasal passages (Meatus nasi superior, Infundibulum ethmoidale media, vertical
part of the 3rd
medius and inferior), which each run below the corresponding na­ Hiatus semilunaris basal lamella
sal concha. The bony parts of the nasal conchae are covered by a inferior
cavernous body tissue (› Fig. 9.89), which when swollen only
Bulla ethmoidalis Bony nasal
leaves narrow spaces between themselves and the nasal septum
septum
(collectively referred to as the Meatus nasi communis). Depending Hiatus semilunaris
superior
on the particular state of swelling, approximately 35% of the nasal
mucosa volume is composed of vascular plexus. The cavernous body
tissue is most pronounced on the lower and middle nasal concha
(as well as in the nasal septum at KIESSELBACH's area, see be­
low). Between the vessels of the cavernous body tissue there are
large quantities of serous glands, which moisten the respiratory cil­
iated epithelium covering the muscles. In approximately 80 % of
people, there is a nasal cycle, i.e. the nasal mucosa of both nasal
Concha nasalis media,
sides swells and subsides for 2-7 hours with alternating nasal resis­ horizontal part of the
tance during breathing at a ratio of 1:3, but with the same overall 3rd basal lamella
resistance. The inferior nasal concha is the largest nasal concha. Its
head lies approximately 1 cm behind the nasal valve and its tail Fig. 9.91 Horizontal section through nasal septum and osteomeatal
ends approximately 1 cm in front of the entrance into the Tuba au­ complex of the left side of the nose just above the inferior nasal con-
ditiva at the level of the corresponding choane. The middle nasal cha. [L126]

497
9 Head

Table 9.31 Clinical terminology of the lateral nasal cavity wall and Table 9.32 Confluence points of the nasolacrimal ducts and of the
the paranasal sinuses. paranasal sinuses.

Term Explanation Lower nasal Middle nasal Upper nasal

passage passage passage
Agger nasi An anterior ethmoidal cell in front of and above the attach-
ment of the middle nasal concha with close topographical Ductus nasolacrimalis x
relationship to the Ductus nasolacrimalis
Sinus frontalis X
Atrium meatus Region before the middle nasal passage above the head of
Cellulae ethmoidales X
medii the inferior nasal concha
anteriores
Bulla ethmoi­ Anterior ethmoidal cell above the Hiatus semilunaris, which
Cellulae ethmoidales X
dalis very regularly develops, but can also be missing
posteriores
Fontanelle Accessory opening in the medial maxillary sinus wall that is
Sinus maxillaris X
covered by mucous membrane
Sinus sphenoidalis x
Basal lamellae Lamellae, which pass through the ethmoid bone as embryolog-
(› Fig. 9.88) ical residues. Four basal lamellae (BL) can be distinguished:
• BL 1: Proc. uncinatus
• BL 2: Bulla ethmoidalis
• Below the lower nasal concha:
• BL 3: Concha nasalis media – The lacrimal nasal passage (Ductus nasolacrimalis) confluenc­
• BL 4: Concha nasalis superior es at the lateral nasal cavity wall of the Meatus nasi inferior via
HALLER's cells An ethmoidal cell that pneumatises the lower orbital wall
the Apertura ductus nasolacrimalis (HASNER's valve) under
(infraorbital cell) the front edge of the inferior nasal concha. In the mucosa of
Maxillary hiatus A large opening of the Sinus maxillaris into the nasal cavity,
the lower nasal duct there is often a mucosal groove dorsally
which is partially closed by the Proc. uncinatus of the Os eth- aligned from the aperture that corresponds to the flow of se­
moidale and mucous membranes cretions. The Ductus nasolacrimalis is situated in a bony canal
Hiatus semi­ A crescent-shaped and up to 3 cm wide cleft between the Bul-
in the lateral nasal cavity wall formed by the Os lacrimale and
lunaris la ethmoidalis and the upper free margin of the Proc. uncina- the Maxilla, which runs from cranial to caudal in front of the
tus; the Hiatus semilunaris provides access to the Infundibu- head of the middle nasal concha and under the head of the in­
lum ethmoidale ferior nasal concha. Dorsally the canal borders on the maxil­
Infundibulum A deepening behind the Hiatus semilunaris, which lies lary sinus.
ethmoidale between the Proc. uncinatus and the Bulla ethmoidalis • Below the middle nasal concha:
ÓNODI-GRÜN- A posterior ethmoidal cell which bulges backwards over the – The frontal sinus (Sinus frontalis) directs its secretions via the
WALD cells Sinus sphenoidalis Ductus nasofrontalis and the Infundibulum ethmoidale to the
Osteomeatal Umbrella term for the complicated anatomy of the Hiatus anterior, cranial area of the Hiatus semilunaris.
complex semilunaris and its surroundings – The anterior ethmoidal sinuses (Cellulae ethmoidales anteri­
Proc. uncinatus A thin bone lamellar of the Os ethmoidale that forms part of
ores) also drain into the Ductus nasofrontalis or the Infundib­
the medial wall of the Sinus maxilaris by incomplete closure ulum ethmoidale of the Hiatus semilunaris. The Bulla eth­
of the Hiatus maxillaris and confines the Hiatus semilunaris at moidalis, which limits the Hiatus semilunaris at the upper
its lower anterior aspect rear and drains into it, belongs to the anterior ethmoidal cells .
Recessus fron- A gap that produces the connection between the nasofrontal Other anterior ethmoidal sinuses will open on or just above
talis sinus and nasal cavity (Ductus nasofrontalis, Canalis naso­ the Bulla ethmoidalis and thus reach the Hiatus semilunaris.
frontalis) – The maxillary sinus (Sinus maxillaris) confluences in the low­
Sulcus olfac­ Channel between the anterior attachment of the Concha nasa- er section in the Hiatus semilunaris (Infundibulum maxil­
torius lis media at the skull base and the roof of the nose lare), usually directly below the Bulla ethmoidalis.
• Behind the upper nasal concha:
• At the centre the Proc. uncinatus of the Os ethmoidale is insert­ – The posterior ethmoidal sinuses (Cellulae ethmoidales poste­
ed in the opening of the Hiatus maxillaris. At the top edge of riores) usually confluence on the lateral paranasal sinus wall
the Proc. uncinatus a sickle-shaped smooth gap remains (Hiatus of the meatus nasi superior.
semilunaris › Table 9.31). The front and cranial end of the – The Sinus sphenoidalis flows as the only paranasal sinus not
­Hiatus semilunaris form a depression, which is known as the In­ on the lateral paranasal sinus wall. Its Apertura sinus sphenoi­
fundibulum ethmoidale. Behind and beneath the Proc. uncina­ dalis is located on the rear wall of the nasal cavity and conflu­
tus further openings are present. ences in the Recessus sphenoethmoidalis (space above the
• The Os lacrimale and the inferior nasal concha border in front of Concha nasalis superior in the area of the nose roof at the
and below the Hiatus maxillaris. transition between Lamina cribrosa and Corpus ossis sphe­
• From posterior above the anterior ethmoidal cells protrude into noidalis) behind the upper nasal concha in the Meatus nasi
and in front of the Hiatus maxillaris (Bulla ethmoidalis,› Ta­ superior.
ble 9.31). At the same time, they border the Hiatus semilunaris
to the back and above. NOTE
With the exception of the Hiatus semilunaris, all openings around Overall, the lateral nasal wall is individually constructed showing
the Proc. uncinatus which are not sealed by bone are normally cov­ large differences in strength. The size of the upper nasal concha
ered with mucous membranes and therefore not visible (rear and can vary greatly, even the confluence of the frontal sinus via the Hi-
front fontanelles, › Table 9.31). atus semilunaris often differs from the manner described here.
The lacrimal nasal passage and most of the sinuses confluence with
their excretory ducts at the lateral nasal wall (› Table 9.32, › Fig.
9.90, › Fig. 9.87):

498
 9.6 Nose

Clinical remarks only separated from the maxillary sinus by thin bony lamellae or
by mucous membranes. If the Recessus alveolaris is extended, the
The structures under the middle nasal concha summarised
1st premolars, the Caninus and the Dens serotinus (see below) can
under the term osteomeatal unit are clinically not only ex-
traordinarily important for ventilation, but also for the drain- be included in the maxillary sinus. The front wall is adjacent to the
age of the paranasal sinuses. The area is used as a surgical Sulcus lacrimalis on the efferent lacrimal ducts, the rear wall with
access pathway in endonasal surgery, e.g. in the treatment of the Tuber maxillae at the Fossa pterygopalatina. In the roof, which
chronic sinusitis or Polyposis nasi. is also the floor of the Orbita, run the N. infraorbitalis and the Vasa
In neonates, in the area of the confluence point of the Ductus infraorbitalia. The lateral wall borders on the Os zygomaticum,
nasolacrimalis in the lower nasal passage, there can be a thin medial lies the Hiatus maxillaris with the osteomeatal complex
connective tissue membrane (HASNER's valve) as an embryo-
(› Chap. 9.6.4). Here, the natural maxillary sinus ostium conflu­
logical relict or the Ductus nasolacrimalis finds no connection
to the lower nasal passage. In these cases, the lacrimal drain- ences close to the roof via the Infundibulum maxillare in the mid­
age is hindered. The child suffers from a persistent epiphora dle of the Infundibulum ethmoidale. In this way secretion products
(continuous tear production) on the affected side. The efferent of the maxillary sinus mucosa and air can reach the Hiatus semilu­
lacrimal ducts mostly become inflamed above the membrane naris and the respective nasal cavity. If the mucosa coating in the
or occlusion (Dacryocystitis neonatorum) and there is pus dis- area of fontanelles below the Proc. uncinatus is missing, the maxil­
charge from the lacrimal points. If the HASNER's valve or the lary sinus has in more than 10 % of the cases 1 or even 2 accessory
default canal remain, operative intervention is necessary to
ostia (open fontanelles).
create the physiological flow to the nose.

Frontal sinus
The paired frontal sinus (Sinus frontalis,› Fig. 9.87, › Fig. 9.90,
› Fig. 9.92) is characterised by a particularly large variability in its
9.6.5 Paranasal sinuses expansion as well as between the two cavities. Both front cavities
are usually separated by a bony wall (Septum frontalium), which is
A large part of the bones bordering directly on the paranasal sinus­ often not in a median position. A frontal sinus can extend over the
es are pneumatised in the first years of life up to an advanced age median to the other side (and interfere with the expansion of the
(Ossa pneumatica). This creates the paranasal sinuses (Sinus para­ other cavity). The formation of the frontal sinus reaches the upper
nasales, › Fig. 9.87, › Fig. 9.90, › Fig. 9.92), which are connect­ orbital edge around the 7th year of life. It can then pneumatise the
ed with the nasal cavities via ostias and are lined with mucous Squama frontalis, the Arcus superciliaris or the Pars orbitalis of the
membrane. They are ventilated via the nasal cavities. It is assumed Os frontale. In the case of extensive pneumatisation it can extend
that this process functionally serves the lightweight construction of up to close to the Canalis opticus. In cases of severe pneumatisa­
the skull. They do not have an importance as a resonance room. tion the bone to the anterior cranial fossa is usually only very thin.
Through their topographic relationship with the adjacent struc­ In approximately 5 % the frontal sinus can also be missing (frontal
tures the parasanal sinuses are of major clinical relevance. sinus aplasia). Usually the frontal sinus forms a funnel-shaped
­recess at its lowest point, in which the Ostium frontale forms the
Maxillary sinus connection to the nasal cavity. As a rule, the typical confluence of
The paired maxillary sinus (Sinus maxillaris,› Fig. 9.87, › Fig. the frontal sinus into the nasal cavity emerges in the form of the
9.90, › Fig. 9.92) is usually the largest paranasal sinus. It often Ductus nasolacrimalis, which is formed by anterior ethmoidal si­
completely fills the Corpus maxillae and can be chambered by nuses that limit it and confluences in the Infundibulum ethmoidale
bony membranes (Recessus). The maxillary sinus floor bears a rela­ which is followed by the Hiatus semilunaris. There are numerous
tionship to the alveolar process (alveolar recess). This applies in deviations from the most common orifice shape of the frontal sinus
particular to the root tips of the 2nd premolars and the first two described here.
molars (15, 16, 17, 25, 26, 27; › Chap. 9.7.2), which sometimes are

Crista galli

Sinus frontalis

Bulla ethmoidalis

Concha bullosa
Proc. uncinatus

Infraorbital
ethmoid bone cell
(HALLER's cell)

Sinus maxillaris Septum nasi

Fig. 9.92 Frontal section

through the viscerocranium/
facial skeleton. Presentation of
anatomic variants of the eth-
moidal bone. [L126]

499
9 Head

Ethmoidal cells into the Recessus sphenoethmoidalis in the skull base. Close topo­
The ethmoidal cells (Cellulae ethmoidales,› Fig. 9.87, › Fig. graphic relationships exist laterally to the Canalis opticus with the
9.90, › Fig. 9.92, › Fig. 9.93) are also summarised under the N. opticus (› Fig. 9.93), the A. carotis interna, the Sinus caverno­
terms ethmoidal cell complex or ethmoidal cell labyrinth (Labyrin­ sus and the N. trigeminus [V], as well as at the front to the rear eth­
thus ethmoidalis). According to their location in relation to the at­ moidal cells and upper posterior to the pituitary gland. In the for­
tachment of the middle nasal concha, they are divided from an em­ mation of an ÓNODI-GRÜNWALD cell (› Table 9.31, › Fig.
bryological and clinical point of view into the front (Cellulae eth- 9.93), the Sinus sphenoidalis lies partially below these sphenoidal
moidales anteriores) and posterior (Cellulae ethmoidales cells. In the case of extensive pneumatisation the bony walls are
posteriores) ethmoidal cells. Ultimately, all anterior ethmoidal si­ usually only extremely thin.
nuses drain into the Infundibulum ethmoidale and, therefore, in
the same way as the maxillary sinus and the frontal sinus into the
Hiatus semilunaris. In contrast, the posterior ethmoidal cells flow
Clinical remarks
into the upper nasal passage. Size and shape of the ethmoidal si­ Inflammation of the paranasal sinuses (sinusitis) is a com-
nuses and their relationship to each other are extremely variable; mon disease. In children the ethmoidal sinuses are particular-
however, the cells are usually much smaller than the Sinus maxil­ ly affected, in adults the maxillary sinus, but also frontal and
lares, frontales and sphenoidales and are therefore only referred to sphenoidal sinuses can become inflamed. Unilateral Sinus
maxillaris inflammation is often caused odontogenically
as cells. Since the ethmoidal sinuses often grow into bones outside
(odontogenic Sinusitis maxillaris). The inflammation usually
of the Os ethmoidale, their walls can consist completely of Os originates at the 2nd premolar or the 1st molar (see above).
frontale, Os maxillare, Os lacrimale, Os sphenoidale, Os palatinum Feared complications of ethmoiditis are the spreading to the
or a combination of the individual bones. Examples of this are the Orbita via the thin Lamina papyracea (orbital phlegmon) and
Agger nasi cells, a Bulla frontalis, an infraorbital cell (HALLER's the spreading of the inflammation via the bony walls of the
cell) and the Cellula sphenoethmoidalis (ÓNODI-GRÜNWALD Canalis opticus to the N. opticus with risk of optic nerve dam-
cell) (› Table 9.31, › Fig. 9.92, › Fig. 9.93). The largest and age if the posterior ethmoidal sinuses or the sphenoidal sinus
are affected. If the Sinus frontalis is highly developed occipi-
most constant ethmoidal cell is the Bulla ethmoidalis that borders
tally via the orbital roof (Recessus supraorbitalis), clinicians
the Hiatus semilunaris from above. The ethmoid bone has a close refer to a dangerous frontal sinus. A frontal sinus inflamma-
topographic relationship to the Orbita. The bony walls between the tion can lead via the thin bony walls of the anterior cranial fos-
ethmoidal cells and the Orbita are extremely thin. You can almost sa e.g. to meningitis, epidural abscesses or brain abscesses.
see through them on the bony skull (Lamina papyracea - paper Malignant tumours of the nose have become less frequent
thin). The bony walls of numerous ethmoidal cells form a part of due to improved occupational health and safety measures. If
the floor of the anterior cranial fossa in the area of the Crista galli. they occur, they are extremely dangerous and difficult to treat
due to their infiltrative growth into the neighbouring regions,
Here they form the Foveolae ethmoidales ossis frontalis.
such as the Orbita, skull base, palate and throat.

Sphenoidal sinus
The paired sphenoidal sinus (Sinus sphenoidalis ,› Fig. 9.87,
› Fig. 9.90, › Fig. 9.92) is located in the Corpus ossis sphenoida­ NOTE
lis immediately below the Cella turcica. As with all other sinuses Access to the nasal cavities
the pneumatisation of the sphenoidal bone is extremely variable In the nasal skeleton there are various access points for nerves and
and is laterally differently developed. A Septum sinuum sphenoi­ blood vessels:
dale separating both sphenoidal sinuses runs in most cases asym­ • Lamina cribrosa
• Foramen sphenopalatinum
metrically and can be partially or completely missing. Additional
• Canalis incisivus
incomplete septa are possible. The sphenoidal sinus enters through • Nostrils
the Apertura sinus sphenoidalis of the sphenoidal sinus front wall

9.6.6 Vascular, lymphatic and nervous systems

Arteries
The blood supply to the nose and the paranasal sinuses (› Fig.
9.94) is provided by branches of the A. carotis externa and the
A. carotis interna.
The A. ophthalmica originates from the A. carotis interna and
passes through the Canalis opticus into the Orbita. It emits the
A. ethmoidalis posteriorat the medial orbital wall and further for­
ward the A. ethmoidalis anterior. Both arteries penetrate through
the corresponding Foramina ethmoidalia anterior and posterior
into the ethmoidal complex and run through the Canales ethmoid­
ÓNODI-GREENWALD cell
ales between the ethmoidal cells up into the nasal cavity. Here they
Sinus sphenoidalis
branch out to the nasal septum and to the lateral nasal wall. The
N. opticus [II] A. ethmoidalis anterior emits the Rr. nasales laterales anteriores
and Rr. septales anteriores which anastomise with the other vessels
Fig. 9.93 Horizontal section through the ethmoid bone at the level supplying the nasal cavity. The A. ethmoidalis posterior perfuses a
of the Canalis opticus. Relationships during formation of an ÓNODI- smaller area near the skull base.
GRÜNWALD cell. [L126]

500
 9.6 Nose

A. ethmoidalis anterior
Concha nasalis media

A. ethmoidalis A. ethmoidalis
posterior posterior,
(R. septalis)
Concha nasalis superior
A. ethmoidalis anterior,
A. spheno- R. septalis anterior
palatina

KIESSELBACH's area
A. ethmoidalis anterior,
(R. nasalis externus)

A. labialis superior, A. sphenopalatina, A. labialis superior,

R. septi nasi R. septalis posterior R. septi nasi
A. sphenopalatina,
Aa. nasales posteriores
laterales
A. palatina Concha nasalis A. nasopalatina A. palatina major
a major inferior b

Fig. 9.94 Arterial blood supply to the nasal cavity. a Lateral wall of the right nasal cavity. b Nasal septum of the right nasal cavity. [E402]

The outer nose receives blood via the A. dorsalis nasi, which via the • The frontal sinus in the Sinus sagittalis superior and the Plexus
A. supratrochlearis is also a branch of the A. ophthalmica. Anasto­ pterygoideus
moses exist to the A. angularis in the face. The Vestibulum nasi re­ • The sphenoidal cavity in the Sinus cavernosus and the Plexus
ceives blood via the R. septi nasi from the A. labialis superior. pterygoideus
The main blood supply of the nasal cavity is carried out via the A. The Plexus pterygoideus forms a central drainage station for all pa­
sphenopalatina, a terminal branch of the A. maxilliaris from the ranasal sinuses, which is of clinical significance due to its connec­
A. carotis externa. It passes via the Fossa pterygopalatina through tions to the middle cranial fossa and the Sinus cavernosus.
the Foramen sphenopalatinum into the nose and splits into the Aa.
nasales laterales posteriores and Rr. septales posteriores. Extensive Lymph vessels
anastomoses exist between the arteries and connections to the A. The Nodi lymphoidei submandibulares are regional lymph nodes
palatina descendens and to the A. palatina major (via Canalis inci­ of the external nose and nasal atrium. The lymph of the nasal cavi­
sivus). There is a vessel-rich region in the anterior lower area of the ties and paranasal sinuses is drained largely in the direction of the
nasal septum with a thin mucous membrane (KIESSELBACH's throat to the Nodi lymphoidei retropharyngeales and from here to
area). It is supplied with blood mainly from the septal part of the the Nodi lymphoidei cervicales profundi and to a lesser extent
A. ethmoidalis anterior with participation of the septal part of the forward to the Nodi lymphoidei submandibulares.
A. sphenopalatina.
The arterial blood supply of the paranasal sinuses is carried out for: Innervation
• The maxillary sinus via a branch of the A. sphenopalatina, the The nose and the paranasal sinuses are innervated sensitively by
A. infraorbitalis and the A. alveolaris superior posterior (all branches of the N. ophthalmicus [V/1] and the N. maxillaris [V/2]
branches of the A. maxillaris) (› Fig. 9.95). The N. olfactorius [I] gives the sense of smell. The
• The ethmoidal cells via the Aa. ethmoidales innervation of secretory active glands and of the blood vessels in
• The frontal sinus via the A. ethmoidalis anterior the nose and paranasal sinus mucosa is provided via parasympa­
• The sphenoidal sinus from above via branches of the dural arter­ thetic fibres of the N. facialis [VII], which rest primarily in the N.
ies. maxillaris [V/2] in the Fossa pterygopalatina, and via sympathetic
fibres, which are switched in the Ganglion cervicale superius.
Veins Sensory innervation:
The external nose drains its blood via Vv. nasales externae in the • The N. ethmoidalis anterior (branch of the N. nasociliaris from
V. facialis. The nasal cavities lead the blood into the Plexus cavernosi V/3) divides into a R. nasalis externus for the innervation of the
concharum and other venous networks of the nasal mucosa. From external nose and in Rr. nasales interni, which innervate as Rr.
here, the blood is drained into Vv. ethmoidales to the V. ophthal­ nasales laterales the front area of the lateral nasal wall and with
mica superior, in Vv. nasales internae via Plexus pterygoideus, Vv. Rr. nasales mediales innervate the nasal septum.
maxillares and V. retromandibularis in the V. jugularis interna and • The N. ethmoidalis posterior innervates the mucosa of the pos­
in the V. palatina major. terior ethmoidal cells and the sphenoidal sinus.
The paranasal sinuses drain their blood in different ways: • Rr. nasales posteriores superiores laterales and mediales pass as
• The maxillary sinus in vascular networks of the dental roots to branches of the N. maxillaris [V/2] through the Foramen sphe­
the Plexus pterygoideus nopalatinum into the nasal cavity and innervate the nasal muco­
• The ethmoidal cells in Vv. ethmoidales to the orbital veins and sa at the back of the upper area of the nasal cavity (nasal septum,
from there to the Sinus cavernosus, into the cavernous body tis­ lateral and rear nasal cavity wall in the area of the Recessus
sue of the efferent lacrimal ducts and from there to the orbital sphenoethmoidalis).
veins as well as in the Plexus pterygoideus

501
9 Head

N. ethmoidalis anterior N. ethmoidalis anterior,

Bulbus olfactorius (R. septalis)

N. olfactorius [I] N. olfactorius [I],

Fila olfactoria
Foramen
sphenopalatinum

N. ethmoidalis anterior,
R. nasalis externus

N. maxillaris,
[V/2], Rr.
nasales pos-
N. infraorbitalis, teriores
Rr. nasales interni superiores laterales
N. palatinus major,
Rr. nasales posteriores
inferiores
N. alveolaris
a superior b N. nasopalatinus

Fig. 9.95 Innervation of the nasal cavity. a Lateral wall of the right nasal cavity. b Nasal septum of the right nasal cavity. [E402]

• Rr. nasales posteriores inferiores emerge from the N. nasopalati­ 9.7 Oral cavity, masticatory apparatus, tongue,
nus and innervate in the area of the middle and lower nasal pas­ palate, floor of the mouth, salivary glands
sage, including the lower nasal concha and the lower portion of Wolfgang H. Arnold
the nasal septum.
• Sneezing reflex: the afferent arm of the triggered protective reflex
in the nasal mucosa, which is associated with a reflectory closure Skills
of the glottis, runs across the N. maxillaris [V/2] to the Medulla
oblongata. After working through this chapter, you should be able to:
Sense organ innervation: • name all oral structures
• describe the nerve course in the oral cavity
• From the olfactory fields, the Fila olfactoria passes through the
• explain the vascular supply to the oral cavity
Lamina cribrosa of the skull base. After switching in the Bulbus • explain the development of the teeth
olfactorius, the fibres continue via the Tractus olfactorius to the • describe the detailed structure of the various teeth
central core areas. • describe the structure and function of the Articulatio tem-
Parasympathetic innervation: poromandibularis, and the location and function of the mas-
• The intermediate part of the N. facialis [VII] passes as N. petro­ ticatory muscles
sus major and in the further course as N. canalis pterygoidei to • describe the construction, location and functions of the
tongue and of the palate
the Ganglion pterygopalatinum. After switching, the postgangli­
• reproduce the location, structure and function of the sali-
onic fibres run together with the sensory fibres of the N. maxil­ vary glands
laris [V/2] out of the Fossa pterygopalatina to the nasal mucosa. • explain the construction of the floor of the mouth and its
The fibres provide activation of the gland secretion, and vessel compartments
dilatation. • name the blood supply, innervation and lymph drainage of
Sympathetic innervation: the abovementioned structures and organs
• Postganglionic fibres from the Ganglion cervicale superius pass • describe the topographical location and the neighbourhood
relationships of the structures and organs to each other and
as N. petrosus profundus through the Canalis pterygoideus and
to be able to classify the surrounding areas and describe
reach the Fossa pterygopalatina and the Foramen sphenopalati­ their function
num via the nasal cavity. They are responsible for inhibiting • explain the development of the oral cavity, masticatory ap-
gland secretion and for vasoconstriction. paratus, tongue, palate and salivary glands

Clinical remarks
A hyposmia (decreased olfactory sensation) or an anosmia Clinical case
(missing olfactory sensation) can be caused by viral infec-
tions, chronic sinusitis, obstructions due to relocation of the Perimandibular abscess
airways to the olfactory mucosa, e.g. in the case of allergies, Case study
drug side effects, brain tumours or brain trauma with injuries A 50-year-old male patient, who underwent root canal treat-
of the olfactory nerves when passing through the cribriform ment 1 year ago due to profound caries of tooth 46, presents
plate. with significantly reduced general health and an increased
temperature of 38.5 °C. He states that he has pain in the right

502
 9.7 Oral cavity, masticatory apparatus, tongue, palate, floor of the mouth, salivary glands

cheek and throat area that radiates into the right ear so that 9.7.1 Oral cavity
he can no longer open his mouth properly and also has swal-
lowing difficulties. The oral cavity is the beginning of the digestive system and is di­
vided into several sections (› Fig. 9.96): the Vestibulum oris
Initial examination
The pulse rate of the patient is increased, swallowing difficul- forms the oral vestibule and is bordered outside by the lips and the
ties and limited mouth opening are clear. The patient has inad- cheeks and inside by the alveolar processes and the teeth. The
equate oral hygiene. The medical records show that in the pre- Cavitas oris propria is the actual oral cavity. The Isthmus fauci-
ceding investigations the patient has had gingival recession um, the oropharyngeal isthmus, borders the oral cavity dorsally.
(inflammation-free gum recession) and periodontal pocket There the oral cavity passes to the Pars oralis of the pharynx (oro­
depths up to 12 mm. The right cheek and the throat area at the pharynx). Between the tooth row of the lower jaw (Mandibula)
right below the lower jaw are clearly swollen, whereby the
there is the tongue body (Corpus linguae). In the oral cavity the ex­
swelling is only local and includes the submandibular soft tis-
sue. The mandible is not palpable in this area. Submandibular cretory ducts of three large salivary glands emerge (Glandula pa­
lymph nodes are palpable. Clinically, this gives the impression rotidea, Glandula submandibularis and Glandula sublingualis),
of a spread of the swelling into the parapharyngeal area. With their secretions form the total saliva, which moistens the oral cavi­
moderate spontaneous pain, there is severe pressure pain. ty. Overall, the oral cavity is lined with a cutaneous mucous mem­
brane.
Diagnostics
From a differential diagnostic point of view the clinical find-
ings indicate a perimandibular abscess on the right side, a Development
salivary calculus in the Glandula submandibularis or a tumour In evolutionary terms, the development of the oral cavity originates
of the Glandula submandibularis. In order to rule out a sali- from 2 germ leaves. The rear section evolves from the entodermal
vary calculus or tumour, an ultrasound examination is con- foregut, the front section from the ectodermal mouth recess.
ducted. In addition, a panoramic x-ray and a dental CT are Through the development of the front brain the unpaired fore-
conducted to visualize a possible osteolytic process. The in- head bulge grows forward and downwards, while the two paired
terpretation of the findings shows a diagnosis of a periman-
maxillary and mandibular bulges grow forwards. Finally, all 5
dibular abcess.
face bulges include the primary oral cavity (Stomatodeum). The
Treatment primary oral cavity is a uniform oral nasal space which is separated
The dentist opts for the intraoral opening of the abscess and from the foregut by the pharangeal membrane (Membrana bucco-
the administration of an antibiotic. Penicillins are the pre- pharyngea). As early as the 3rd embryonic week the buccopha­
ferred antibiotics for odontogenic infections. After opening ryngeal membrane tears, so that the Stomatodeum and the intesti­
the abscess, the dentist inserts a drainage, so pus and wound
nal tube are connected to each other. Approximately in the 6th em­
secretions can be drained away. The wound in the oral cavity
heals completely within a short time. After healing the renova- bryonic week the primary palate forms from the forehead bulge of
tion of the root filling follows with apicoectomy in a second the unpaired primary palate; from the two maxillary bulges the
session. The dentist advises the patient to urgently improve palatinal processes emerge laterally. These grow medially towards
his oral hygiene habits. In addition, he tells the patient to each other, where they fuse in the midline, so that oral and nasal
come every quarter year to check the periodontal condition cavity are completely separated from each other.
with professional tooth cleaning.

Frenulum labii superioris

Uvula palatina
Palatum durum, Raphe palati

Palatum molle [Velum palatinum]

Fossa supratonsillaris

Arcus palatopharyngeus

M. buccinator
Arcus palatoglossus

Platysma
Pars oralis pharyngis Bucca

Dorsum linguae

Tonsilla palatina

Isthmus faucium

Gingiva

Frenulum labii inferioris

Vestibulum oris Fig. 9.96 Oral cavity, Cavitas
oris. Frontal view, mouth open.

503
9 Head

Limitation of the oral cavity Oral mucosa

The oral opening (Rima oris) represents the entrance to the Cavi- Classification
tas oris. Laterally, the oral cavity is restricted by the cheeks , the The oral mucosa (Mucosa oralis) is formed differently in the vari­
muscular base is the M. buccinator. The roof of the oral cavity ous regions of the oral cavity. In principle it is cutaneous mucosa,
forms the palate, which is divided into the hard palate (Palatum i.e., it is a multilayered epithelium that is mostly keratinised on the
durum) and the soft palate (Palatum molle). The floor of the palate and on the back of the tongue, but is not keratinised on the
mouth is mainly formed by the Corpus linguae. Under the tongue cheeks and on the floor of the mouth. The gums (Gingiva), are lo­
is the Diaphragma oris, with the muscular base of the M. mylohy­ cated around the teeth, which are divided into different sections.
oideus. Dorsally the Cavitas oris opens through the Isthmus fauci­ Directly at the neck of the tooth one refers to the Gingiva margin-
um into the oropharynx. alis, which is movable and forms the Sulcus gingivalis between the
tooth neck and the Gingiva. The Gingiva propria that is firmly
Orientation fused with the periosteum of the Proc. alveolaris connects to this
Principally, the directional terms of the body also apply to the oral and cannot be moved. Between the teeth there is the Papilla inter-
cavity: however, since the teeth are arranged in a ellipsoid dental dentalis (› Fig. 9.98). The upper lip is attached via the Frenulum
arch, additional directional names are required. Dental surfaces, labii superioris, which is situated between the first two incisors, to
which face the Vestibulum oris are in the front tooth region in both the Mucosa oralis and the Gingiva. The lower lip is attached via the
the upper and lower jaw the labial surfaces, in the posterior region Frenulum labii inferioris, which runs from the lower lip to the
the vestibular and buccal surfaces. The surfaces facing the oral oral mucosa, usually between the canine and the first premolars on
cavity are referred to in the lower jaw as lingual, in the upper jaw the right and left side.
as palatinal surfaces. Together, one can also use the name: oral.
Tooth surfaces that are in the direction of the throat, are referred to
as distal, tooth surfaces in the direction of the Rima oris, as mesial
Clinical remarks
surfaces. Together, the tooth surfaces of adjacent touching teeth are Normally, the oral mucosa is coloured pink. Keratinisation dis-
referred to as approximal surfaces (› Fig. 9.97). orders with cellular and epithelial atypia are often the cause
of white mucosal changes (leucoplakia). If the mucosal chang-
es cannot be wiped away, it is precancerous, and can be at-
Dens incisivus medialis tributed to the premalignant diseases of the oral mucosa.
Dens incisivus lateralis
They always require a histopathological evaluation, surgical
removal and continuous observation. White deposits of the
Dens caninus oral mucosa that can be wiped away are most commonly
­fungal infections (Candida albicans), which can be treated
Dens premolaris I with medication.
In the context of analysing familial relationships (paternity
Dens premolaris II
Mesial
test) or to detect criminal offences, a cytological mouth swab
Dens molaris I is taken for DNA analysis with which a genetic fingerprint is
Palatinal Vestibular
created. For this purpose, a few mucosal skin cells are taken
Dens molaris II Distal with a sterile swab from the inside of the mouth cavity and the
DNA is then extracted.
Dens molaris III
[serotinus]

a Vascular, lymphatic and nervous systems

The Gingiva and the oral mucosa are very well perfused. The blood
vessels form a close capillary network directly under the epitheli­
um. In the area of the Gingiva marginalis the capillaries are devel­
oped as vessel loops that are closely positioned (› Fig. 9.99). In
the cheek and the base of the mouth there is a flatter network, lying
Foramen under the epithelium.
mandibulae

Gingiva
Distal
Dens Lingual Frenulum labii Tunica mucosa oris
Vestibular
molaris III superioris
[serotinus] Mesial Gingiva propria
maxillae
Dens
molaris II Gingiva Gingiva
marginalis
Dens molaris I maxillae Papilla gingivalis
Dens premolaris II [interdentalis]
Gingiva
marginalis Gingiva
Dens premolaris I mandibulae
Frenulum labii
Dens caninus Gingiva propria inferioris
Dens incisivus medialis mandibulae
b Dens incisivus lateralis
Tunica mucosa oris
Fig. 9.97 Dental arches with presentation of the directional terms,
as well as the individual types of tooth. a Upper jaw. b Lower jaw. Fig. 9.98 Classification of the Gingiva and Mucosa oralis. [L127]

504
 9.7 Oral cavity, masticatory apparatus, tongue, palate, floor of the mouth, salivary glands

Table 9.33 Innervation of the oral mucosa.

Nerve Innervation area Course

N. maxillaris [V/2] Upper jaw • Foramen rotundum
Capillaries • Fossa pterygopalatina
of the Gingiva
• N. infraorbitalis Vestibular gingiva of • Canalis infraorbitalis
marginalis
the upper front teeth • Foramen infraorbitale
• N. nasopalatinus Palatinal gingiva of the • Septum nasi
upper front teeth • Foramen incisivum
• N. palatinus major Palatinal gingiva and • Canalis palatinus major
mucosa of the Palatum • Foramen palatinum major
durum
• Nn. palatini Mucosa of the Palatum • Canaliculi palatini minores
minores molle
Fig. 9.99 Scanning electron microscopy image of a corrosion prepa- N. mandibularis [V/3] Lower jaw • Foramen ovale
ration of capillary loops of the Gingiva marginalis. [T785] • Fossa infratemporalis
• N. buccalis Buccal mucosa, front ⅔ Under the M. pterygoideus

Clinical remarks • N. lingualis of the tongue, floor of

the oral mucosa, lin-
medialis on the M. buccinator,
on the inner side of the Ramus
gual gingiva mandibulae under the M. pter-
Via the capillary network of the floor of the mouth and the
ygoideus medialis on the M.
cheek medication can be resorbed. This can be used in an
hyoglossus to the tongue
emergency, e.g. in the treatment of angina pectoris seizures
with nitroglycerin (nitrospray). • N. alveolaris inferi- Lower jaw teeth, vestib- • Foramen mandibulare
or ular gingiva • Canalis mandibulae
• Foramen mentale

The oral mucosa is innervated via terminal branches of the N. tri­

geminus [V]. In the upper jaw area, it is the N. maxillaris [V/2], in
the lower jaw area the N. mandibularis [V/3] (› Fig. 9.100, › Ta­
ble 9.33).

A. temporalis superficialis, N. auriculotemporalis

R. parietalis
N. meatus A. temporalis media A. temporalis profunda posterior;
acustici externi N. temporalis profundus

R. auricularis (X) N. mandibularis [V/3]

N.; M. pterygoideus lateralis

A. maxillaris

N. infraorbitalis
A.; N. auricularis
posterior A. infraorbitalis
A. temporalis N. supratrochlearis
superficialis
N. infratrochlearis
N. facialis [VII]
A. angularis
R. digastricus
A. occipitalis A. sphenopalatina

A. meningea media N. infraorbitalis

A. maxillaris Rr. alveolares
Chorda tympani superiores posteriores

A. alveolaris inferior N. massetericus

N. hypoglossus [XII] N. buccalis
A. lingualis A. buccalis
A. palatina ascendens N. alveolaris inferior
A. carotis communis
N. lingualis
N. vagus [X]
Mandibula
(Ansa cervicalis profunda)
Glandula sublingualis
A. facialis
N. hypoglossus [XII] A. sublingualis

Ganglion submandibulare N. hypoglossus [XII]

N. mylohyoideus A. submentalis

Fig. 9.100 Arteries and nerves of the head.

505
9 Head

Oral epithelium

Dental ridge Outer

enamel epithelium

Enamel reticulum

Inner enamel epithelium

Coronal
mesenchymal consolidation

Pulp mesenchyme

Dental follicle

Fig. 9.101 Dental development.

Alveolar Cap stage of the development of
bone N. alveolaris a molar in the lower jaw with
enamel organ and pulp system.
[T785]

9.7.2 Masticatory apparatus – teeth which the blood vessels and nerves grow. In the immediate vicinity
mesenchymal cells form an epithelial band due to factors from the
Development inner enamel epithelium, which form the future dentine (preodon-
Dental development starts around the 40th day of embryonic de­ toblasts). The tooth saccules, which are the basis of the later dental
velopment with the invagination of the oral cavity epithelium into holding apparatus, differentiates from the mesenchymal cells and
the underlying mesenchyme. As a result, a U-shaped epithelial fibres around the bell and the papilla. The preodontoblasts in the
ridge is developed in each of the upper jaw and the lower jaw, the pulp form long processes (odontoblast processes, TOMES' pro-
general dental ridge. The close relationship between the two differ­ cesses), which begin with the secretion of organic basic substance
ent embryonic tissues triggers a complex cascade of genetic inter­ (predentine) and are referred to as odontoblasts . After the first
actions that ultimately lead to the formation of the teeth (› Table predentine is formed, the cells in the immediate vicinity of the pre­
9.34). Reciprocally, in the epithelial cells (ectodermal origin) and dentine on the border between predentine and inner enamel epitheli­
in the mesenchymal connective tissue cells (cells from neural crest um begin to differentiate to ameloblasts, which in turn begins with
cells of the head) genes are activated that are responsible for the the formation of the enamel matrix (› Fig. 9.102). As in the case of
production of certain messengers (inductors). The inductors make predentine the enamel matrix mineralises initially extracellularly.
another differentiation in neighbouring cells to highly specialised
cells or the production of further differentiation factors.
The deeply proliferating epithelium of the dental ridge grows
around the mesenchyme and leads to a consolidation of mesenchy­
mal cells and thus to the formation of the enamel bud. The further Predentine

proliferation of the epithelium is associated with the development

of the enamel organ that consists of the outer enamel epithelium,
the enamel pulp and the inner enamel epithelium. The cell densi­ Odonto
ty of the mesenchyme, in turn, has the consequence that the inner blasts
process
enamel epithelium is pushed in the direction of the outer enamel
epithelium and as such can form the enamel cap (cap stage, › Fig. Enamel-
9.101). Due to continued growth of the enamel epithelium into the dentine-border
depths the dental cap enlarges to the enamel bell (bell stage). At Stratum
this stage the mineralisation of hard dental substances begins. reticulare
Dentine
During the development of the enamel organ the determined den­
tal mesenchyme compresses in the bell to dental papillae, into

Table 9.34 Germ layer, derivatives of teeth.

Germ layer Embryonic tissue Dental tissue

Amelo-
Ectoderm Melting organ Enamel blasts
Mesenchyme Tooth papilla Dentine
(neural crest) Enamel
Odontoblasts
Pulpar mesenchyme
Fig. 9.102 Dental development with incipient mineralisation of
Dental sacules Periodontium
tooth enamel. [T785]

506
 9.7 Oral cavity, masticatory apparatus, tongue, palate, floor of the mouth, salivary glands

Unlike the odontoblasts the ameloblast processes are very short root sheath odontoblasts continue to differentiate, which forms the
and only form pyramid-shaped protrusions of cells. The enamel root dentine. The cells of the epithelium of the HERTWIG's sheath
matrix is resorbed again after the initiation of the mineralisation of die from apoptosis. Mesenchymal cells of the tooth saccule come
the ameloblasts, so that the enamel is largely free of organic materi­ into contact with the exposed root dentine, which differentiate to
al. The structure of the enamel prisms comes from the arrangement cementoblasts and deposit the dental cement onto the dentine as
of the ameloblasts. The result of the activity of the ameloblasts well as forming root skin (desmodont).
­(secretion of the enamel matrix, initiation of mineralisation, ab­
sorption of the matrix proteins) is inorganic enamel prisms, which Tooth structure and components
consist almost exclusively of hydroxyapatite. While the enamel is Structure
formed from the inside to the outside (centrifugal), this occurs in Each tooth consists of a dental crown (Corona dentis), a tooth neck
the case of dentine centripetal to the pulp. The predentine formed (Cervix dentis) and a tooth root (Radix dentis):
by the odontoblast processes consists mainly of collagen fibres, • The dental crown (Corona dentis) is covered cap-like by the
which are subsequently covered with hydroxyapatite and miner­ enamel (Enamelum). It protrudes from the gums (Gingiva).
alised in this way. Dentine is therefore made of organic collagen • On the tooth neck (Cervix dentis) the coverage of the crown
fibres and inorganic hydroxyapatite. The odontoblast processses ends with enamel and passes into the dental cement.
remain in the cavities, the dentine canules, and continue to be able • The dentine of the tooth root (Radix dentis) is covered by the
to produce predentine. The cell bodies of the odontoblasts remain dental cement (Cementum). The lowest point of the tooth root
lying at the inner wall of the pulp. With increasing dentine thick­ is the root tip (Apex radicis dentis). Here there is the root
ness the odontoblaste processes extend steadily. They are the cellu­ papilla (Papilla dentis), which is penetrated at the Foramen api­
lar elements of the dentine, which are responsible for the reaction cis dentis by the root canal (Canalis radicis dentis). Through
of the dentine to external stimuli. the Foramen apicis dentis, vessels and nerves enter the pulp cav-
ity (Cavitas dentis). The pulpa cavity is divided into the root
pulp (Cavitas pulparis) and the crown pulp (Cavitas coronae).
Clinical remarks The pulp contains arteries and veins, lymph vessels and nerves
With the odontoblast processes, nerve fibres pass into the and consists of loose connective tissue (› Fig. 9.103).
dentine canules, so that dentine in contrast to enamel, is sen- The root is attached by the periodontal apparatus (periodontium)
sitive to pain. In the course of life, the pulp becomes smaller In the upper and lower jaw. It is suspended from SHARPEY's
due to the constant dentine formation. Therefore, there is a ­fibres (Fibrae cementoalveolares, collagen fibres) of the root skin
risk of opening of the pulp during caries removal in children
(syn.: Periodontium, periodontal or parodontal ligament, des­
greater than in older people.
modentium alveolar dental membrane) in the dental alveola (Alveo­
lus dentalis of the Proc. alveolaris of the Maxilla or the mandible).
Due to further proliferation of enamel epithelium it extends like a A distinction is made between the fibres of the periodontium:
tube into the depths, whereas the enamel reticulum always be­ • Dentoalveolar comb fibres which radiate from alveolar edge up­
comes narrower and ultimately touches the inner and outer enamel ward into the gingiva
epithelium and the epithelial root sheath (HERTWIG's sheath). • Horizontal fibres that run from the alveolar edge horizontal to
By touching the inner and outer enamel epithelium a further dif­ the cement and complete the Sulcus dentalis
ferentiation of the ameloblasts is prevented. On the inside of the • Fibres, which run obliquely from the top exterior to the bottom

Oral Vestibular

Enamelum
Corona Corona
dentis clinica
Dentinum

Cavitas coronae;
Pulpa coronalis
Cervix
dentis
Margo gingivalis

Cavitas dentis;
Pulpa dentis

Cementum Radix
Radix clinica
dentis
Periodontium
[Desmodontium]

Canalis radicis
dentis;
Pulpa radicularis
Fig. 9.103 Anatomical con-
Apex radicis dentis struction of a tooth with the
Foramen apicis dentis Periodontium (incisor, Dens
incisivus).

507
9 Head

• Circular apical fibres in the area of the root tip • Curvature feature: it describes the different curvature of the
• Inter-radicular fibres in the bifurcation of the roots of vestibular surface. The mesial area is more severely curved par­
­multirooted teeth ticularly in the posterior region than the distal area.
• Angle feature: the chewing edge of a crown forms a more acute
Hard tooth tissue angle with the mesial contact area than with the distal contact area.
Enamel, dentine and cement are the hard dental substances. In • Root feature: it describes the deviation of the root course from
contrast to bones they have no blood vessels. the dental axis distally.

Enamel Permanent dentition (Dentes permanentes)

Enamel (Enamelum, Substantia adamantina) is the hardest sub­ The permanent adult dentition consists of 32 teeth with 16 upper
stance in the human body. Mature enamel consists almost entirely and 16 lower jaw teeth. Each dental arch is divided into 2 symmet­
of hydroxylapatite crystals that are stored together to enamel rical halves, making a total of 4 quadrants. The 4 quadrants are
prisms. The enamel prisms extend from the dentine enamel border numbered in sequence from the top right to bottom right from 1 to
to close under the enamel surface. As the enamel is cell-free, it can 4, yielding a denture scheme each with 8 teeth. In each quadrant in
no longer be replaced after loss. turn 4 dental types are differentiated, 2 front teeth (Dentes inci-
sivi, incisors), 1 canine (Dens caninus), 2 premolars (Dentes
Dentine premolares) and 3 molars (Dentes molares) (› Fig. 9.104). The
Dentine (Dentinum, Substantia eburnea, dentine) is in contrast to Fédération Dentaire International (FDI) (International Dental Fed­
enamel a living tissue and constitutes the major part of a tooth. It is eration) has developed a current globally valid dental scheme in
traversed by dentine canules that run radially from the pulp cavity which each tooth of a quadrant is numbered from 1 to 8, and the
to the outside and in which the processes of the odontoblasts run respective number of the quadrant is set before the tooth number.
for a lifetime as TOMES' fibres together with fine nerve fibre end­ In the case of deciduous dentition (20 teeth), the quadrants from
ings. In the dental crown the dentine is covered by enamel (crown 5 to 8 are counted according to the adult dentition.
dentine), at the root by cement (root dentine). The enamel-cement Dental notation of the permanent dentition
border above the dentine corresponds to the tooth neck. Dentine is
after enamel the body's hardest substance. 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Cement
Cement (Cementum) is relatively similar to bone, contains almost Dental scheme in deciduous dentition
as much organic matrix, but a higher proportion of minerals and
around only half the amount of water. Like the osteocytes in bone, 55 54 53 52 51 61 62 63 64 65
the cementocytes lie in Lacunas of cement. The SHARPEY's fibres, 85 84 83 82 81 71 72 73 74 75
which suspend the tooth in the alveola of the upper and lower jaw
(see above) are fixed in the cement.
NOTE
The incisors (Dentes incisivi) are single root teeth with a cutting
Characteristics of teeth edge. The canines (Dentes canini) also have only one root, their
Since the teeth are not arranged in a circular arch, but are arranged crown resembles a sharp chisel. The premolars (Dentes premo-
in a parabolic arch, they have a different radius of curvature. They lares) are constructed differently: the first upper premolar is a dou-
are also mirror imaged on both sides, so that they cannot be inter­ ble rooted tooth, whereby one root points in a palatinal and the
changed. The following characteristics are used for differentiation other in a vestibular direction. The second premolar is like the two
of individual teeth: lower jaw premolars single rooted. The premolars have no cutting
edge, but a chewing surface with a hump relief. The 3 upper jaw

Quadrant 1 right maxilla Quadrant 2 left maxilla

Dentes Dens Dentes

incisivi caninus premolares Dentes molares

Fig. 9.104 Permanent teeth,

Quadrant 4 right mandible Quadrant 3 left mandible Dentes permanentes. Vestibular
view.

508
 9.7 Oral cavity, masticatory apparatus, tongue, palate, floor of the mouth, salivary glands

molar teeth (Dentes molares) are three rooted teeth with 1 palati- Premolars, Dentes premolares
nal and 2 vestibular roots. The lower jaw molars (Dentes molares) Crowns
each have 2 roots with a mesial and a distal root. All molars are
The premolars have no cutting edge, but an occlusal surface (Fa­
characterised by a very differentiated hump relief in the occlusal
surface that are used for food fragmentation. cies occlusalis). The top premolars each have 2 humps, a vestibular
and a palatal. The vestibular hump is greater than the lingual. Be­
tween the two humps a distinct side ridge runs on the mesial and
Incisor teeth, Dentes incisivi distal side. A longitudinal fissure runs from mesial to distal, at its
The incisors have chisel-shaped crowns and a root. The upper inci­ ends there is a mesial and a distal pit. In the lower premolars the
sors are larger than those of the lower jaw. humps are smaller and therefore the marginal ridges are less devel­
oped. The 1st molar has predominantly a double hump crown pat­
Crowns tern, the 2nd lower premolar can also have 3 humps. The Facies oc­
In the case of incisor crowns a distinction is made between a Facies clusalis is similar in double hump premolars of the lower jaw to
vestibularis and a Facies lingualis. On the cutting edge of younger those of the upper premolars. Because the vestibular hump is larger
teeth there are several small edge tubercles. The Facies lingualis is than the lingual, the chewing surfaces incline inwards, which is re­
characterised by marginal ridges (Cristae marginales), which run ferred to as a crown escapement. Consequently, the tip of the ves­
convex in a gingival direction and form the Tuberculum dentis in tibular hump lies in the middle of the chewing surface and that of
the cervical area of the tooth. Above the Tuberculum dentis of the the lingual on the lingual crown edge. The triangular type of the
upper incisors is the Foramen caecum, an enamel indentation in Facies occlusalis, 2 lingual and 1 vestibular hump can be found.
which caries often develops. The two lingual humps are separated by a transverse fissure, so that
a Y-shaped fissure pattern is created.
Roots The Facies vestibularis of all premolars is similar to the canines.
The incisors are single-rooted teeth, longitudinal ridges can often The occlusal crown section is moved to lingual, considerably re­
be found on their mesial and distal surfaces. The root tip is bent ducing the crown escapement. The Facies lingualis is much nar­
towards distal. The strongest and longest root is in the 1st upper rower and smaller than the Facies vestibularis. The transverse arch
incisor, the smallest root in the 1st lower. of this surface passes directly into the approximal surface, the lon­
gitudinal arch is relatively flat, causing the lingual crown wall to
Pulp stand perpendicular.
The Cavitas coronae of the incisors corresponds in their shape to
the shape of the dental crown. Roots
The upper 1st premolar usually has 2 roots, 1 stronger vestibular
Root canal and 1 weaker palatinal. All other premolars have only 1 root, it is
The root canal (Canalis radicis dentis) is usually narrow and often shaped like a canine tooth.
interrupted by dentine bridges. The root canal often forms branch­
es. Pulp
The Cavitas coronae of premolars corresponds to the shape of the
Canine teeth, Dentes canini dental crowns.
The canine teeth are the largest teeth in the frontal tooth area. They
are important corner pillars between the incisors and the premolars Root canal
and in prosthetic dentistry anchor teeth for bridges and brackets. The single-rooted premolars very often have 2 root canals. Particu­
larly often single-rooted first upper premolars have 2 root canals.
Crowns
The cutting edge runs obliquely in a slightly offset mesial tip so that Molars, Dentes molares
the crown is more like a chisel. The mesial cutting edge is shorter The molars in permanent dentition are the biggest teeth. They have
and thinner than the distal. From the tip of the crown a flat, mid­ several humps in the masticatory surface that serve the disintegra­
line ridge runs cervically, which divides the vestibular area into a tion of food. For this reason, they are referred to as the grinders.
mesial and a distal facet. On the Facies lingualis there are 2 cervi­ The molar teeth in the upper and the lower jaw differ greatly.
cally merging marginal ridges. Also the lingual surface is divided
by a medium edge into a mesial and distal facet. At the cervical end Upper jaw molars
of the merging marginal ridges there is the Tuberculum dentis. Crowns
The Facies occlusalis usually has 4 humps, 2 vestibular and 2 lin­
Roots gual. Sometimes there are only 3 humps, sometimes a 5th hump
The canines are single-rooted teeth, whose roots are formed stron­ occurs (Tuberculum CARABELLI see below). The mesial humps
ger vestibularly than lingualy. The root of the upper jaw canine is are higher than the distal ones. The largest is the mesiolingual hump
the longest of all teeth. which is connected by an enamel ridge (Crista transversalis) with
the distovestibular hump. The smallest is the distolingual hump.
Pulp The fissure system consists of a mesiovestibular and a distolingual
The Cavitas coronae of the canine is a narrow, long extended space fissure. Both fissures are connected to one another by a transvers
which in the dental neck area runs continuously into the root canal. fissure. The mesiovestibular fissure separates the two mesial humps
and the mesiovestibular from the distovestibular hump. The disto­
Root canal lingual fissure separates the two distal and lingual humps from
The Canalis radicis dentis of the upper canine tooth runs without each other. At the intersection points of the transverse fissure with
branches and is relatively long. In the lower jaw the root canal is the two other fissures there are small depressions, the Fovea mesi­
often split into 2 sub-branches. alis and the Fovea distalis. In front of the edge between the mesio­

509
9 Head

vestibular and mesiolingual or the distovestibular and distolingual verse fissure separates the distal bump from the distovestibular. At
humps is the Fovea triangularis. Mesially the Facies vestibulares the intersection points of the longitudinal and transverse fissures,
and Facies lingualis are higher than distal. The crown of the upper smaller depressions are again present. The fissures pattern of the
wisdom tooth is similar to the crown of the 2nd molar; however, 2nd lower molars is formed by a transverse fissure which separates
the crown shape of the upper wisdom tooth varies greatly. the hump into 2 vestibular and 2 lingual humps. The mesial humps
are slightly larger than the distal.
Tuberculum CARABELLI The lower wisdom tooth shows a large number of size and shape
The Tuberculum CARABELLI (CARABELLI hump) is an addi­ variations. The chewing surface has often 4 or 5 humps which are
tional hump in the mesial section of the lingual crown wall and can separated from each other by the corresponding fissures.
be most often found on the 1st molars.
Roots
Roots The molar teeth in the lower jaw are double-rooted teeth with a
The upper molars are three-rooted teeth with a Radix lingualis, a mesial and distal root. The mesial root is flat and wide, the distal
Radix vestibularis mesialis and a Radix vestibularis distalis. The root round and relatively pointed. The Radix mesialis is bent for­
Radix lingualis is the strongest of the three roots. It is projected be­ ward; the Radix distalis runs quite straight. The roots of the 2nd
tween the two vestibular root origins. The roots are wide open, molars are formed much more simply. They are not as far apart as
whereby the root tips are bent towards one another. The roots of the 1st molars. In the wisdom teeth the roots again show large
the wisdom teeth show large form variability. The root tips of the shape variability.
upper jaw molars are in close contact to the base of the maxillary
sinus. The bone lammelle between the alveoli and the maxillary si­ Pulp and root canals
nus is often paper thin (› Fig. 9.105). The shape and size of the Pulpa coronalis reflect the shape of the
dental crown. In adolescents the crown pulp is larger than in older
people. The pulp of the upper molars is relatively large and has 4
Clinical remarks walls that bulge slightly into the pulp. They run cervically like a
In the extraction of molars in the upper jaw, there is the risk of funnel, pulp horns can be found under the humps occlusally. The
opening the maxillary sinus. A link between oral and maxillary root canal of the lingual root is the widest; the two vestibular root
sinus leads to the degeneration of the ciliated epithelium in canals are more closely constructed. The mesiovestibular root
the maxillary sinus with a chronic infection. shows numerous variations, often the root canal is divided into 2
canals. The wisdom teeth have a very richly varying root canal sys­
tem. The pulp of the lower molars corresponds to a cube with a
Mandibular molars smaller distal and a larger mesial wall. Under each hump there is
Crowns usually a pulp horn. In the mesial root, especially in the 1st molars,
The Facies occlusalis of the 1st molars very often has 5 humps, 2 there are often 2 root canals. The lower wisdom tooth also shows
vestibular, 2 lingual and 1 distal hump. In contrast, the 2nd lower strong variability in the number and form of the root canals just as
molars has only 4 humps. The distal hump is not present. The big­ the upper wisdom tooth.
gest hump is the mesiovestibular hump. The smallest hump is the
distal hump. Milk dentition (Dentes decidui)
In contrast to the permanent dentition the milk dentition (decid-
Fissures uous teeth) contains only 20 teeth with 5 teeth in each quadrant
At the first molars there is a mesiodistal longitudinal fissure and 3 (› Fig. 9.106).
transverse fissures. Through the mesiovestibular transverse fissure,
the two vestibular humps are separated from each other, the two NOTE
lingual humps by the lingual transverse fissure and the distal trans­ A distinction is made between milk incisors (Dentes incisivi decid-
uales), the milk canine (Dens caninus decidualis) and the milk mo-
lars (Dentes molares deciduales). The milk front and canine teeth
Hiatus maxillaris are single-rooted teeth with chisel-shaped cutting edges in the
crown. There are no premolars in milk teeth. The milk molars of the
Sinus maxillaris, upper jaw are three-rooted with 1 palatal and 2 vestibular roots.
Lamina medialis The mandibular molars of the deciduous dentition each have 2
roots, of which one is mesial and the other distal oriented.

Spina nasalis
anterior Sinus maxillaris,
Fundus Milk incisors, Dentis incisivi deciduales
Proc. alveolaris The crowns in the upper incisors are low and wide with a strongly
protruding cervical enamel bulge, the Cingulum. The heads of the
lower incisors have hardly any form differences. Sometimes the
first incisor has 3 ridge tubercles in the masticatory edge.

Milk canines, Dentes canini deciduales

The upper milk canines have a wider crown than the first milk inci­
Dentes molares,
Radices
sors. In addition, they have a wide Cingulum. The area on the lin­
gual side is often divided by a ridge in the middle, on which a clear
Fig. 9.105 Extent of the maxillary sinus with illustration of the rela- tubercle emerges cervically. The lower canine is narrower than the
tionship between the tooth roots to the maxillary sinus floor. [L266] upper. The Cingulum is not as clearly pronounced.

510
 9.7 Oral cavity, masticatory apparatus, tongue, palate, floor of the mouth, salivary glands

Quadrant 5 right maxilla Quadrant 6 left maxilla

Dentes Dens Dentes

incisivi caninus molares
decidui deciduus decidui

Fig. 9.106 Milk teeth, Dentes

Quadrant 8 right mandible Quadrant 7 left mandible decidui, approx. 3-year-old
child. Vestibular view.

Milk molars, Dentes molares deciduales are the additional teeth. During the dental change the size of the
The crown of the upper milk molars is similar to the crown shape Maxilla and mandible increases and reach their final size after all
of the permanent molars. On the Facies vestibularis the Tubercu­ permanent teeth have erupted.
lum molare is located in the lower quadrant mesially. A Tubercu­ The dental changing period is in two phases:
lum CARABELLI can often be found on the Facies lingualis. • First, (5th–9th year of life) the additional teeth and the perma­
The roots of the upper milk molars are spread far apart. The upper nent incisors (replacement teeth) erupt.
milk molar comes in two versions: as premolar type with 2 humps • Then (10th–12th year of life), the milk molars are replaced by the
and as a molar type with 4 humps. The 4 hump variant shows an premolars (replacement teeth) and the milk canines by the per­
H-shaped fissure pattern, similar to the first permanent upper molar. manent canines.
At the lower molars there are 2 shape variants, the premolar and As a rule of thumb:
molar type. The chewing surface of the molar type has 4 or 5 • the 1st molar is the 6-year molar,
humps. The lingual humps are long and pointed. Distally a 3rd • the 2nd molar is the 12-year molar and
hump can often be found. The roots are spread far apart and bend at • the 3rd molar is the wisdom tooth (Dens serotinus, Dens sapi­
the end together. The mesial root is wider and longer. The lower 1st entiae, 17–25 years).
milk molar has a significant crown escapement which is heightened
by a projection of the Cingulum and a Tuberculum molare. The Innervation of the teeth
lower 2nd milk molar corresponds in its appearance to the first Upper jaw
lower permanent molars. It has mostly 5 humps with an irregular The upper jaw teeth are all sensitively innervated by different indi­
fissure pattern. A Tuberculum molare is usually not present. vidual branches of the N. infraorbitalis, a branch of the N. maxil­
laris [V/2], (› Table 9.36, › Fig. 9.107). The result is that the
Tooth eruption and change of teeth teeth of the Maxilla are innervated individually. The entire nerve
Roughly from the 6th month of life the milk teeth erupt in a coordi­ plexus, innervated by the upper jaw teeth, is referred to as Plexus
nated order into the oral cavity, the range of the eruption is, how­ dentalis superior.
ever, highly variable and can be less or exceed the times outlined in
› Table 9.35. The cutting teeth in the lower jaw come first, with
the eruption of the 2nd milk molars up to the age of 2 ½ to 3 years,
Clinical remarks
when the milk dentition is complete. The milk teeth are slightly Because of the individual innervation of the upper jaw teeth
smaller than the permanent teeth. block anaesthesia is not possible. In the upper jaw infiltration
The changing dentition period starts roughly from the 6th year of anaesthesia of individual teeth is preferable. The upper jaw
life. In the process, the tooth roots and the bony alveolar walls are front teeth are innervated both from the vestibular as well as
from the palatine side.
resorbed. This loosens the milk tooth crown more and more, and it
eventually falls out. The milk teeth are replaced by permanent
teeth, which are referred to as replacement teeth. The additional
teeth of the permanent dentition which do not replace milk teeth, Table 9.36 Branches of the N. infraorbitalis and their innervation
areas.
Table 9.35 Eruption times of milk teeth in months. Nerve Innervation area Course
Dental 1st 2nd Canine 1st molar 2nd Rr. alveolares supe- Molars On the Tuber maxillae through the
type ­incisor ­incisor molar riores Foramina alveolaria to the lateral
maxillary sinus mucosa
Upper jaw ♂ 9.1 ± 1.5 10.4 ± 2.4 18.9 ± 2.7 16.0 ± 2.3 27.6 ± 4.4
R. alveolaris superi- Premolars In the Canalis infraorbitalis to the
Upper jaw ♀ 9.6 ± 2.0 11.9 ± 2.7 20.1 ± 3.2 15.7 ± 2.3 28.4 ± 4.3
or medialis maxillary sinus mucosa
Lower jaw ♂ 7.3 ± 1.6 13.0 ± 2.8 19.3 ± 2.9 16.2 ± 1.9 25.9 ± 3.8
Rr. alveolares supe- Canine and incisors From the Foramen infraorbitale on
Lower jaw ♀ 7.8 ± 2.1 13.8 ± 3.6 20.2 ± 3.4 15.6 ± 2.2 27.1 ± 4.2 riores anteriores the Corpus maxillae to the front teeth

511
9 Head

N. infraorbitalis Rr. alveolares N. ophthalmicus [V/1]

superiores
N. trigeminus [V]
Ganglion trigeminale
N. maxillaris [V/2]
N. mandibularis [V/3]

N. lingualis

N. alveolaris inferior

N. mentalis Plexus dentalis

superior

Plexus dentalis inferior Fig. 9.107 Innervation of the

teeth.

Lower jaw 9.7.3 Masticatory apparatus –

The lower jaw teeth are only sensitively supplied by a single nerve Masticatory muscles
the N. alveolaris inferior, a branch of the N. mandibularis [V/3]. It
passes through the Foramen mandibulae in the Canalis mandibu­ The masticatory muscles are responsible for the movement of the
lae, where it forms the Plexus dentalis inferior. Prior to entering lower jaw against the upper jaw. All 4 masticatory muscles (› Ta­
the Canalis mandibulae the N. mylohyoideus leaves the nerve as a ble 9.37) have their origin at the skull base and run to the mandi­
motor branch of the N. alveolaris inferior. ble. They ensure that food can be bitten off and can be reduced to
small pieces. The group of masticatory muscles is supported by fur­
ther muscles of the head and throat area. These include mimic
Clinical remarks muscles, the suprahyoid and the infrahyoid muscles, the M. sterno­
At the entrance of the N. alveolaris inferior in the Canalis man- cleidomastoideus and neck muscles.
dibulae, all teeth of the lower jaw are simultaneously anaes-
thetised in a quadrant using block anaesthesia; however, due M. masseter
to the proximity, the N. lingualis and the N. mylohyoideus are The M. masseter is attached on the outside of the Ramus mandibu­
are always anaesthetised with it, leading to taste and sensory
lae. The Pars superficialis runs obliquely from above downwards
failures of the tongue.
towards the lower front, the Pars profunda runs vertically. The rear
edge of the muscle is covered by Glandula parotidea. The cheek fat
globule lies at the front edge between the M. masseter and the M.
Periodontium buccinator (BICHAT's fat pad). It shapes the contour of the rear
The Periodontium consists of 4 different elements (› Fig. 9.103): cheek area and forms a raphe at the rear edge of the Ramus man­
• Gums (gingiva) dibulae together with the M. pterygoideus medialis that originates
• Alveolar bone (Proc. alveolares maxillae and mandibulae) at the inner side.
• Root skin (periodontal ligament, desmodentium)
• Dental cement (Cementum) M. temporalis
The Periodontium is a tooth-dependent structure and reforms al­ The M. temporalis fills the Fossa temporalis and is covered on its
most completely after loss of a tooth. front side by the Fascia temporalis, which passes from the Linea
temporalis superior to the zygomatic arch. Just above the zygomat­
ic arch the Fascia temporalisis forms a superficial and a deep layer
Clinical remarks that are attached on the outer and inner surface of the Arcus zygo­
A chronic parodontitis leads to decomposition of the alveolar maticus. The osteofibrous space created between is filled with
bone and degeneration of the periodontal ligaments with loss structural fat. The attachment area at the Proc. coronoideus of the
of SHARPEY's fibres (periodontosis). Periodontitis is the most Mandibula is hidden by the zygomic bone and M. masseter. The
common disease that leads to tooth loss in old age. The re- M. temporalis is the largest and strongest masticatory muscle. It is
traction of the alveolar bone can lead to problems in the inser-
often associated with the Mm. masseter (see above) and pterygoi­
tion of implants for dental prostheses.
deus lateralis. At the bottom of the anterior border is the upper
part of the cheek fat globule.

M. pterygoideus medialis
The M. pterygoideus medialis (› Fig. 9.108) and the M. masseter
are usually connected to one another by a connective tissue raphe

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 9.7 Oral cavity, masticatory apparatus, tongue, palate, floor of the mouth, salivary glands

Table 9.37 Masticatory musculature.

Innervation Origins Attachment Function Blood supply

M. masseter
N. massetericus • Pars superficialis: lower edge of • Pars superficialis: Tuberositas Adduction, protrusion in unilateral A. masseterica (A. maxillaris),
[from V/3] the Os zygomaticum, anterior masseterica contraction, laterotrusion A. facialis, A. transversa faciei of
two thirds • Pars profunda: outer surface of the A. temporalis superficialis,
• Pars profunda: inner surface of the Proc. coronoideus A. buccalis (A. maxillaris)
the Os zygomaticum, rear third
M. temporalis
Nn. temporales • Pars profunda: Planum tempora- Proc. coronoideus mandibulae Adduction, retrusion Aa. temporales profundae anterior
profundi [from V/3] le of the Os zygomaticum and posterior (A. maxillaris),
• Pars superficialis: Facies tempo- A. temporalis media (A. temporalis
ralis superficialis)
M. pterygoideus medialis
N. pterygoideus • Pars medialis: Fossa pterygoidea Tuberositas pterygoidea mandibu- Adduction, protrusion, mediotru- A. alveolaris superior, A. alveolaris
medialis [from V/3] • Pars lateralis: Lamina lateralis lae sion inferior, A. buccalis (A. maxillaris)
of the Proc. pterygoideus
M. pterygoideus lateralis
N. pterygoideus • Caput inferius: Lamina lateralis, Fovea pterygoidea mandibulae, Protrusion on bilateral contraction, R. pterygoideus (A. maxillaris)
lateralis [from V/3] Proc. pterygoidei joint capsule and Discus articu- mediotrusion and adduction in
• Caput superius: Facies and Cris- laris unilateral contraction
ta infratemporalis

at the lower rim of the mandible, so that they encompass the Cor­ • The Pars lateralis comes from the outside of the Lamina lateralis
pus mandibulae in the area of the Angulus mandibulae like stir­ of the Proc. pterygoideus.
rups. This way they can enforce maximum power and induce the The Caput inferius of the M. pterygoideus lateralis slides between
mouth closure and the grinding movements for the disintegration both parts.
of food. The M. pterygoideus medialis has 2 origins:
• The Pars medialis is bigger and comes from the Fossa ptery­
goidea.

N. opticus [II]
N. trochlearis [IV]
N. oculomotorius [III]
N. trigeminus [V]

N. abducens [VI]
A. temporalis, R. frontalis

A. carotis interna
M. temporalis
Fossa mandibularis
Capsula articularis
Discus articularis
M. pterygoideus lateralis,
Caput mandibulae
Caput superius
M. pterygoideus lateralis, Lig. sphenomandibulare
Caput inferius
Palatum molle N. lingualis

M. pterygoideus medialis N. alveolaris inferior

M. masseter
Hamulus pterygoideus

Angulus mandibulae

M. mylohyoideus
Os hyoideum, Cornu majus
M. genioglossus
M. omohyoideus
M. geniohyoideus
Platysma
M. thyrohyoideus
M. sternohyoideus

Fig. 9.108 Masticatory muscles. Dorsal view.

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9 Head

M. pterygoideus lateralis surface of the Caput mandibulae. At the lowest point of the Fossa
The M. pterygoideus lateralis is essentially involved in the oral mandibularis the bone is paper thin and translucent at the skull.
opening. It has a smaller upper head (Caput superius) and a larger The articular surface passes forward to the vertex of the joint tu-
lower head (Caput inferius). A part of the muscle fibres of the Ca­ bercles (Tuberculum articulare). The Tuberculum articulare is lo­
put superius inserts on the anterior ligament of the Discus articu­ cated in front of the Fossa mandibularis and forms a slanting,
laris and on the joint capsule of the temporomandibular joint and downward angled articular surface, which is also called the tuber-
attaches in bilateral activity the Caput mandibulae at the tubercu­ cular slope. On the Tuberculum articulare the cartilage coating is
lum slope during adduction of the lower jaw. Unilateral activity especially thick, because here the power transfer takes place via the
leads to the grinding movement on the working side and to stabi­ Discus articularis. Together with the Fossa mandibularis the Tu­
lising the Caput mandibulae on the dormant side. The Caput infe­ berculum articulare forms an S-shaped joint path.
rius is the only masticatory muscle part which is involved in the
jaw opening. It induces the oral opening and forces the further mo­ Discus articularis
tion in the form of a combination of rotation and translation. The Discus articularis sits like a cap on the joint head and divides
the temporomandibular joint into an upper somewhat larger joint
NOTE (Articulatio discotemporalis) and a lower joint (Articulatio disco­
The M. pterygoideus lateralis takes a key position for the kinemat- mandibularis). It has therefore 2 chambers (dithalamic joint). The
ics of the temporomandibular joint. discus is tightly frontally fused medially and laterally with the joint
capsule. In the centre it is very thin and becomes thicker at the edg­
es. It consists of connective tissue and fibrous cartilage and shows a
regionally different structure (› Fig. 9.109) which is divided into 4
9.7.4 Masticatory apparatus – temporomandibular sections (from front to back):
joint • Anterior ligament (here the tendons of the muscle fibres of the
Caput superius musculi pterygoidei lateralis radiate from the
The paired temperomandibular joint is part of the masticatory ap­ front into the Discus articularis)
paratus. Functionally, the temporomandibular joints enable food • Intermediate zone
intake and fragmentation, as well as articulation when speaking • Posterior ligament
and singing. Both temporomandibular joints form a functional • Bilaminary zone (connective tissue, which splits in front of the
unit and thus work always at the same time. cartilaginous portion of the external auditory duct into 2 sheets,
an upward and downward part)
Development The lower sheet of the bilaminary zone is attached at the Collum
The temporomandibular joint is an accumulation joint. It is mandibulae with the joint capsule and thus forms the rear border
formed between the Mandibula and Os temporale from secondary of the lower joint fissure. It consists of taut collagen fibres and pass­
cartilage with a growth zone. The joint form is connected to the es further to the rear into a highly vascularised connective tissue,
development of the dentition and thus not only dependent on the Plexus retroarticularis. The top layer consists mainly of elastic
whether or not there are teeth, but also on the bite form. fibres, which are attached to the Fissura tympanosquamosa and the
Fissura petrosquamosa. When the mouth is opened, the lower lay­
Structure er is stretched, while the top layer is relaxed. When closing it is vice
The joint head (Caput mandibulae) of the temporomandibular versa. At the front the Discus articularis is connected medially and
joint forms the biconvex curved articular process of the lower jaw. laterally to the joint capsule.
It articulates with the front part of the Fossa mandibularis and the As the Caput mandibulae and the Fossa mandibularis (joint socket)
Tuberculum articulare of the Os temporale. The rear part of the do not fit together exactly, the Discus has the function of balancing
Fossa mandibularis, which belongs to the Pars tympanica of the Os this mismatch of articulating skeletal elements. When opening and
temporale, is not part of the temporomandibular joint and lies
­extracapsular. The joint surfaces are not covered with hyaline car­ Discus articularis Tuberculum articulare
tilage, but by a fibrous cartilage which indicates the biomechanical Fossa articularis M. pterygoideus
features of the temporomandibular joint. Between the joint surfac­ lateralis, Caput superius
Meatus acusticus
es there is a Discus articularis, which divides the joint cavity into 2
externus
chambers (dithalamic joint). The axes of the joint heads are slanted
and intersect in front of the Foramen magnum at an angle between
150° and 165°. The temporomandibular joint is completely
­enclosed by a rough joint capsule.

Caput mandibulae
It forms the upper end of the Proc. articularis (Proc. condylaris,
Condylus mandibulae) and is roll-shaped. Its shape shows great
individual variation. The joint heads are usually not bilaterally
structured as a mirror image. The articular surfaces of the Caput Retro-articular
mandibulae are covered by fibrous cartilage and are mainly on the venous pad
front of the joint head. Proc. condylaris M. pterygoideus
mandibulae lateralis, Caput inferius
Fossa mandibularis
The temporomandibular joint pit is located on the underside of the Fig. 9.109 Bony parts of the temporomandibular joint with Discus
Os temporale and is two to three times larger than the articular articularis and M. pterygoideus lateralis. [L127]

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 9.7 Oral cavity, masticatory apparatus, tongue, palate, floor of the mouth, salivary glands

closing the mouth, the discus articularis is shifted (it slides on to the Table 9.38 Ligaments of the temporomandibular joint.
tubercular slope) and adapts to the changing size conditions.
Ligament Function Relationship Connection
with the joint
NOTE capsule
Even at maximum chewing force development on the occlusal sur-
Lig. laterale Involved in the joint Reinforces the Arcus zygomaticus
face, the temporomandibular joint in the Fossa mandibularis is
(Lig. temporo- guidance, inhibits joint capsule on inclined towards
barely loaded since the chewing pressure from the teeth is derived
mandibulare) edge movements and the outside the rear to the Col-
via the trajectories of the viscerocranium at the skull base and the
stabilises the condylus lum mandibulae
cranium.
on the working side
Lig. mediale Variably formed, rein- Reinforces the Inner edge of the
Clinical remarks forces the joint cap-
sule, inhibits edge
joint capsule on
the inside
Fossa mandibu-
laris to the Collum
Occlusion disorders, dysgnathia or tooth loss may cause movements mandibulae
chronic biomechanical stress of the temporomandibular joint, Lig. spheno- Inhibits mouth open- No relation- Spina ossis sphe-
which is often associated with degenerative changes of joint mandibulare ing near the end posi- ships noidalis between
cartilage and the Discus articularis. Degenerative changes (os- tion Mm. pterygoidei to
teoarthritis) are usually associated with defects in the lateral the Lingula man-
area of the Discus articularis (perforation). As the jaw joints are dibulae
true joints (diarthroses), they can be affected by all diseases,
Lig. styloman- Mostly weak, supports No relation- The lower margin
which also affect the large limb joints (e.g. diseases of the dibulare Lig. sphenomandibu- ships of the Proc. styloi-
rheumatic type). Stronger violent impacts on the Mandibula lare deus to the poste-
can lead to fractures of the Collum mandibulae (Collum frac- rior border of the
ture). with or without dislocation. Even without fracture, bleed- Ramus mandibulae
ing often occurs from the retroarticular venous plexus with dif-
ficulties to open the mouth. In older people, owing to strong
atrophy of the bone in the Fossa mandibularis a central frac-
ture of the Fossa mandibularis with an intrusion in the middle Main movements of the jaw joints in the context of mastication are:
cranial fossa may occur after falls or knocks on the chin. The • Abduction and adduction (opening and closing, raising and
pain in all diseases of the temporomandibular joint is often lowering of the lower jaw): this is a combined gliding hinge
projected into the external auditory canal. In this case the tem- movement that takes place bilaterally and symmetrically. The
poromandibular joint must always be taken into consideration. Discus articularis slides under the force of the M. pterygoideus
lateralis on the Tuberculum articulare to forward below. In do­
ing so, the Angulus mandibulae moves backwards. The axis of
this hinge motion passes through the Foramen mandibularae,
Joint capsule which is why the N. alveolaris inferior is not stretched in this
The thin joint capsule passes from the edge of the Fossa mandibu­ movement.
laris around the Tuberculum articulare and attaches above the Fo­ • Grinding movements: These asymmetric movements are made
vea pterygoidea on the lower jaw. Because it is closely connected up of combined translational and rotational motion:
with the Discus, the Discus articularis separates the joint cavity – Protrusion and retrusion (forward and backward move­
into the Articulatio discotemporalis and discomandibularis. Both ment) of the lower jaw: this movement takes place in the Ar­
joint cavities typically have no connection to each other. The joint ticulatio discotemporalis and is guided through the rows of
capsule is reinforced by ligaments (› Table 9.38). teeth. For this reason, deformities of the teeth and occlusion
disorders can affect the movement in the jaw joints.
Ligaments – Mediotrusion and laterotrusion (medial or lateral transla­
The movements of the temporomandibular joint are influenced by tion): this movement is also guided by the rows of teeth. On
ligaments of the joint capsule as well as through ligaments that are one side the joint head turns around a vertical axis in the joint
not associated with the joint capsule (› Table 9.38). socket, while the other slides forward on the Tuberculum ar­
ticulare and separates the teeth on this side.
Biomechanics The grinding movement takes place on the side of the rotation
The temporomandibular joint is a combination joint, which allows (working side, active side, laterotrusion side, rotation condyle, dor­
for movement in all three planes. Because of its shape, it is referred mant condyle). The Mandibula is pushed against the upper jaw.
to as a bicondylar joint (Articulatio bicondylaris). As both jaw The extent of the lateral transfer is the BENNETT's angle, and lies
joints are connected via the mandibular brace, independent move­ between 15° and 20° in healthy individuals. The contralateral side,
ments of a joint is not possible (biomechanical coupling). which only responds to movement, is the balance side (mediotru­
sion side). This side is called the oscillating condyle or translational
condyle.
Clinical remarks
The shape of the articular surfaces, the shape and position of Vascular, lymphatic and nervous systems
the teeth, the condition of the dentition, the occlusion, the Arteries and veins
muscles of mastication and their innervation form a common The temporomandibular joint is supplied with blood vessels via the
functional system (craniomandibular system; CMS) which af- following:
fects the movements in the temporomandibular joint. Interfer-
• A. temporalis superficialis
ence in this system, such as e.g. an incomplete dentition or
occlusion disorders, lead to disruptions of the movement pro- • A. transversa faciei
cess in the jaw joints. • A. auricularis profunda
• Rr. articulares (A. maxillaris)

515
9 Head

The venous drainage occurs via corresponding veins, as well as the so, the ligaments and the joint capsule are at maximum tension,
Plexus retroarticularis. meaning that no further movements are possible.

Innervation
The mandibular joint is sensory innervated by a multitude of nerve
Clinical remarks
branches (› Table 9.39). In younger people, the Discus articularis The bite height (jaw occlusion) is of importance for the manu-
is fully sensory innervated. In older people it should, however, only facture of prostheses in edentulous jaws.
be innervated in areas where it is fused with the joint capsule. The In a hyper-extension of the ligaments and the joint capsule or
Lig. laterale and the surrounding tissue are particularly finely in­ in the case of a flat tubercle the joint heads can slip in front of
the Tuberculum articulare (luxation) and thus evoke a jaw lock
nervated. This is the basis for the pain of the temporomandibular
(the lower jaw can no longer be adducted). A jaw clamp refers
joint in the case of functional impairment. to a handicapped jaw opening, e.g. in the context of a retroar-
ticular haematoma after falling or impact on the Mandibula or
Location positions of the Mandibula in the case of a parotid gland inflammation (parotitis).
In each position the Mandibula assumes a corresponding position
relative to the Maxilla. The condyles are located in different posi­
tions in the joint cup:
• Occlusion: it describes the positional relationship between the
upper and lower jaws and is the basis for functional analyses of 9.7.5 Tongue
the masticatory system. Different routes are taken into account:
– Bite height (so-called vertical occlusion: describes the distance Overview
of the jaw position in a fully dentulous dentition in a vertical Functions
direction in the occlusion position The tongue has a wide range of functions:
– Lip closure line: describes the height of the masticatory level • Transport, shaping and mechanical grinding: during food
– Laughter line: corresponds to the course of the upper lip when grinding the food bolus is formed by the tongue, in that the
laughing tongue body pushes the food between the masticatory surfaces
– Sagittal and horizontal occlusion: describes the positional re­ of the molars and then pushes the food bolus in the direction of
lationship of upper and lower jaws in the sagittal and horizon­ the pharynx. In addition, softer food ingredients are pulverised
tal plane by the pressure of the tongue against the hard palate.
• Central relation: at the central relation the lower jaw is in its • Flavour: in the epithelium of the dorsum of tongue, at the edge
most vital location relative to the skull. The joint heads are on and the base of the tongue, there are numerous taste buds for
both sides at the lowest point of the Fossa mandibularis. taste sensation.
• Resting position: in the resting position, the dental arches are • Feeling: numerous sensitive tactile corpuscles of the tongue mu­
unconsciously held a few millimetres apart at a distance. Both cosal membrane make the tongue an extremely sensitive tactile
condyles and the Discus articularis lie at the rear wall of the Tu­ organ, with which items in the oral cavity can be multiply en­
berculum articulare. The resting position is set by the tone of the larged in our perception.
masticatory muscles. If the muscles of mastication sag, e.g. during • Speech: due to its very good mobility and formability thanks to
sleep, or in the case of loss of consciousness, the lower jaw drops the tongue muscles, the tongue significantly contributes to
down. The head position also affects the resting position. speech formation (phonation).
• Terminal occlusion location: the final occlusion location (ha­
bitual intercuspidation) is the final position of the lower jaw, Structure of the tongue
where the teeth are in their maximum tubercle-fossa-dentition The tongue is divided into tongue body (Corpus linguae) and
position. The condyles are at the lowest point of the Fossa articu­ tongue root (Radix linguae). Corpus linguae and Radix linguae are
laris. In the final occlusion location the roof of the socket is, separated from each other by the V-shaped Sulcus terminalis, with
however, only slightly loaded, because the chewing pressure is the tip of the V in the middle of the tongue facing the Isthmus fau­
derived over the rows of teeth on the trajectories of the viscero­ cium. At the top of the V there is the Foramen caecum linguae, a
cranium. rudimentary remnant of the Ductus thyroglossus (syn.: Ductus
• Ligament location: in the ligament location (ligament position) ­thyroglossalis), from which the Glandula thyroidea has developed.
the mouth is open to the maximum degree and the condyles lie The front part of the tongue forms the tip of the tongue (Apex lin-
behind the lowest point of the Tuberculum articulare. In doing guae). The tongue body passes seamlessly into the tip of the tongue.

Development
Table 9.39 Innervation of the temporomandibular joint. Roughly in der 4th embryonic week the development of the tongue
Nerve Innervation area unit begins in the 1st pharyngeal arch. First, 3 protrusions appear
under the ectoderm of the Stomatodeum, 2 paired laterally, the Tu­
• N. auriculotemporalis Joint capsule lateral, dorsal, medial bercula lingualia lateralia, and in the middle at the rear the Tuber­
• Rr. articulares
culum impar. All 3 bulges merge with each other and later form the
• N. massetericus
anterior two-thirds of the tongue. From the 2nd, 3rd and 4th pha­
• Nn. temporales profundi Joint capsule anterior
ryngeal arches another bulge develops behind the Tuberculum im­
• N. pterygoideus lateralis, Rr. articu-
lares
par, the Copula, from which the tongue root emerges. The Sulcus
terminalis marks the boundary between tongue body and tongue
N. facialis [VII] Lig. laterale
root. Between the Tuberculum impar and the Copula the Tuber­
Ganglion oticum, Rr. articulares Membrana synovialis, parasympathet- culum impar is created in the middle, its epithelium constricted as
ic, secretory
a Ductus thyroglossus, grows in the neck area into the depth and

516
 9.7 Oral cavity, masticatory apparatus, tongue, palate, floor of the mouth, salivary glands

forms the thyroid gland (Glandula thyroidea). The constriction merous small, partially macroscopically visible connective tissue
point of the Ductus thyroglossus is marked by the Foramen cae­ papillae (Papillae linguae), which are for the touch and taste sensa­
cum in adults. The tongue muscles develop in the areas of the oc­ tion. The papillae generally form a core (primary papilla), from the
cipital myotome of the N. hypoglossus [XII] and migrate from the other small secondary pupillae. The mucosa is fixed on a rough
dorsal side under the tongue epithelium. The development of the plate of connective tissue (Aponeurosis linguae), but a Tela sub­
tongue from multiple pharyngeal arches and the occipital myo­ mucosa is missing.
tome explains the complex innervation of the tongue.
Tongue papillae
Tongue mucosa Papillae filiformes
The tongue surface (Dorsum linguae) passes on the tongue mar- The thread-shaped papillae (Papillae filiformes) are distributed
gin (Margo linguae) over to the tongue lower surface (Facies in- over the entire dorsum of the tongue and are covered by a kerati­
ferior linguae). In the middle the tongue dorsum is divided by the nized squamous epithelium. The tips are keratinized and point to­
Sulcus medianus linguae into a right and left half (› Fig. 9.110). wards the throat. On the papillae there are free nerve ends, tactile
The section of the dorsum of tongue in front of the Sulcus termi- corpuscles in the form of terminal clusters, non-myelinated nerve
nalis is referred to as Pars presulcalis (Pars anterior), the section fibres and MEISSNER's tactile corpuscles which are for tactile,
behind the Sulcus terminalis as Pars postsulcalis (Pars posterior). depth, temperature and pain perception. They enlarge felt items by
The mucosa of the Dorsum linguae in the area of Pars presulcalis is a factor of 1.6 (stereognosis).
covered with a variety of tongue papillae (Papillae lingualis). A
distinction is made between the following structures on the tongue Papillae fungiformes
surface: Mushroom papillae (Papillae fungiformes) are rare on the tongue
• Mucosa and lie distributed between the Papillae filiformes. They can be rec­
• Thread-shaped papillae, Papillae filiformes ognised as bright red points between the Papillae filiformes. The
• Mushroom-shaped papillae, Papillae fungiformes Papillae fungiformes have a conical shaped connective tissue core
• Leaf-shaped papillae, Papillae foliatae from which superficial short secondary papillae radiate into the ep­
• Valate papillae, Papillae vallatae ithelium. In the periphery of the connective tissue core of the
The papillae are distributed differently over the tongue. Papillae papillae there is a thick vascular plexus, which is responsible for
filiformes and fungiformes are mainly located on the back of the the red colouring of the papillae. The Papillae fungiformes are cov­
tongue. Papillae foliatae focus on the edge of the tongue, Papillae ered by a multi-level keratinized squamous epithelium. In the epi­
vallatae (only approx. 9-14) lie in front of the Sulcus terminalis thelial surface a few taste buds are stored. There are also numerous
(› Fig. 9.110). mechanoreceptors and thermal receptors and free nerve endings in
the connective tissue. Thus the fungal papillae are for taste percep­
Mucosa tion as well as thermal and mechanoreceptors.
The mucous membrane (Tunica mucosa linguae) is rough in the
front section of the dorsum of the tongue and in front of the Sulcus Papillae foliatae
terminalis a multilayered keratinized squamous epithelium with Foliate papillae (Papillae foliatae) are located on the rear side of the
different degrees of keratinisation. The roughness comes from nu­ tongue and run vertically from the tongue dorsum to the base of

Epiglottis
Vallecula epiglottica
Plica glossoepiglottica mediana
Plica glossoepiglottica lateralis
Tonsilla lingualis;
Cryptae tonsillares Radix linguae
Foramen caecum linguae
M. palatopharyngeus
Sulcus terminalis linguae
Tonsilla palatina

Fossulae tonsillares, M. palatoglossus

Cryptae tonsillares

Dorsum linguae, (Plica triangularis)

Pars posterior
Arcus palatoglossus
Papillae vallatae

Papillae foliatae

Dorsum linguae,
Papillae fungiformes Pars anterior
Margo linguae

Papillae filiformes
Corpus linguae

Sulcus medianus linguae

Apex linguae Fig. 9.110 Tongue, Lingua.

Superior view.

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9 Head

the tongue. They are covered by multilayered keratinized squa­ ulum the joint excretory duct (Ductus submandibularis, WHAR­
mous epithelium; in their lateral folds there are taste buds. On the TON's duct) the Glandulae submandibularis and sublingualis con­
floor of the folds excretory ducts from serous VON-EBNER's fluence at the Caruncula sublingualis.
glands confluence. The glands lie in the Lamina propria under the
epithelium. NOTE
Under the tongue there is a subepithelial vein network in the Lami-
Papillae vallatae na propria. Here, sublingually applied drugs are rapidly absorbed
On the front edge of the Sulcus terminalis there are approximately (e.g. nitroglycerin for angina pectoris).
9–14 valate papillae (Papillae vallatae). They consist of a wide
­papillary body that is surrounded by a deep circular walled trench.
At the floor of the walled trench the excretory ducts of serous Tongue root
glands (Glandulae gustatoriae, VON-EBNER's glands) open. The Behind the Sulcus terminalis, lies the tongue root (Radix linguae)
papillary body is covered by a slightly keratinised squamous epithe­ with the tongue tonsil (Tonsilla lingualis), which is part of
lium and is located on the level of the tongue surface. In the epithe­ WALDEYER's tonsillar ring. The base of the tongue is covered by
lium of the walls of the wall trench there are numerous taste buds multi-layered keratinised squamous epithelium and has in relation
on both sides. to the palatine tonsil (Tonsilla palatina) low, widely spaced crypts.
In the crypts the excretory ducts of the mucous Glandulae lin-
NOTE guales meet. On the tongue root the unpaired Plica glossoepiglot-
• Papillae filiformes: touch, depth, temperature and pain perception tica mediana and the paired Plicae glossoepiglotticae laterales to
• Fungiform papillae: taste sensation, thermal and mechanoreception the epiglottis originate and limit the intervening pits (Valleculae
• Papillae foliatae: taste perception epiglotticae).
• Papillae vallatae: taste perception

Clinical remarks
Taste buds Tongue injuries are common from scalding or chemical burns.
All taste buds (Caliculi gustatorii) together form the taste organ Especially in the case of pipe smoking, potential precancerous
(Organum gustus). The taste buds are located in the epithelium of cells occur at the tongue base as hyperkeratoses or leucopla-
the Papillae vallatae, Papillae fungiformes and Papillae foliatae. In kias.
The term glossitis includes acute and chronic diseases or
infants and children there are also taste buds on the laryngeal en­
changes in the tongue surface and/or the tongue body, which
trance and the oesophageal entrance, which slowly recede in the could have very different causes,such as bacterial and viral
course of life. The taste buds consist of onion skin-like arranged infections, fungal infestation, toxic effects (smoking, alcohol),
sensory cells and support cells. The basal cell pole of sensory cells iron deficiency, and many more. If swallowed, foreign bodies
is attached to the basal membrane. The apical cell pole ends at the can pass to the Valleculae epiglotticae at the base of the
taste pore and has long microvilli. The basal section of the sensory tongue and relocate the airway by pressure on the epiglottis.
cells is connected with the taste buds via synapses. It is assumed There is a danger of asphyxiation.
that the supporting cells are for the regeneration of the taste cells.
Via the taste buds we perceive 5 taste qualities: sweet, sour, salty,
bitter and umami (hearty). Recent findings assume that there is Tongue muscles
still another 6th taste quality (greasy). A difference is made between intrinsic (own) muscles and extrin-
sic muscles, which originate from the skeleton. Extrinsic muscles
Tongue inferior surface change the location, intrinsic muscles the shape of the tongue. A
The tongue inferior surface is covered by a smooth, multi-level large part of the tongue muscles are anchored at the Aponeurosis
non-keratinised, very thin squamous epithelium. The mucosa is linguae. In the midline the Septum linguae divides the tongue in­
located directly on the Lamina propria, a Tela submucosa is not completely into two halves. The development of the tongue muscles
present. In the midline is the mucosa to the tongue frenulum is individually just as diverse as the movement options.
(Frenulum linguae). 2 serrated mucosal folds also run on the right
and left from the tongue edge to the tip of the tongue (Plicae fim- Intrinsic muscles
briatae). Laterally on the underside of the tongue tip the excretory The intrinsic muscles have their origin and attachment in the
ducts of the Glandulae linguales anteriores empty (BLANDIN-­ tongue (› Table 9.40). They stand in the 3 planes perpendicular to
NUHN glands). The two seromucous salivary glands lie between each other and are interwoven. Functionally they enable chewing,
the muscles of the tongue tip. On both sides of the base of the fren­ talking, singing, sucking or whistling.

Table 9.40 Intrinsic muscles of the tongue.

Innervation Origin Attachment Function

M. longitudinalis superior
N. hypoglossus [XII] Aponeurosis linguae Aponeurosis linguae Curvature of the tongue downwards
M. transversus linguae
N. hypoglossus [XII] Aponeurosis linguae of the tongue edge Septum linguae Tongue extension
M. verticalis linguae
N. hypoglossus [XII] Aponeurosis linguae of the superior surface of Aponeurosis linguae of the infe- Flattening of the tongue and groove formation in the dorsum
the tongue rior surface of the tongue of the tongue

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 9.7 Oral cavity, masticatory apparatus, tongue, palate, floor of the mouth, salivary glands

Table 9.41 Extrinsic tongue muscles.

Innervation Origin Attachment Function

M. genioglossus
N. hypoglossus [XII] Spina mentalis Corpus linguae Management of the dorsum of tongue and the tongue base
to the front, extension of the tongue
M. styloglossus
N. hypoglossus [XII] Proc. styloideus Margo linguae to the Apex lin- Withdrawal of the Corpus linguae
guae
M. hyoglossus
N. hypoglossus [XII] • Os hyoideum, Cornu majus (M. ceratoglos- Corpus linguae Rotation of the tongue and flattening of the rear section of
sus) the tongue
• Os hyoideum, Cornu minus (M. chondro-
glossus)
M. palatoglossus
N. glossopharyngeus Rear section of the M. transversus linguae Aponeurosis palatina Closure of the Isthmus faucium, lowering of the velum
[IX] and N. vagus [X];
R. pharyngeus

Table 9.42 Innervation of the tongue.

• A. sublingualis: supplies the Glandula sublingualis and mucous
Nerve Quality Areas innervated membranes of the mouth floor
The arteries are accompanied by veins of the same name. The
N. lingualis (branch from Sensible Front ⅔ of the tongue
[V/3])
V. lingualis discharges the blood in the V. facialis to the V. jugularis
interna.
N. glossopharyngeus [IX] Sensible Posterior ⅓ of the tongue
Sensory Papillae foliatae and vallatae
Lymph vessels
N. vagus [X] Sensible Transition to the epiglottis
The regional lymph nodes of the tongue are:
N. laryngeus superior Sensory
(branch from [X])
• Nodi lymphoidei submandibulares
• Nodi lymphoidei submentales
Chorda tympani (branch of Sensory • Papillae fungiformes
• Nodus jugulodigastricus (from the tongue root)
the intermedius part from parasym- • Glandula submandibularis, Glan-
[VII]) pathetic dula sublingualis, salivary glands
From here, the lymph is drained into the deep cervical lymph
of the oral mucosa nodes (Nodi lymphoidei cervicales profundi) (also › Chap. 9.7.8).
N. hypoglossus [XII] Motor All of the tongue muscles with the
exception of the M. palatoglossus Clinical remarks
Plexus pharyngeus (branch- Motor M. palatoglossus
es of [IX and X]) The A. sublingualis runs relatively superficially along the edge
of the Corpus mandibulae. On surgical removal of molars or
the preparation of the jaw crest for bone augmentation, care
Extrinsic tongue muscles must be taken to ensure that the A. sublingualis is not injured
when exposing the jaw.
The extrinsic tongue muscles are all paired and radiate from out­
side into the tongue (› Table 9.41).

Innervation of the tongue

Clinical remarks The tongue has a complex innervation due to its development
In deep unconsciousness the N. genioglossus sags and the (› Table 9.42).
tongue sinks back into the pharynx in the supine position and
can relocate the airway. For this reason, unconscious people Sensible
always have to be positioned in the stable recovery position • Anterior two thirds: the N. lingualis (branch from [V/3]) runs
as quickly as possible.
into the Spatium infratemporale and runs from dorsal to the M.
constrictor pharyngis superior and the M. hyoglossus lying lat­
erally in the tongue.
Vascular, lymphatic and nervous systems • Rear third: the N. glossopharyngeus [IX] lies on the M. stylo­
Arteries and veins pharyngeus and runs from dorsal under the M. hyoglossus into
The tongue is supplied with blood via the A. lingualis from the A. the base of the tongue. The mucosa at the transition to the epi­
carotis externa. The A. lingualis passes via the rear edge of the Dia­ glottis is innervated by the N. laryngeus superior (a branch of
phragma oris medial to the N. hypoglossus and under the M. hyo­ [X]).
glossus into the Corpus linguae and divides it into its terminal
branches: Sensory
• A. profunda linguae (Main branch): runs to the tip of the The Chorda tympani is responsible for sensory innervation of the
tongue (Fig. 10.17) anterior two thirds (branch from [VII]), the N. glossopharyngeus
• Rr. dorsales linguae: supply the base of the tongue and emit [IX] is responsible for the rear third. The Chorda tympani radiates
small branches to the Tonsilla palatina from dorsal in the Spatium infratemporale into the N. lingualis and

519
9 Head

continues with it to the tongue. The Papillae vallatae and foliatae of tween the medial nasal process and maxillary bulge. It can
the tongue are sensory innervated via the N. glossopharyngeus also lead to the formation of cleft jaw, which occurs between
[IX]. The branches of the taste buds in the transition area to the the primary palatal processes and the palatal bulges and can
epiglottis partly join to the N. vagus. be attributed to a non-fusion of the primary palate with the
secondary palatal bulges. They run distally from the second
upper incisors to the Foramen incisivum. Finally, cleft palates
Parasympathetic emerge in the middle of the palate, in which the secondary
The parasympathetic fibres for the Glandula submandibularis and palatal plates do not fuse together and lead to a connection
the Glandula sublingualis run as preganglionic fibres with the between the oral and nasal cavities either on both sides or
Chorda tympani into the N. lingualis and branch from here to the only on one side. Between the different characteristics of the
Ganglion submandibulare, where they are switched to being post­ clefts, there are numerous combinations and degrees of se-
ganglionic. The fibres then run with the terminal branches of the verity. Lip, jaw and palate malformations are the most com-
mon developmental disorders in humans. The form known col-
N. lingualis to the Glandula sublingualis or from the ganglion di­
loquially as a ‘hare-lip’ is a one or two-sided fissure formation
rectly into the Glandula submandibular. on the upper lip. The mildest form is a split uvula. (Uvula bifi-
da). Not all clefts are of genetic origin, but can also be traced
Motor back to a folic acid deficiency of the mother during pregnancy.
With the exception of the M. palatoglossus, all the tongue muscles are
innervated by the N. hypoglossus [XII]. The M. palatoglossus gets its
fibres from the Plexus pharyngeus (branches from [IX] and [X]).
Hard and soft palate
The palate forms the roof of the oral cavity and the floor of the na­
Clinical remarks sal cavity. It is divided into the hard palate (Palatum durum) and
Injuries of the N. hypoglossus [XII] lead to the tongue diverg- the soft palate (Palatum molle). Functionally the hard palate con­
ing to the affected side when extended; in the process, there tributes to the phonation of consonants and serves as an abutment
is muscle atrophy on this side. for the tongue when crushing food. The soft palate blocks off the
nasopharynx from the oropharynx during swallowing (› Chap.
10.7.6) by folding back onto the posterior pharyngeal wall.

9.7.6 Palate Hard palate

The hard palate (Palatum durum) is a domed bony plate and con­
Development sists of the Proc. palatinus of the Maxilla and the Lamina horizon­
From an evolutionary viewpoint, the palate is developed from 3 talis of the Os palatinum. The bony plates meet in the middle in the
palatal processes. In the forehead bulge the unpaired primary pal­ Sutura palatina mediana. At the back the Lamina horizontalis is
ate emerges, which extends from horizontal to dorsal. In the maxil­ connected via the Sutura palatina transversa with the Proc. palat­
lary bulges the two palatal bulges form on the left and right side, inus. The hard palate is penetrated at the front by the Foramen in­
which initially grow around from cranial to caudal on the side edg­ cisivum and at the back by the paired Foramen palatinum majus
es of the tongue. Roughly in the 7th embryonic week the floor of the and the paired Foramina palatina minora.
mouth sinks, whereby the palatal processes rest on the tongue and
reorientate in a horizontal direction. Then they grow as far medial­ Soft palate
ly until they touch in the midline and fuse with the vomer which is The soft palate (Palatum molle) attaches onto the back of the hard
growing from top to bottom. The merger process begins between palate and during the inspection of the oral cavity can be distin­
the primary palate and the palatal processes and continues gradu­ guished from the hard palate by the so-called A line. The basis of
ally dorsally to the rear edge of the palate (› Fig. 9.111). It is com­ the Palatum molle is formed by a horizontal plate of connective tis­
pleted approximately in the 12th week. The epithelium wall lying sue (Aponeurosis palatina), which radiates into the 5 muscles
between the palate processes (HOCHSTETTER's epithelial wall) (› Table 9.43). The Aponeurosis goes back into the fibromuscular
recedes, so that a connective tissue bridge is formed and the clo­ posterior edge of the soft palate, on which the uvula (Uvula palatina)
sure of the palate is completed. sits. Laterally, 2 folds radiate into the uvula on each side, the front
and the rear palatal arch (Arcus palatoglossus and Arcus palato­
pharyngeus).
Clinical remarks
If the palatal processes do not fuse with each other, the result Isthmus faucium
is a variety of cleft formations (cleft lip and palate). A distinc- The palatal arches (Arcus palati) each enclose a pit (Fossa tonsil­
tion is made between cleft upper lip, which is always created laris) in which the palatine tonsil (Tonsilla palatina) is located.
on the side and can be attributed to a lack of closure be- There is a small triangular depression over the Tonsilla palatina
(Fossa supratonsillaris).

Primary
palate Primary palate
Palatine Fig. 9.111 Development of the
Secondary palate
process palate, separation of the nose
Raphe palati and throat area. a 7th week. b
a b c
8th week. c 10th week. [E838]

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 9.7 Oral cavity, masticatory apparatus, tongue, palate, floor of the mouth, salivary glands

• The anterior palatal arch (Arcus palatoglossus) radiates into

the lateral margin of the tongue. Its free medial border can easily
cover the Tonsilla palatina. It is elevated by the M. palatoglossus.
Tuba auditiva
• The posterior palatal arch (Arcus palatopharyngeus) radiates [auditoria]
from behind into the pharyngeal wall. It is elevated by the M. M. tensor
palatopharyngeus. veli palatini
The palatal arches together with the soft palate and the base of the M. levator
tongue form the pharyngeal isthmus (Isthmus faucium) (› Fig. veli palatini
9.112) and make the transition to the oropharynx. M. salpingo-
pharyngeus

Clinical remarks M. uvulae

M. constrictor
About 60 % of men and 40 % of women over the age of 40 pharyngis superior
years snore on a regular basis. In children, it is only 10 %. M. palatoglossus
Snoring (compensated snoring) is to a lesser extent normal
and does not have any value as a disease. The soft palate gen- Tonsilla palatina
erally flutters when it is relaxed during sleep. The clinicians M. palato-
call snoring (ronchopathy) a loud rattling noise, which is cre- pharyngeus
ated in the upper respiratory system and leads to a reduced M. constrictor
supply of oxygen and subsequently to sleep disorders. This is pharyngis medius
known as obstructive snoring.
M. constrictor
If you touch the base of the tongue, the palatal arch or the rear pharyngis inferior
wall of the pharynx, the swallowing or gag reflex is generally
triggered. The muscles of the tongue, the throat, the larynx
and the oesophagus are involved in the reflexes.
Allergic reactions can result in a life-threatening swelling of
the mucosal lining of the soft palate. Fig. 9.112 Muscular base of the Isthmus faucium and the muscles of
Inflammation in the area of the soft palate is usually associat- the soft palate, as well as the pharynx.
ed with severe difficulty in swallowing.
Circulatory disorders of the brain stem occur at an advanced
age in many people. If they affect the catchment area of the A. Palatal mucosa
vertebralis, they are often associated with paralysis of the pal- The palatal mucosa consists of multilevel keratinised squamous ep­
atal muscles on the affected side, the result is swallowing and
ithelium. It cannot be moved on the hard palate, but can be moved
tube ventilation disorders. This can lead to soft palate parese
(damage to the core areas of the N. glossopharyngeus [IX] and
on the soft palate. The hard palate is well perfused. Hundreds of
N. vagus [X]). Due to paralysis of the M. levator veli palatini, small salivary glands (Glandulae palatinae,› Fig. 9.114) are lo­
the soft palate may hang down on the affected side and the cated in the mucosa. Laterally, the mucous membrane runs to the
uvula is shifted to the healthy side. front and side into the gingiva. In the midline, the mucosa is ele­
vated to the Raphe palati. In the front part of the hard palate there
are numerous transverse ridges (palatal graduations, Rugae palati­
nae) which serve the fixation and disintegration of food com­
ponents. On the side facing the nose the soft palate is covered by

M. uvulae

M. tensor veli palatini

Aponeurosis palatina

Proc. pterygoideus, Lamina medialis

Hamulus pterygoideus Proc. pterygoideus
Lamina lateralis

M. tensor veli palatini

M. tensor veli palatini
Lamina lateralis Cartilago tubae
Lamina medialis auditivae

M. levator veli palatini Fossa mandibularis

Semicanalis tubae auditivae

Cartilago tubae auditivae
[auditoriae] M. levator veli palatini

Canalis caroticus, Apertura externa

Fig. 9.113 M. levator veli palatini, M. tensor veli palatini and cartilage of the pharyngotympanic tube, Cartilago tubae auditivae.

521
9 Head

­ ultiple rows of ciliated epithelium, on the oral cavity side by

m porale. On contraction it raises and opens the Ostium tubae audi­
­multilayered squamous epithelium. tivae.

Palatal muscles Vascular, lymphatic and nervous systems

The Aponeurosis palatina forms the connective tissue anchor for 4 Arteries and veins
paired muscles and the unpaired M. uvulae (› Fig. 9.112, › Fig. The arterial supply (› Fig. 9.114) is carried out by:
9.113, › Table 9.43). • A. palatina descendens (terminal branch of the A. maxillaris): it
The M. tensor veli palatini runs from the Lamina medialis of the comes from the Fossa pterygopalatina via the Canalis palatinus
Proc. pterygoideuss forwards below and then bends around the major and the Foramen palatinum majus and reaches the muco­
Hamulus pterygoideus, to horizontally radiate into the Aponeuro­ sa at the transition from the hard to soft palate.
sis palatina. The M. levator veli palatini crosses under the Tuba • A. palatina major: it originates from the A. palatina descendens
auditiva medially below on its way from the outside of the Os tem­ and after penetrating the Foramen palatinum majus runs into

Raphe palati

Glandulae palatinae A. palatina major

N. palatinus major
Hamulus pterygoideus Foramen palatinum majus

Hamulus pterygoideus
M. uvulae
M. constrictor pharyngis superior,
Pars glossopharyngea
Arcus palatopharyngeus
M. buccinator
Arcus palatoglossus
Raphe pterygomandibularis
Tonsilla palatina
M. palatoglossus
Isthmus faucium
M. palatopharyngeus
Dorsum linguae

Fig. 9.114 Oral cavity, Cavitas

oris, and palatal muscles, Mm.
palati. Anterior view.

Table 9.43 Muscles of the soft palate.

Innervation Origin Attachment Function

M. levator veli palatini
Plexus pharyngeus Facies inferior of the Pars petrosa of the Os Aponeurosis palatina Tenses and raises the soft palate, opens the Tuba auditiva
(branches of [IX] and temporale and Cartilago tubae auditivae and closes the nasopharyngeal space together with the M.
[X]), sometimes also constrictor pharyngis superior, bulges out the levator bulge
the N. facialis [VII] of the pharyngeal wall
M. tensor veli palatini
N. tensor veli palatini Lamina medialis of the Proc. pterygoideus, Aponeurosis palatina Tenses the soft palate, opens the Tuba auditiva and deforms
(from [V/3]) Ala major of the Os sphenoidale, Lamina the palate for articulation
membranacea of the Tuba auditiva, it bends
horizontally around the Hamulus pterygoide-
us
M. palatopharyngeus
Plexus pharyngeus Aponeurosis palatina, Hamulus pterygoideus Lateral pharyngeal wall and rear Elevates the pharynx, base of the Arcus palatopharyngeus
(branches from [IX]) and Lamina medialis of the Proc. pterygoide- edge of the Cartilago thyroidea,
us base of Arcus palatoglossus
M. palatoglossus
Plexus pharyngeus Dorsal separation from M. transversus linguae Aponeurosis palatina Closes the Isthmus faucium, sinks the soft palate, base of
(branches from [IX] the Arcus palatoglossus
and [X])
M. uvulae
Plexus pharyngeus Aponeurosis palatina Mucosa of the uvula Shortens the uvula
(branches from [IX]
and [X])

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 9.7 Oral cavity, masticatory apparatus, tongue, palate, floor of the mouth, salivary glands

the palatal mucosa forward to the Foramen incisivum, where it Table 9.44 Vascular supply to the Tonsilla palatina.
establishes contact with the A. nasopalatina of the A. sphenopal­
Supplying artery Terminal branch
atina via the Canalis incisivus.
• Aa. palatinae minores: they originate from the A. palatina de­ A. lingualis Rr. dorsales linguae
scendens and after passing through the Canalis palatinus and the A. palatina ascendens Rr. tonsillares
Foramina palatina minora run to the back to the soft palate and A. pharyngea ascendens Rr. pharyngeales with Rr. tonsillares
to the adjacent structures.
A. palatina descendens R. pharyngeus with Rr. tonsillares
• A. palatina ascendens (from the A. facialis) for the soft palate
and the palatal arches.
• A. pharyngea ascendens (from the A. carotis externa) for the Lymph vessels
soft palate and the palatal arches. The lymph enters regional Nodi lymphoidei cervicales profundi
The venous blood is transported in the Plexus pterygoideus in the (also › Chap. 9.7.8).
Fossa infratemporalis.
Innervation
Blood supply of the Tonsilla palatina It follows via (› Fig. 9.116):
Together with the Tonsilla lingualis in the base of the tongue, the • Terminal branches of the N. nasopalatinus: palatal mucosa and
Tonsilla palatina belongs to WALDEYER's tonsillar ring gingiva in the area of the front teeth (the N. nasopalatinus passes
(› Chap. 10.7.7). The Tonsilla palatina has a highly differentiated through the Foramen incisivum to the hard palate)
vascular supply (› Fig. 9.115, › Table 9.44). • N. palatinus major: gingiva and mucous membranes in the side
tooth region (the N. palatinus major runs on both sides through
the Foramen palatinum majus to the palate)
Clinical remarks • Nn. palatini minores: mucosa of the soft palate (they pass
Tonsillitis is a highly painful inflammation of the Tonsillae through the Foramina palatina minora of the same name to the
­palatinae. It is contagious and can be transmitted by aerosol soft palate)
infection. The main cause of acute tonsillitis are usually Strep-
tococci. Tonsillitis is one of the 20 most common diseases in
general medicine. Clinical remarks
In the case of surgical removal of the Tonsilla palatina (tonsil-
lectomy) the danger of postoperative bleeding is relatively The N. palatinus major at the Foramen palatinum majus can
large and feared due to the large number of arteries. If there is be blocked by conduction anaesthesia. This attains freedom
a so-called dangerous carotid loop (course variant of the Pars from pain in the palatal gingiva in the posterior region. Free-
cervicalis of the A. carotis interna in relation to the rear pha- dom from pain in the palatal gingiva of the front teeth is
ryngeal wall), due to the close relationship of the A. carotis achieved by conduction anaesthesia of the N. nasopalatinus
interna and the tonsil bed (location of the Tonsilla palatina at at the Foramen incisivum.
the posterior margin of the Isthmus faucium) within the frame-
work of a tonsillectomy or when opening a peritonsillar abcess
the A. carotis interna may be damaged and this may lead to a
fatal bleeding. Innervation of the Tonsilla palatina
The innervation of the tonsil bed takes place via the Rr. tonsillares
of the Nn. palatini minores and the N. glossopharyngeus [IX].

Rr. tonsillares M. palatoglossus

(Nn. palatini minores)
Uvula

N. nasopalatinus

M. constrictor pharyngis
Foramen
superior
incisivum
A. palatina descendens
Rr. tonsillares
Sutura palatina
(A. pharyngea ascendens)
mediana
Rr. tonsillares
(A. pharyngea ascendens)
Rr. dorsales linguae A. palatina N. palatinus
(A. lingualis) major major
Rr. tonsillares
(A. palatina ascendens)
N. glossopharyngeus; Aa. palatini Nn. palatini
Rr. tonsillares minores minores
(N. glossopharyngeus)
M. palatopharyngeus
Dorsum linguae
Hamulus Vomer Proc. pterygoideus,
pterygoideus Lamina lateralis
Proc. pterygoideus,
Epiglottis Lamina medialis

Fig. 9.116 Innervation and vascular supply to the hard and soft pal-
Fig. 9.115 Vascular supply to the Tonsilla palatina. ate. [L266]

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9 Head

9.7.7 Floor of the mouth Clinical remarks

Following complete tooth loss in the lower jaw the Proc. alveo-
The floor of the mouth (Diaphragma oris) consists of several
laris recedes. As a result, the Linea mylohyoidea reaches the
muscles, which are stretched between the Corpus mandibulae and upper edge of the Corpus mandibulae. Total prostheses in the
the Os hyoideum (› Fig. 9.117) (› Fig. 9.117–› Fig. 9.119). The lower jaw can therefore have difficulties holding as they sit on
central element of the Diaphragma oris are the two Mm. mylohy- the bone crest of the Corpus mandibulae and the prosthesis is
oidei, which are connected in the midline via the connective tissue pushed upwards on contraction of the muscle when swallow-
Raphe mylohyoidea (› Fig. 9.118, › Fig. 9.119). In addition the ing.
Mm. geniohyoidei, digastrici and stylohyoidei are involved in the
formation of the floor of the mouth. All muscles are directly or
­indirectly connected with the hyoid bone (Os hyoideum, see
› Chap. 10.2.1) and are referred to as Mm. suprahyoidei or supra­ Muscles of the floor of the mouth
hyoid muscles (› Fig. 9.118, › Fig. 9.119, › Table 9.45). The The muscles of the floor of the mouth and the Venter posterior of
floor of the mouth of the tongue functionally serves as an abut­ the M. digastricus or the M. stylohyoideus (which do not belong to
ment. the muscles of the floor of the mouth) are presented in › Table
9.45.
Hyoid bone
The hyoid bone (Os hyoideum) is a U-shaped bone on the floor of Compartments of the floor of the mouth
the mouth (› Fig. 9.117). Since it is not connected with the rest of Between the muscles of the floor of the mouth, connective tissue
the skeleton, but is only suspended via muscles and ligaments, it is gap spaces form, which are referred to as compartments of the
usually missing in the human skeletons used in training. Embryo­ floor of the mouth (› Fig. 9.120):
logically it consists of the cartilage of the 2nd and 3rd pharyngeal • The Spatium parapharyngeum continues between the M. ge­
arches. 2 pairs of horns sit laterally on the body (Corpus hyoidei). nioglossus and the M. geniohyoideus in its anterior part. It con­
The large horn (Cornu majus) is connected to the larynx via the tains the A. lingualis and the V. lingualis.
Membrana thyrohyoidea and its reinforcements (› Chap. 10.2.1) • The Spatium sublinguale extends between the M. geniohyoide­
and dorsally, the small horn (Cornu minus) is connected via the us and the M. mylohyoideus. Medial to the Glandula sublingua­
Lig. stylohyoideum with the Proc. styloideus of the temporal lis is the N. lingualis.
bone. • Under the M. mylohyoideus covered by the platysma, is the Spa-
tium submandibulare with the Glandula submandibularis.
Each of the three oral floor compartments is connected dorsally to
the neurovascular cord of the neck.
Cornu majus

Clinical remarks
Cornu minus
Abscesses in the floor of the mouth can spread out dorsally
and caudally over the vascular nerve cord of the neck into the
Corpus
mediastinum, which may give rise to life-threatening situa-
tions.
Fig. 9.117 Hyoid bone, Os hyoideum. Frontal view from above

Proc. pterygoideus, Lamina medialis M. levator veli palatini

M. tensor veli palatini Tonsilla pharyngea
Hamulus pterygoideus
M. pterygoideus lateralis
Vibrissae Lig. sphenomandibulare
Palatum durum M. pterygoideus
medialis
M. orbicularis oris
Ramus mandibulae
Glandulae labiales
Proc. styloideus
Raphe pterygomandibularis
M. buccinator
Lig. stylohyoideum
Lig. stylomandibulare
M. genioglossus
M. stylohyoideus
Mandibula M. longus capitis
M. digastricus
M. mylohyoideus
Os hyoideum,
M. geniohyoideus Cornu majus

M. hyoglossus
Os Corpus Fig. 9.118 Oral cavity, Cavitas
M. mylohyoideus hyoideum Cornu minus
oris, with presentation of the
Diaphragma oris.

524
 9.7 Oral cavity, masticatory apparatus, tongue, palate, floor of the mouth, salivary glands

Corpus mandibulae
M. digastricus,
M. digastricus, Venter posterior
Venter anterior M. stylohyoideus

M. mylohyoideus M. hyoglossus

Raphe mylohyoidea Os hyoideum

M. digastricus,
M. digastricus, Tendo intermedius
Ansa tendinis
Fig. 9.119 Muscles of the floor
of the mouth. Lateral view from
below.

Mandibula

Glandula
sublingualis
M. mylo-
hyoideus N. lingualis

A.; V.; N. alveolaris

Spatium
inferior
sublinguale
N. hypoglossus [XII]
Platysma
Glandula
M. geniohyoideus submandibularis Fig. 9.120 Horizontal section
through the musculature of the
Spatium sub- floor of the mouth in the area of
Spatium lateropharyngeum M. genio-
mandibulare the Os hyoideum with presenta-
[parapharyngeum], anterior section glossus V. lingualis A. lingualis Os hyoideum tion of the compartments of the
floor of the mouth. [L127]

Table 9.45 Suprahyoid muscles.

Innervation Origin Attachment Function

M. mylohyoideus
N. mylohyoideus Caudal to Linea mylohyoidea, medial to Hyoid bone and Raphe Elevation of the floor of the mouth during swallowing
(branch from [V/3]) Raphe mylohyoidea mylohyoidea
M. geniohyoideus
N. hypoglossus [XII], Spina mentalis Os hyoideum In the case of fixation of the Os hyoideum by the Venter pos-
Plexus cervicalis (C1, terior of the M. digastricus and the M. stylohyoideus, open-
C2) ing of the mouth in fixation of the lower jaw by the masticato-
ry muscles, lifting of the larynx
M. digastricus, Venter anterior
N. mylohyoideus Fossa digastrica of the Mandibula Intermediate tendon of the M. Elevation of the floor of the mouth during swallowing
(branch from [V/3]) digastricus at the Os hyoideum
M. digastricus, Venter posterior (not a muscle of the floor of the mouth)
N. facialis [VII], Incisura mastoidea medial of the mastoid Intermediate tendon at the Os Fixation of the hyoid bone, lifting the larynx
R. digastricus process hyoideum
M. stylohyoideus (not a muscle of the floor of the mouth)
N. facialis [VII], Proc. stylohyoideus Corpus and Cornu majus of the Raises the hyoid bone upwards and backwards during swal-
R. stylohyoideus Os hyoideum lowing

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9 Head

9.7.8 Lymphatic pathways of the oral cavity – Glandulae palatinae (palate)

– Glandulae linguales (tongue), this also includes the paired
The lymph from the oral cavity (› Fig. 9.121, › Table 9.46) col­ Glandula lingualis anterior (BLANDIN -NUHN gland)
lects on both sides in the Truncus jugularis, which extends together – Glandulae gingivales (gums)
with the A. carotis communis and the V. jugularis interna to the V. – Glandulae molares (area of the molar teeth)
subclavia. The major salivary glands partly discharge via longer excretory
ducts into the oral cavity.
Clinical remarks Development
Inflammatory processes in the lower jaw area often lead to a The salivary glands arise during the 6th–7th week as a solid epithe­
swelling of the submental and submandibular lymph nodes. lium sprouting of the ectodermal Stomatodeum.
They are then palpable under the chin or in the Trigonum sub-
mandibulare. Carcinomas of the floor of the mouth metasta- Saliva
sise in the submandibular lymph nodes, in contrast carcino-
The oral cavity is continuously moistened by the saliva (daily ap­
mas of the base of the tongue metastasise to the Nodi lym-
phoidei cervicales profundi. proximately 1.5 l) which is produced in the three major and nu­
merous minor salivary glands. The secretions of the Glandulae
sublinguales and the minor salivary glands serve to moisten the
mucosa of the oral cavity, the secretions of the Glandulae parotide­
ae and submandibulares are in contrast excreted on stimulation.
9.7.9 Salivary glands Saliva consists to 96 % of a liquid part and to 4 % of solid constitu­
ents. The liquid part consists of:
The excretory ducts of the 3 paired large salivary glands as well as • Water
various small salivary glands flow into the oral cavity which, in • Electrolytes
their entirety, are summarised as Glandulae salivariae oris: • Mucus components (mucines)
• Major salivary glands: • Enzymes (α-amylase)
– Parotid gland (Glandula parotidea, Parotis) • Antimicrobial agents (e.g. IgA, lysozymes, defensins)
– Saliva gland of the lower jaw (Glandula submandibularis, Sub­ Solid components are sloughed epithelial cells and a number of
mandibularis) bacteria that colonize inside the oral cavity as physiological flora.
– Sublingual gland (Glandula sublingualis, Sublingualis) The saliva secretion is stimulated by mechanical, chemical, olfacto­
• Minor salivary glands: ry and psychological stimuli.
– Glandulae buccales (cheek)
– Glandulae labiales (lips)

Nodi lymphoidei parotidei superficiales

Nodus lymphoideus buccinatorius

Nodus lymphoideus facialis Nodi lymphoidei mastoidei

Nodus lymphoideus
M. digastricus, Venter anterior jugulodigastricus

Nodi lymphoidei submandibulares

Nodi lymphoidei submentales Nodi lymphoidei occipitales

Nodi lymphoidei cervicales laterales, M. sternocleidomastoideus

Nodi lymphoidei profundi superiores M. splenius capitis
M. omohyoideus, Venter superior Nodi lymphoidei cervicales laterales,
Nodi lymphoidei superficiales
Nodi lymphoidei cervicales laterales,
Nodi lymphoidei profundi inferiores M. levator scapulae
N. accessorius [XI]
Nodus lymphoideus juguloomohyoideus
M. scalenus medius
A. carotis communis
M. trapezius
V. jugularis interna
M. scalenus posterior
Nodus lymphoideus cervicalis lateralis, Plexus brachialis,
Nodus lymphoideus profundus inferior Pars supraclavicularis
M. scalenus anterior M. omohyoideus, Venter inferior

Fig. 9.121 Superficial lymph vessels, Vasa lymphatica superficialia and lymph nodes, Nodi lymphoidei of the head and throat. Lateral view.

526
 9.7 Oral cavity, masticatory apparatus, tongue, palate, floor of the mouth, salivary glands

Table 9.46 Regional lymph nodes of the oral cavity.

Lymph node group Inflow Outflow

Nodi lymphoidei occipitales lie on the origin of the M. trape- Occipital until the skull vertex, neck Nodi lymphoidei cervicales profundi
zius at the level of the Linea nuchae
Nodi lymphoidei retroauriculares lie on the attachment of Back of the ear, skin at the occiput Nodi lymphoidei cervicales profundi
the M. sternocleidomastoideus at the Proc. mastoideus
Nodi lymphoidei parotidei lie on the Glandula parotidea in Forehead, temples, lateral part of the eyelids, nose root, outer Nodi lymphoidei cervicales profundi
front of the outer ear canal ear, outer ear canal, tympanic membrane, Tuba auditiva, Glan-
dula parotidea, nasopharyngeal space
Nodi lymphoidei submandibulares lie in the Spatium sub- Split flow: Nodi lymphoidei cervicales superficiales
mandibulare • Superficial: middle of the forehead and eyelids, outer nose, and profundi
upper lip and cheek
• Deep: tip of the tongue, anterior palatal section and oral
cavity, teeth, gingiva, Vestibulum nasi, Fossa infratemporalis
In addition, they receive inflow from the Nodi lymphoidei facia-
les and submentales
Nodi lymphoidei submentales lie laterally under the Mandib- Chin and the middle of the lower lip, lower jaw incisors and • Nodi lymphoidei submandibulares
ula in the Trigonum submentale gingiva, tongue tip and the floor of the mouth • Nodi lymphoidei cervicales profundi
and superficiales
Nodi lymphoidei buccales lie in the region of the cheek Rear Cavitas nasi and oral cavity and tongue base – Fossa pter- Nodi lymphoidei cervicales profundi
ygoidea and infratemporal palate and pharynx

Clinical remarks dula parotidea lie the A. carotis externa, the V. retromandibularis,
the N. auriculotemporalis and the stem of the N. facialis [VII]. The
For the protection of the teeth they are covered by a largely
bacteria-free, thin biofilm, the pellicle,. The pellicle consists
A. transversa faciei and the Ductus parotideus, which leave the
of the organic components of the saliva and protects the gland toward the anterior section.
enamel from abrasion and acids in food components; howev-
er, various bacteria can become attached and form the basis
for the dental plaque (plaque, pathogenic bacterial biofilm).
Clinical remarks
By brushing your teeth, the pellicle is removed and needs sev- On the outside, the parotid gland compartment is tightly bor-
eral minutes to form again from the saliva. Regular intake of dered by the close-fitting Fascia parotidea, so inflammation
food containing acids (e.g. apples) shortly before brushing and tumours can only spread with difficulty. Inflammatory
can lead to damage to the enamel because brushing the teeth processes (parotitis) spread medially into the Spatium para-
removes the pellicle, but not the entire acid of the saliva in the pharyngeum. On the other hand, infections of the tonsils can
oral cavity, which then attacks the teeth. If minerals are de- break through into the Spatium parapharyngeum. Above the
posited (calcium deposits) in the plaque, calculus occurs. A. carotis externa and the V. retromandibularis, there is a con-
nection to the neurovascular cord of the neck to the mediasti-
num. Suppurative processes in the parotid gland compart-
ment or the Spatium parapharyngeum can therefore spread to
Parotid gland the mediastinum.
The Glandula parotidea is situated in the Regio parotideomasse­ Parotid tumours often require operative treatment. In the pro-
cess, sympathetic and parasympathetic nerve fibres within
terica and is sheathed by a tough fascia (Fascia parotidea) which
the glandular tissue are severed. In the context of the subse-
limits the parotid gland compartment. At the posterior margin of quent recovery parasympathetic fibres can connect to formerly
the Ramus mandibulae the Fascia masseterica divides into a super­ sympathetically innervated sweat glands of the skin above the
ficial and a deep layer. The deep layer medially limits the Spatium parotid gland and lead to gustatory sweating (FREY's syn-
parapharyngeum (› Fig. 9.122), the superficial layer lies close to drome). This is possible because the neurotransmitter on the
the gland as the Fascia parotidea. At the front, the Glandula parot­ postganglionic synapses of both sympathetic and parasympa-
idea lies on the M. masseter, cranially it extends up to the Arcus thetic nerves is acetylcholine. Each time when the parasympa-
thetic system is now activated, e.g. when the affected person
zygomaticus, at the back it borders on the external auditory canal,
is hungry and sees something to eat, the sweat glands are ac-
the Tragus and the Proc. mastoideus, caudally it covers the upper tivated with perspiration formation on the cheek.
part of the M. sternocleidomastoideus. The largest part of the gland Malignant parotid gland tumours can lead to peripheral facial
lies behind the Ramus mandibulae and extends medially to the M. palsy; benign tumours do not normally do this.
pterygoideus medialis and the Proc. styloideus (› Fig. 9.122). The Mumps (Parotitis epidemica) is an acute systemic viral dis-
excretory duct (Ductus parotideus, STENSEN's duct) runs over ease (mostly in childhood), which causes severe swelling of
the M. masseter, penetrates the M. buccinator and flows into the the gland within the parotid gland fascia. This is extremely
Papilla parotidea, opposite the 2nd upper molars. Often, the Duc­ painful for those affected.
SJÖGREN's syndrome is a chronic inflammation of the glands
tus parotideus is surrounded by widely dispersed glandular tissue. of the head and throat area region, but particularly the salivary
These glandular parts are referred to as Glandulae parotideae glands. A distinction is made between primary and secondary
­accessoriae. SJÖGREN's syndrome. At the forefront of the disease is a Sicca
The N. facialis [VII] radiates from the dorsal side into the gland symptomatic, including the dryness of oral (xerostomia) and
and forms the Plexus parotideus within the gland. Through the eye surfaces (xerophthalmia). The salivary glands, in particu-
Plexus parotideus, the gland is divided into a Pars superficialis lar the Glandula parotidea, may be swollen.
and a Pars profunda. In the retromandibular section of the Glan­

527
9 Head

Papilla parotidea

Fascia masseterica
Raphe pterygo-
mandibularis

M. palatoglossus
M. masseter
Tonsilla palatina
Ductus parotideus
M. constrictor pharyngis
superior
M. palato-
pharyngeus
A.; V.; N. alveolaris inferior
Aponeurosis
stylopharyngea Glandula parotidea,
pars superficialis
Septum sagittale
Fascia parotidea
Proc. styloideus with
Mm. stylopharyngeus, stylo- N. facialis [VII]
glossus and stylohyoideus V. retromandibularis
Spatium lateropharyn-
A. carotis externa
geum [parapharyngeum]
Glandula parotidea,
N. glossopharyngeus [IX]
Pars profunda
N. vagus [X] M. sternocleido-
mastoideus Fig. 9.122 Section preparation
A. carotis interna V. jugularis through the parotid gland com-
interna
M. digastricus partment at the level of the
Truncus Foramen mandibulae with pre-
sympathicus Prevertebral Lamina prevertebralis
cervical muscles fasciae cervicalis sentation of the fascia of the
N. hypoglossus [XII] parotid gland compartment.
[L238]

Submandibular gland the gland swells each time (Tumor salivaris) and is painful
The Glandula submandibularis lies in the Trigonum submandib- (salivary stone colic).
ulare (Spatium submandibulare), which is bordered laterally by Malformations in the main excretory ducts, especially of the
the Corpus mandibulae lateral, the Venter anterior of the M. digas­ Ductus submandibularis, can lead to a retention cyst filled
tricus medial and the Venter posterior of the M. digastricus occipi­ with saliva (Ranula).
tally. The roof of the Trigonum submandibulare is formed by the M.
mylohyoideus. The gland body bends together with the Ductus sub­
mandibularis in a hook shape around the rear edge of the M. mylo­ Sublingual gland
hyoideus and connects the Trigonum submandibulare with the Spa­ The Glandula sublingualis is located immediately below the mu­
tium sublinguale (› Fig. 9.123). The Trigonum submandibulare cosa of the floor of the mouth in the Spatium sublinguale on the M.
and the Spatium sublinguale are connected at the rear to the neuro­ mylohyoideus (› Fig. 9.123). The gland body forms the Plica sub­
vascular cord of the neck. The Ductus submandibularis (WHAR- lingualis in the floor of the mouth, in which several small excretory
TON's duct) is surrounded by glandular tissue and lies on the Dia­ ducts of the Glandula sublingualis flow (Ductus sublinguales mi-
phragma oris, where it passes medially beside the Glandula sublin­ nores) . The gland of the Mm. geniohyoideus, genioglossus and hy­
gualis to the Caruncula sublingualis. The gland excretory duct is oglossus lies medially. At the rear the Glandula sublingualis borders
accompanied by the N. lingualis and the A. and V. sublingualis. Ini­ on the Glandula submandibularis (› Fig. 9.123). Apart from the
tially, the A. lingualis is lateral of the glandular excretory duct, then small excretory ducts the Glandula sublingualis has one large ex­
crosses under it and finally enters medially into the tongue. cretory duct (Ductus sublingualis), which merges with the Ductus
submandibularis and flows into the Caruncula sublingualis.
Clinical remarks Vascular, lymphatic and nervous systems
In the excretory duct system of the Glandula submandibularis Glandula parotidea
there is sometimes salivary calculus formation (sialolith). The Glandula parotidea is supplied with blood via the A. tempora-
Through an accumulation of salts and thickened saliva, crys- lis superficialis, a branch of the A. carotis externa. The venous
tallisation germs form that can grow into a salivary calculus and blood flows via the Vv. parotideae, which form the Plexus ptery­
can completely displace the excretory duct. When eating
goideus, in the V. facialis.

528
 9.7 Oral cavity, masticatory apparatus, tongue, palate, floor of the mouth, salivary glands

Plica sublingualis
Ductus sublinguales minores

Caruncula sublingualis
M. pterygoideus
Ductus sublingualis major medialis
Glandula sublingualis N. lingualis
M. genioglossus Glandula submandibularis
M. geniohyoideus Ductus submandibularis

M. digastricus, Venter anterior Fig. 9.123 Glandula subman-

Os hyoideum dibularis and Glandula sublin-
M. mylohyoideus
gualis of the right side.

The lymph is transported away via Nodi lymphoidei parotidei su­ the N. auriculotemporalis (branch from [V/3]), reach the parotid
perficiales and profundi in the Nodi lymphoidei cervicales superfi­ gland compartment via it and branch out as the Plexus parotideus
ciales. in the gland parenchyma. They accompany the branches of the N.
The parasympathetic innervation takes place via JACOBSON's facialis [VII] in sections in the Glandula parotidea (› Fig. 9.124).
anastomosis. The nerve cell body lies in the Nucleus salivatorius The sympathetic innervation begins from the Ganglion cervicale
inferior, the nerve fibres run with the N. glossopharyngeus [IX] superius. The postganglionic sympathetic fibres pass with the
via the N. tympanicus, Plexus tympanicus and N. petrosus minor branches of the A. carotis externa into the gland.
to the Ganglion oticum.. The switched, postganglionic fibres join

R. communicans*
Glandula lacrimalis
Nn. ciliares breves
Ganglion ciliare N. oculomotorius [III]
Radix para- Nucleus oculomotorius accessorius
sympathica (autonomicus)**
(oculomotoria)
N. ophthalmicus [V/1]
M. sphincter pupillae N. maxillaris [V/2]

M. ciliaris N. petrosus major

N. trigeminus [V]
Nucleus salivatorius superior
R. communicans* N. facialis [VII]

Ganglion pterygopalatinum Nucleus salivatorius inferior

N. glossopharyngeus [IX]
Glandulae nasales
N. tympanicus***
Ganglion oticum
Chorda tympani
Glandulae palatinae
Rr. parotidei and Rr. communi-
cantes cum nervi faciali
Glandula lingualis anterior
N. facialis [VII]
(Apicis linguae)****
Glandulae linguales N. auriculotemporalis
N. glossopharyngeus [IX]
N. lingualis
N. mandibularis [V/3]
Glandula sublingualis Glandula parotidea
N. lingualis
Ganglion sublinguale
Glandula N. lingualis
submandibularis
Ganglion submandibulare

Fig. 9.124 Parasympathetic innervation of the salivary glands of the head;∗ lacrimal gland anastomosis, ∗∗ EDINGER-WESTPHAL nucleus,
∗∗∗
JACOBSON'S nerve, ∗∗∗∗ BLANDIN-NUHN gland.

529
9 Head

Glandula submandibularis lingualis originates from the A. carotis externa. The venous dispos­
The Glandula submandibularis is supplied with blood via the A. al takes place via the V. sublingualis, which flows into the V. lin­
facialis and the A. lingualis from the A. carotis externa. The ve­ gualis. From here, the blood drains into the V. jugularis interna.
nous blood flows via the V. submentalis, which discharges into the As for the Glandula submandibularis, the lymph is transported in
V. facialis. From here, the blood drains into the V. jugularis interna. the directly neighbouring Nodi lymphoidei submandibulares and
The lymph is transported into the directly neighbouring Nodi lym­ from here to the Nodi lymphoidei cervicales superficiales and pro­
phoidei submandibulares and from here to the Nodi lymphoidei fundi.
cervicales superficiales and profundi. The parasympathetic secretory innervation corresponds to the
The parasympathetic secretory innervation of the gland takes innvervation of the Glandula submandibularis and therefore fol­
place from the Nucleus salivatorius superior via the N. intermedius lows the Chorda tympani, which passes with the N. lingualis to the
of the N. facialis [VII]. This emits the Chorda tympani backwards Ganglion submandibulare. Postganglionic fibres join the N. lingua­
in front of the Foramen stylomastoideum, which passes through lis again and reach the gland (› Fig. 9.124). The sympathetic in-
the middle ear to the skull base, usually penetrates the Fissura nervation also corresponds to that of the Glandula submandibu­
sphenopetrosa and radiates behind the temporomandibular joint laris.
caudally in the N. lingualis. From the N. lingualis the Rr. ganglion­
ares pass to the Ganglion submandibulare, in which the switch to
postganglionic fibres is carried out (› Fig. 9.124). The sympathet-
Clinical remarks
ic innervation takes place via the Ganglion cervicale superius. In the context of kidney disease, urea-containing substances
From here the postganglionic fibres pass together with the A. sub­ are excreted via the salivary glands.
mandibularis into the gland. Radiation therapy for the treatment of tumours of the head
and throat area region or radioactive irradiation can lead to
sicca syndrome (dry mouth) with swallowing and speech diffi-
Glandula sublingualis
culties.
The Glandula sublingualis is supplied with blood via the A. lingua-
lis, from which the A. sublingualis leaves as a small branch. The A.

530
10 Neck
10.1 Overview 10.5 Thyroid and parathyroid glands
Michael Scholz . . . . . . . . . . . . . 533 Michael Scholz . . . . . . . . . . . . . 559
10.1.1 Surface anatomy 10.5.1 Location and function . . . . . . 559
of the neck . . . . . . . . . . . . . . . . 533 10.5.2 Development . . . . . . . . . . . . . . 559
10.1.2 Regions of the neck 10.5.3 Vascular, lymphatic
and neck triangles . . . . . . . . . 534 and nervous systems . . . . . . . 561
10.2 Musculoskeletal 10.6 Larynx
system of the neck Friedrich Paulsen . . . . . . . . . . . 562
Michael Scholz . . . . . . . . . . . . . 534
10.6.1 Overview . . . . . . . . . . . . . . . . . 563
10.2.1 Passive sections . . . . . . . . . . . 534
10.6.2 Development . . . . . . . . . . . . . . 563
10.2.2 Active sections –
neck muscles . . . . . . . . . . . . . . 535 10.6.3 Laryngeal skeleton . . . . . . . . . 564
10.6.4 Laryngeal levels . . . . . . . . . . . 571
10.3 Cervical fascia and 10.6.5 Structure of the Plicae vocales
connective tissue spaces und Plicae vestibulares . . . . . 572
Michael Scholz . . . . . . . . . . . . . 541
10.6.6 Vascular, lymphatic
10.3.1 Neck fasciae . . . . . . . . . . . . . . 542 and nervous systems . . . . . . . 573
10.3.2 Connective tissue
spaces of the neck . . . . . . . . . 543 10.7 Pharynx
Wolfgang H. Arnold . . . . . . . . . 575
10.4 Vascular, lymphatic and 10.7.1 Development . . . . . . . . . . . . . . 575
nervous systems of the neck
Michael Scholz . . . . . . . . . . . . . 545 10.7.2 Levels of the pharynx . . . . . . . 575

10.4.1 Arteries of the neck . . . . . . . . 545 10.7.3 Pharyngeal wall . . . . . . . . . . . 576

10.4.2 Veins of the neck . . . . . . . . . . 548 10.7.4 Pharyngeal musculature . . . . 576

10.4.3 Nerves of the neck . . . . . . . . . 550 10.7.5 Vascular, lymphatic

and nervous systems . . . . . . . 577
10.4.4 Lymph nodes of the neck . . . . 557
10.7.6 Swallowing . . . . . . . . . . . . . . . 579
10.7.7 Lymphatic pharyngeal ring . . 579
 CLINICAL CASE

Branchial cleft cyst

(median) branchial cysts and laterally located branchial cysts. A
Case study lateral neck cyst is the result of an incorrect degeneration of the
A father comes with his 6-year-old daughter to the paediatrician. For embryonic pharyngeal arch system in this area (Sinus cervicalis). This
some time now the daughter has been complaining of a recurrent means that in most cases lateral branchial cysts are found on the
swelling with pressure on the left side of the neck. Until now, the side of the neck area above the M. sternocleidomastoideus.
swelling always went away without medical treatment. For over a
week now, however, the swelling has been permanently present with
increasing pain, significant redness at the site and high temperature.
Treatment
Firstly the acute inflammation is treated with antibiotics, analgesics
and fever-reducing medications; however, because the infection is
Further diagnostics and diagnosis likely to recur or a fistula may form, the neck cyst should be opera-
To determine the suspected diagnosis of a branchial cleft cyst, the tively removed. Typically, this operation is a relatively complica-
paediatrician advises the girl to see an ear, nose and throat special- tion-free, routine procedure; however, great care should be taken to
ist, who carries out an ultrasound examination and magnetic completely remove all of the cyst tissue, to ensure that there is no
resonance imaging (MRI) of the neck area. Here, a lateral neck cyst on recurrence. When the parents decided on surgery, the girl was
the anterior margin of the left M. sternocleidomastoideus can be ­operated shortly after. She stayed overnight on a ward for obser­
unequivocally seen and can be differentiated from any other possible vation and was discharged the next day. Since then, the wound has
swellings. Branchial cleft cysts (closed) or neck fistulae (perforating healed well and there are no further symptoms.
the skin) are created by congenital developmental abnormality of the
neck structures. A differentiation is made between centrally located

You are completing your paediatric rotational placement and are involved in examining a young
patient with a suspected lateral cervical cyst. Since you find this case exciting and would like to use
it for the patient presentation in the paediatric seminar, you make notes.

From the paediatrician to ENT

6 year-old female patient with recurrent swelling
and feeling of pressure in the area of the left side of the neck,
to date, the swelling has always disappeared by itself
Current: permanent swelling for more than 1 week, increasing
level of pain, obvious redness, increased temperature.

Suspected diagnosis: lateral cervical cyst

CAVE! Difference median and lateral cervical cysts?!?

Further Proc: Transfer to ENT specialist (scan?)

Read at home: Etiology, pathology, clinical aspects, differential
diagnosis, treatment!!!
 10.1 Overview

The neck (Collum, Cervix) is the tubular, mobile connecting ele- 10.1.1 Surface anatomy of the neck
ment between the head and the upper body. The cervical spine is
the bony foundation on which the head sits. The arrangement and The shape and appearance of the throat area are primarily defined
structure of the cranial joints permit the free rotation of the head by the more or less strongly defined neck muscles, the size and
in relation to the trunk by almost 90° on each side. In evolutionary shape of the thyroid gland (Glandula thyroidea) and larynx, as well
development, this only became possible about 370 million years as the distribution of subcutaneous fat. A cranial view reveals an
ago, at a time when the first amphibians conquered solid ground. elongated oval shape, while a caudal view shows a more trans-
In comparison, in fish the head and spine remain immobile in rela- verse-oval cross-section of the neck. In men, the thyroid cartilage
tion to each other even today; however, in phylogenetic terms, the (Cartilago thyroidea) can be clearly recognised and palpated in
neck area with its structures should not be thought of as a funda- the throat as the Adam's apple (Prominentia laryngea) (› Ta-
mentally new idea. In fact, this part of the body is expressed in the ble 10.1). Conversely, in women and children this structure hardly
most understandable way as an almost protracted head–torso bor- stands out in relief from the throat area. The position of the hyoid
der area. Taken from this perspective, this also explains why, for bone (Os hyoideum) can be determined by a transverse skin fold
example, the nerves of the head are also involved in the innerva- above the larynx, which also represents the visible external border
tion of the shoulder muscles and why it is that the upper limbs are between the base of the mouth and neck.
supplied by nerves exiting from the cervical spine. The neck is not The bony limits of the neck are cranially the lower jaw (Mandibu-
just purely a connecting element; it also contains organs, such as la) and the occipital bone (Os occipitale), and caudally the collar-
the thyroid gland, parathyroid gland and the larynx. bones (Claviculae) and the upper edge of the shoulder blades
(Scapulae). Through the upper thoracic aperture, an interconnect-
Clinical remarks
Table 10.1 Easily palpable structures and bone points in the neck
Injuries to the neck region are generally regarded as very dan- region.
gerous, since close to the cervical spine in the soft tissues
there are many important structures, such as large blood ves- Anatomical structure Palpable section
sels and nerves and the respiratory and digestive tracts.
Lower jaw (Mandibula) • Lower edge
Os temporale • Proc. mastoideus
Os occipitale • Protuberantia occipitalis externa

10.1 Overview Breast bone (Sternum) • Upper edge

Michael Scholz Clavicle (Clavicula) • Upper edge
Shoulder blade (Scapula) • Acromion
Os hyoideum • Corpus
Skills • Cornu majus ossis hyoidei

After working through this chapter, you should be able to: Larynx • Cartilago thyroidea
• name the specific structures of the neck and describe its • Cartilago cricothyroidea
ana­tomical structures Windpipe (Trachea) • Cricoid cartilage
• describe the various regions of the neck in a topographically
Jugular fossa (Fossa jugularis)
correct way and clearly define their limits
VII Cervical vertebra; Vertebra prominens • Proc. spinosus

M. stylohyoideus M. digastricus, Venter posterior

Trigonum submandibulare
M. sternocleidomastoideus
M. digastricus,
Venter anterior

Trigonum submentale Trigonum caroticum

Os hyoideum
Trigonum cervicale posterius
Trigonum musculare

M. omohyoideus, Venter superior M. trapezius

Trigonum omoclaviculare M. omohyoideus, Fig. 10.1 Anterior (blue) and

Venter inferior lateral (green) neck regions
from left lateral (diagram). The 4
sections of the anterior neck tri-
angle with the structures delim-
iting it are also shown. [E402]

533
10 Neck

ed bony ring made up of the breastbone (Sternum), the first pair of 10.2 Musculoskeletal system of the neck
ribs and the first thoracic vertebra, the neck passes caudally by Michael Scholz
definition into the Mediastinum of the thorax. At the base of the
anterior cervical region, just above the sternum as a clearly visible
trough is the jugular fossa (Fossa jugularis). By light pressure in Skills
this area, one can easily feel the upper cartilaginous braces of the
windpipe (Trachea) just under the skin. To the dorsal side of the After working through this chapter, you should be able to:
airway (larynx, trachea) in the throat area are the cervical sections • name the active and passive musculoskeletal system of the
neck individually, as well assign their structures and func-
of the gastrointestinal tract (pharynx, oesophagus) and behind
tions to each of them
them is the cervical spine.

10.1.2 Regions of the neck and neck triangles In the neck, the parts of the musculoskeletal system can be divided
up into passive and active elements.
In principle the neck can be divided into 4 large regions (› Fig.
11.2):
• Regio cervicalis anterior 10.2.1 Passive sections
• Regio sternocleidomastoidea
• Regio cervicalis lateralis The passive parts include the cervical spine and its skeletal joints,
• Regio cervicalis posterior the intervertebral discs and ligaments (› Chap. 3.3.2) and the hy-
In addition, several of the respective regions can be defined as sin- oid bone (Os hyoideum) with its ligament connections. The hyoid
gle, subdividing neck triangles (Trigona cervicis) (› Fig. 10.1, bone is a horseshoe-shaped, curved bone of approximately 3–5 cm
› Table 10.2). The M. sternocleidomastoideus, which is in the in size, made up of a body (Corpus ossis hyoidei) and 2 greater
lateral neck area and represents a clear ridge under the skin, is the horns (Cornua majora) and 2 lesser horns (Cornua minora)
prominent structure for classifying the cervical regions. The mus- (› Fig. 10.2). The hyoid body and the Cornua majora can usually
cle originates from the Manubrium sterni (Caput sternale) and at be easily palpated externally.
the sternal end of the clavicle (Caput claviculare) and runs cranial- The medial constrictor muscles of the pharynx (M. constrictor
ly and to the back to the Proc. mastoideus of the Os temporale and pharyngis medius) are attached to this. The hyoid bone has no
the Linea nuchalis superior. The lateral neck region, which is de- connection to other bony structures and is stretched between the
fined by this muscle, is referred to as the Regio sternocleidomas- muscles of the base of the mouth (suprahyal muscles) and the in­
toidea. Medial to the two Mm. sternocleidomastoidei is the frontal frahyoid muscles. As a result it is hinged and mobile within this
triangle of the neck (Regio cervicalis anterior; Trigonum cervi- muscle sling. The Lig. stylohyoideum connects the hyoid bone
cale anterius). This region (› Fig. 10.1, blue) can be topographi- with the base of the skull (Os temporale). The ligament stops the
cally divided, due to the deeper lying structures, into other smaller Os hyoideum from being pulled below the level of the IV cervical
neck triangles (› Table 10.2). Lateral to the M. sternocleidomas- vertebra and can completely or partially ossify with age. Via the
toideus is the lateral triangle of the neck (Regio cervicalis latera- Membrana thyrohyoidea, the hyoid bone is connected with the
lis; Trigonum cervicale posterius), which is delimited posteriorly thyroid cartilage (Cartilago thyroidea) of the larynx (› Fig. 10.3,
by the anterior border of the M. trapezius and caudally by the mid- also › Chap. 10.6.3). The membrane is centrally reinforced by the
dle third of the clavicle. Here (› Fig. 10.1, green) the Venter infe- Lig. thyrohyoideum medanium which runs from the Incisura
rior musculi omohyoidei runs in the lower part, creating another thyroidea superior to the Corpus ossis hyoidei. The reinforced rear
triangle, the Trigonum omoclaviculare (Fossa supraclavicularis
major), (› Fig. 10.1). The posterior neck region (Regio cervica-
lis posterior) is mainly characterised by compact, strongly built Cornu majus
neck muscles.
Cornu minus

Corpus
Table 10.2 Subdivision of the Regio cervicalis anterior in its Trigona
with its respective delimitations.
Fig. 10.2 Hyoid bone (Os hyoideum). View from upper front
Subdivision Delimitation
Trigonum submandibulare • Lower rim of the mandibula
Os hyoideum,
(paired) • Venter anterior and Venter posterior of the
Cornu majus
M. digastricus
Lig. thyrohyoideum
Trigonum submentale • Venter anterior of the M. digastricus Os hyoideum,
laterale
(unpaired) • Os hyoideum Corpus
Membrana Cartilago triticea
Trigonum caroticum • Venter posterior of the M. digastricus
thyrohyoidea
(paired) • M. stylohyoideus Cartilago thyroidea,
• Venter superior of the M. omohyoideus Lig. thyrohyoideum Cornu superius
• Anterior border of the M. sternocleidomastoideus medianum
Cartilago thyroidea,
Incisura thyroidea Lamina sinistra
Trigonum musculare • Os hyoideum
superior
(paired) • Venter superior of the M. omohyoideus
• Anterior border of the M. sternocleidomastoideus
Fig. 10.3 Ligament connections between the hyoid bone (Os hyoide-
• Midline of the neck
um) and the thyroid cartilage (Cartilago thyroidea) of the larynx.

534
 10.2 Musculoskeletal system of the neck

Glandula parotidea

M. sternocleidomastoideus
Platysma

M. levator scapulae

M. trapezius

Fig. 10.4 Superficial muscles of

the neck in the anterior and lat-
eral head and neck region. View
from left, lateral.

edge of the Membrana thyrohyoidea is referred to as the Lig. thy- Table 10.3 Stratifying structure of the neck muscles.
rohyoideum laterale and in its course from the Cornu majus ossis
Superficial muscle Middle muscle layer Deep muscle layer
hyoidei to the Cornu superius of the thyroid cartilage, it wraps layer
around a small piece of elastic cartilage of just a few millimetres in
size (Cartilago triticea). • Platysma • Suprahyoid muscles • Mm. scaleni
• M. sternocleidomas- • Infrahyoid muscles • Prevertebral muscles
toideus
Clinical remarks
In the case of a fracture of the hyoid bone by force (e.g. a Superficial layer of the cervical muscles
chokehold) parts of the hyoid bone can drop down to the lar- The superficial neck muscles include the platysma and the M. ster-
ynx and prevent swallowing (risk of aspiration). nocleidomastoideus.

Platysma
The platysma is a thin, broad muscle plate located directly under
10.2.2 Active sections – neck muscles the skin. It belongs to the facial muscles and has no fascia. It origi-
nates variably with its fibres in the skin below the Clavicula in the
The active musculoskeletal system is formed by the throat and neck upper chest and inserts at the lower margin of the Mandibula. In its
muscles. From a topographical viewpoint, the muscles of the nape course it covers the superficial neck veins and a large part of the M.
of the neck as well as the M. trapezius are part of the throat area sternocleidomastoideus. Between the platysma and the M. sterno-
muscles; however, in functional terms the M. trapezius is part of cleidomastoideus is the lower pole of the parotid gland (Glandula
the shoulder girdle muscles and the neck musculature is regarded parotidea) (› Fig. 10.4). There is a great variation in the extent of
as part of the autochthonous back muscles (M. erector spinae). individual platysmas; in rare cases it extends only to the neck mid-
The neck muscles can be divided into a superficial, medium and line or is completely missing. The platysma is innervated by the R.
deep muscle layer (› Table 10.3). colli of the N. facialis [VII]. This nerve branch generally arises
from the branches of the N. facialis [VII] within the parotid gland
and forms a nerve loop with the R. superior of the N. transversus

Table 10.4 M. sternocleidomastoideus.

Innervation Origin Attachment Function

M. sternocleidomastoideus
N. accessorius [XI]) • Caput sternale: upper edge of the Manubrium Proc. mastoideus; Linea nuchalis • With unilateral activity: lateral inclination of the head to
sterni superior the ipsilateral side and rotation to the contralateral side
• Caput claviculare: medial third of the Clavicula • Where there is bilateral activity: dorsiflexion of the head
• Where the head is fixed: auxiliary respiratory muscle

535
10 Neck

colli (From the Punctum nervosum cervicis, ERB's point; Plexus contralateral side (‘head turning muscle’). Simultaneous contrac-
cervicalis) (› Fig. 10.20). Using this connection, motor nerve fi- tion of both Mm. sternocleidomastoidei leads to the dorsiflexion of
bres of the N. transversus colli reach the distant sections of the pla- the head.
tysma. Due to its course, the platysma tenses the skin of the neck When the head is in a fixed position, the M. sternocleidomastoide-
by contraction, so has an impact on facial expressions (threatening us acts as an auxiliary respiratory muscle.
gestures).
Clinical remarks
NOTE
The N. transversus colli runs directly transversally via the M. sterno- A unilateral shortening of the M. sternocleidomastoideus can
cleidomastoideus and below the platysma. lead to a twisted neck muscle (Torticolis muscularis). The
cause is usually a congenital malformation of the muscle;
however, traumatic or inflammatory processes (myositis) may
also lead to scarring and shortening of the muscle. Muscle
M. sternocleidomastoideus
contraction and the associated slanted position of the head
The M. sternocleidomastoideus (› Table 10.4) forms the border can result in facial and cranial asymmetry.
between the anterior (Regio cervicalis anterius) and lateral (Regio
cervicalis lateralis) neck regions. It originates with a head for each
muscle at the upper edge of the Manubrium sterni (Caput ster-
nale) and at the sternal end of the Clavicula (Caput claviculare). Middle layer of the cervical muscles
Located between the two original heads is the Fossa supraclavicu- The middle layer of the neck muscles form the suprahyoid and in­
laris minor (› Fig. 10.5). The Caput sternale and the Caput cla- frahyoid muscles (› Table 10.5). Both muscle groups are attached
viculare join together in their course into a broad muscle belly, to the hyoid bone and their interaction determines the position of
which rises obliquely from the chest to the head and is inserted
with a strong tendon on the Proc. mastoideus and on the Linea Table 10.5 Suprahyoid and infrahyoid muscles.
nuchalis superior. Between the two sternal heads of the right and
left muscles, the Fossa jugularis is easily visible on the surface Suprahyoid muscles Infrahyoid muscles
(jugular fossa). The M. sternocleidomastoideus, together with the • M. stylohyoideus • M. sternohyoideus
M. trapezius receives its motor innervation from the N. accessori- • M. digastricus • M. omohyoideus
us [XI] because at the embryo stage both muscles arose from a – Venter anterior – Venter superior
common system and are derived from former pharyngeal arch – Venter posterior – Venter inferior
muscles. A unilateral contraction of the muscle causes a sideways • M. mylohyoideus • M. thyrohyoideus
• M. geniohyoideus • M. sternothyroideus
tilting of the head to ipsilateral and a rotational movement to the

M. digastricus, Venter anterior

Os hyoideum
A; V. facialis
M. mylohyoideus
Glandula submandibularis M. stylohyoideus

M. masseter M. digastricus,
Venter posterior
Glandula parotidea

M. hyoglossus M. levator scapulae

M. sternohyoideus
M. splenius cervicis
M. scalenus medius
Lig. thyrohyoideum medianum M. longus capitis
A. carotis communis; V. jugularis interna Cartilago thyroidea
M. thyrohyoideus M. omohyoideus, Venter superior
M. sternothyroideus Lig. cricothyroideum medianum
M. scalenus medius M. cricothyroideus
Fascia cervicalis, Lamina pretrachealis Arcus cartilaginis cricoideae
Plexus brachialis, Pars supraclavicularis Glandula thyroidea
M. scalenus anterior M. scalenus medius
M. omohyoideus, Venter inferior M. sternocleidomastoideus
M. trapezius Trachea
V. subclavia Clavicula

Fig. 10.5 Various parts of the neck musculature and throat structures. Ventral view.

536
 10.2 Musculoskeletal system of the neck

the hyoid bone. They are functionally involved in swallowing and M. stylohyoideus
speech formation. The M. stylohyoideus (› Table 10.5) originates with a thin tendon
at the base of the Proc. stylohyoideus and runs ventrocaudally to
Suprahyoid muscles the lateral wall of the Corpus ossis hyoidei. Immediately before its
The muscles summarised by the term suprahyoid have their origins attachment to the hyoid bone it divides into 2 tendon strands and
in different embryonic structures: surrounds the intermediate tendon of the M. digastricus (Ansa
• The M. mylohyoideus and the Venter anterior of the M. digas- tendinis), which it secures (› Fig. 10.6). During swallowing, it
tricus form from the 1st pharyngeal arch. pulls the hyoid bone backwards and upwards. It is innervated by
• The Venter posterior of the M. digastricus and the M. stylohy- the N. facialis [VII].
oideus arise from the 2nd pharyngeal arch.
• The M. geniohyoideus is part of the rectus system of the neck. It M. digastricus
originates from the somites of the neck. The M. digastricus (› Table 10.6) has 2 bellies, a shorter Venter
The varied origins of each individual superior hyoid bone muscles anterior and a longer Venter posterior, which are connected to-
also explains why they are innervated by different nerves. gether by a tendon. This, in turn, is held in place by a loose connec-
tive tissue loop (Ansa tendinis) at the Corpus ossis hyoidei (› Fig.

Table 10.6 Suprahyoid muscles.

Innervation Origins Attachment Function

M. stylohyoideus
R. stylohyoideus of the Proc. styloideus of the Os temporale Corpus and Cornu majus ossis In bilateral activity pulls the hyoid bone backwards and
N. facialis [VII] hyoidei upwards
M. digastricus, Venter anterior and Venter posterior
• Venter anterior: N. mylo- • Venter anterior: Fossa digastrica mandi­ Intermediate tendon via connec- • Hyoid fixed and bilateral activity: sinking (abduction)
hyoideus from [V/3] bulae tive tissue at the Cornu majus of of the Mandibula = mouth opening
• Venter posterior: • Venter posterior: Incisura mastoidea the hyoid bone • Hyoid fixed and unilateral activity: grinding move-
R. digastricus of the ment
N. facialis [VII] • Lower jaw fixed and bilateral activity: lifting of the
hyoid bone during swallowing
M. mylohyoideus
N. mylohyoideus of the Linea mylohyoidea of the Mandibula Raphe mylohyoidea, Corpus ossis • Raises the floor of the mouth, mouth opens (lowers
N. mandibularis [V/3] hyoidei the mandible with bilateral activity and fixed hyoid
bone)
• With unilateral activity and fixed hyoid bone: grind-
ing movement
• With bilateral activity and fixed lower jaw: lifts the
hyoid bone during swallowing
M. geniohyoideus
Muscular branches (C1, C2) Spina mentalis of the Mandibula Corpus ossis hyoidei • Raises the floor of the mouth, mouth opens (lowers
which run with the N. hypo- the mandible with bilateral activity and fixed hyoid
glossus [XII] bone)
• With unilateral activity and fixed hyoid bone: grind-
ing movement
• With bilateral activity and fixed lower jaw: lifts the
hyoid bone during swallowing

Corpus mandibulae

M. digastricus,
M. mylohyoideus
Venter posterior

M. digastricus,
Venter anterior M. stylohyoideus

Raphe mylohyoidea
Os hyoideum
M. digastricus,
Ansa tendinis
M. hyoglossus Fig. 10.6 Mouth base region
with suprahyoid muscles. View
from the side below.

537
10 Neck

10.6). The Venter anterior originates in the Fossa digastrica on the both sides increasingly converge up to the hyoid bone, with the
inside of the Mandibula and is innervated as the superficial separa- Prominentia laryngea (Adam's apple) of the thyroid cartilage re-
tion of the M. mylohyoideus in the same way as the one from the maining uncovered (› Fig. 10.5). In the region of origin of the
N. mylohyoideus (N. mandibularis [V/3]). The Venter posterior M. sternohyoideus an intermediate tendon can be individually
originates on the Incisura mastoidea at the medial side of the Proc. present.
mastoideus (Os temporale). This arises from the same position as
the M. stylohyoideus and is therefore also innervated by the N. fa- M. omohyoideus
cialis [VII] (R. digastricus). When the Mandibula is fixed, the The M. omohyoideus (› Table 10.7) originates from the upper
M. digastricus raises the hyoid bone (swallowing); when the hyoid border of the scapula in the area of the Lig. transversum scapulae
bone is fixed, it opens the mouth (lowering the Mandibula). and is attached to the hyoid bone (› Fig. 10.5). Its origin is also
the reason for its name from the old anatomical term ‘omoplata’
M. mylohyoideus for the shoulder blade. The muscle is divided by an intermediate
The M. mylohyoideus (› Table 10.6) originates at the Linea mylo- tendon into 2 muscle bellies, a Venter superior and a Venter inferi-
hyoidea of the Mandibula and is located above the Venter anterior or. The Venter inferior originates medial of the Incisura supra­
of the M. digastricus. The wide muscle plates on both sides unite scapularis on the Margo superior of the shoulder blade. In its
along the centre line in the approximately 4–5 cm long Raphe my- course, it runs as an upper boundary of the Trigonum omoclavicu-
lohyoidea. The posterior muscle fibres insert on the Corpus ossis lare (Fossa supraclavicularis major) through the lateral triangle of
hyoidei (› Fig. 10.5). The M. mylohyoideus is innervated by the the neck to the front and continues with its intermediate tendon
N. mylohyoideus (N. mandibularis [V/3]) and supports and raises directly on the carotid sheath (Vagina carotica). The Venter supe-
the floor of the mouth. rior has its origin at the intermediate tendon and runs upwards to
the Corpus ossis hyoidei. Here it is located directly lateral to the
M. geniohyoideus attachment point of the M. sternohyoideus (› Fig. 10.5).
The M. geniohyoideus (› Table 10.6) lies cranially on the M. my-
lohyoideus and runs from the Spina mentalis of the Corpus man- NOTE
dibulae to the Corpus ossis hyoidei. It is a narrow, paired muscle, The intermediate tendon of the M. omohyoideus is located behind
the medial sides of which are virtually touching in their course. the M. sternocleidomastoideus and crosses over the carotid
The muscle arises from the rectus system of the neck and hence is sheath. At the intersection point, the intermediate tendon and the
innervated by a branch of the Plexus cervicalis (C1). When the Vagina carotica merge together. Through the background tension of
the M. omohyoideus, the carotid sheath is permanently under ten-
Mandibula is fixed, it raises the hyoid bone and assists with open- sion at this point. Therefore, the lumen of the V. jugularis interna is
ing the mouth when the Os hyoideum is fixed. enlarged and the venous blood return to the heart is better than it
would be without this tension. As a result the point of intersection
Infrahyoid muscles at the level of the cricoid cartilage can also be used as a puncture
The 4 flat muscle pairs of the infrahyoid muscles continue the rec- point for intravenous access.
tus system of the trunk to cranial. All of these are within the Trigo-
num musculare of the Regio cervicalis anterius, and are stretched
between the sternum, thyroid cartilage, hyoid bone and in their M. thyrohyoideus
course cover the trachea, thyroid gland and a large part of the lar- The M. thyrohyoideus (› Table 10.7) runs from the Linea obliqua
ynx. They are divided into 2 layers, with the upper layer formed of the thyroid cartilage (Cartilago thyroidea) to the Cornu majus of
from the M. sternohyoideus and the M. omohyoideus, and the the hyoid bone (› Fig. 10.7). In its course, it lies beneath the Ven-
lower layer from the M. sternothyroideus and the M. thyrohyoi- ter superior of the M. omohyoideus and beneath the M. sternohy-
deus (› Fig. 10.5). All the infrahyoid muscles are innervated by oideus (› Fig. 10.5). It lowers the hyoid and holds it in place. In
nerve branches of the Plexus cervicalis (C1–C4), which clump to a the swallowing process, it raises the larynx.
nerve loop, the Ansa cervicalis (profunda). In conjunction with the
suprahyoid muscles, the infrahyoid muscles determine the position M. sternothyroideus
of the hyoid bone and larynx, and therefore play an important role The M. sternothyroideus runs in the caudal continuation of the
in swallowing and voice formation (phonation). M. thyrohyoideus and beneath the M. sternohyoideus (› Table 10.7).
It has its origin at the rear surface of the Manubrium sterni and
NOTE runs up to the Linea obliqua of the thyroid cartilage. Laterally the
The previously used terms Ansa cervicalis superficialis (anastomo- separation of the M. sternothyroideus and M. thyroideus is incom-
sis of the N. transversus colli with the R. colli of the N. facialis [VII]) plete, since the lateral muscle fibres merge together and run to the
and Ansa cervicalis profunda (motor innervation of the infrahyoid hyoid bone. In its course, the muscle overlays the lateral lobes of
muscles) often led to confusion. Therefore, only Ansa cervicalis is the thyroid gland. The M. sternothyroideus pulls the larynx caudally
still used, by which is meant the nerve loop around the V. jugularis
interna, which serves to innervate the infrahyoid muscles; how­
and fixes the larynx through isometric contraction during phona-
ever, since no term for the former Ansa cervicalis superficialis has tion.
been proposed and the term is still familiar, the previous names
are retained in the figures. Deep layer of the neck musculature
Also included in the deep layer of the neck muscles are 2 muscle
groups:
M. sternohyoideus • The lateral, deep-running Mm. scaleni
The M. sternohyoideus (› Table 10.7) is a long flat muscle arising • The prevertebral muscles passing in front of the cervical spine
from the dorsal side of the Manubrium sterni and the dorsal part The two muscle groups run to the cervical spine or ventrally to the
of the Articulatio sternoclavicularis and runs to the lower margin skull base. They are antagonists of the neck muscles.
of the Corpus ossis hyoidei. In its cranial course, the muscles of

538
 10.2 Musculoskeletal system of the neck

Mm. scaleni NOTE

The M. scalenus anterior and M. scalenus medius together with the
The scalene muscles are the continuation of the intercostal muscles upper edge of the 1st rib, form a triangle, the scalene hiatus,
of the thorax in the neck region (› Fig. 10.7). There are usually through which the A. subclavia and the Plexus brachialis pass.
three scalene muscles (› Table 10.8), all innervated by direct Some authors differentiate between a front and rear scalene hia-
branches of the cervical spinal nerves (C3–C8). The strongest of tus; however, in this case the front scalene hiatus is not an actual
these muscles is the M. scalenus medius and its origin can lie with gap but rather describes the course of the V. subclavia in front of
some fibres on the atlas and the axis. Occasionally (in approximate- the M. scalenus anterior over the 1st rib, whereas the rear scalene
ly one third of the population) a 4th scalene muscle (M. scalenus hiatus describes the topographical course shown above.
minimus) can also be present.

M. stylohyoideus

Glandula parotidea
M. stylopharyngeus
M. masseter M. digastricus, Venter posterior

Mandibula M. sternocleidomastoideus
M. semispinalis capitis

M. digastricus,
Venter anterior

M. mylohyoideus M. splenius capitis

Os hyoideum M. levator scapulae

M. omohyoideus,
Venter superior M. scalenus anterior

M. sternohyoideus
M. scalenus medius
M. thyrohyoideus
M. scalenus posterior
M. sternothyroideus
M. constrictor pharyngis inferior M. trapezius

Glandula thyroidea, Lobus sinister

Acromion
M. sternocleidomastoideus

Clavicula
M. deltoideus
Fig. 10.7 Presentation of the
M. omohyoideus, neck musculature from lateral.
Venter inferior All muscle fascia, the platysma
M. pectoralis major, and the median section of the
Pars sternocostalis M. sternocleidomastoideus are
removed.

Table 10.7 Infrahyoid muscles.

Innervation Origin Attachment Function

M. sternohyoideus
Plexus cervicalis, Ansa Inner surface of the Manubrium sterni Corpus ossis hyoidei Pulls the hyoid bone caudally, fixes the hyoid bone for
cervicalis (profunda) opening the jaw and grinding movement
M. omohyoideus
Plexus cervicalis, Ansa Margo superior of the scapula Venter superior of the Corpus ossis Draws the hyoid bone downwards, fixes the hyoid;
cervicalis (profunda) hyoidei tenses the middle neck fascia, promotes the venous
backflow from the head and neck by holding the
V. jugularis open
M. thyrohyoideus
Plexus cervicalis, Ansa Outer surface of the Lamina of the Cartilago Corpus ossis hyoidei • Where the hyoid bone is fixed: raising the larynx for
cervicalis (profunda) thyroidea the act of swallowing
• Where the larynx is fixed: lowering of the hyoid bone
to influence phonation
M. sternothyroideus
Plexus cervicalis, Ansa Inner surface of the manubrium sterni Lina obliqua of the Lamina of the Pulls the larynx caudally, fixes the larynx during phona-
cervicalis (profunda) Cartilago thyroidea tion

539
10 Neck

Table 10.8 Mm. scaleni.

Innervation Origins Attachment Function

M. scalenus anterior
Plexus cervicalis (Rr. ante- Cervical vertebrae III–VI (Tubercula anteriora) 1st rib (Tubercula musculi scaleni) • Bilateral activity: forward tilt of the cervical spine
riores of the Nn. cervicales • Unilateral activity: tilting sideways and rotating the
IV–VII) cervical spine to the ipsilateral side
• In the case of fixed cervical spine: lifting the 1st rib,
support of inspiration
M. scalenus medius
Plexus cervicalis (Rr. ante- Cervical vertebrae III–VII (Tubercula anteriora) 1st rib dorsolateral of the Sulcus • Bilateral activity: forward tilt of the cervical spine
riores of the Nn. cervicales arteriae subclaviae • Unilateral activity: tilting sideways and rotating the
III–VIII) cervical spine to the ipsilateral side
• In the case of fixed cervical spine: lifting 1st rib, sup-
port of inspiration
M. scalenus posterior
Plexus cervicalis (Rr. ante- Transverse processes cervical vertebrae V–VI 2nd rib (outer surface), sometimes • Unilateral activity: tilting sideways and rotating the
riores of the Nn. cervicales (Tubercula posteriora) also 3rd rib cervical spine to the ipsilateral side
VII–VIII) • In the fixed cervical spine: lifting of the 2nd rib, sup-
port of inspiration
M. scalenus minimus
Plexus cervicalis (Rr. ante- Cervical vertebra VII (Tuberculum anterius) 1st rib (posterior border, dorsal to • Unilateral activity: tilting sideways and rotating the
riores of the N. cervicalis the M. scalenus anterior) cervical spine to the ipsilateral side
VIII) • In the case of fixed cervical spine: lifting 1st rib, sup-
port of inspiration

Table 10.9 Prevertebral muscles

Innervation Origins Attachment Function

M. rectus capitis anterior
Plexus cervicalis (R. anteri- Massa lateralis of the atlas Pars basilaris of the Os occipitale Fine adjustment of the head in the cranial joints, bend-
or of the N. cervicalis I) ing of the head to the front
M. rectus capitis lateralis
Plexus cervicalis (R. anteri- Proc. transversus of the atlas Proc. jugularis of the Os occipitale Fine adjustment of the head in the cranial joints, lateral
or of the N. cervicalis I) bending of the head
M. longus capitis
Plexus cervicalis (Rr. ante- Tubercula anteriora of the Procc. transversi Pars basilaris of the Os occipitale • Bilateral activity: forward tilt of the head
riores of the Nn. cervicales of the IIIrd-VIth cervical vertebrae • Unilateral activity: sideways tilt of the head
I–III)
M. longus colli
Plexus cervicalis (Rr. ante- Corpus of the Vth-VIIth cervical vertebrae and Procc. transversi of the Vth-VIth • Bilateral activity: assistance with the forward tilt of
riores of the Nn. cervicales the Ist-IIIrd thoracic vertebrae; Tubercula cervical vertebrae, Corpus of the the cervical spine
II–IV) anteriora of the Procc. transversi of the II–V IInd-IVth cervical vertebrae, Tuber- • Unilateral activity: tilting sideways and rotating the
cervical vertebrae culum anterius of the atlas cervical spine to the ipsilateral side

Clinical remarks The muscles run on both sides between the transverse appendages
(Proc. transversi) and the Corpora vertebrae of the cervical verte-
Anatomical variations in the area of the scalene hiatus (cervi-
cal rib, narrowed scalene hiatus, accessory M. scalenus mini- brae and the upper 3 thoracic vertebrae. The muscle fibre cords of
mus, aberrant muscle fibres) can accompany a scalenus anti- the M. longus capitis and M. longus colli are usually not clearly
cus syndrome. Here a compression of the Plexus brachialis separated from each other, and form a muscle complex consisting
and/or the A. subclavia commonly occurs with corresponding of longitudinal and diagonal fibre cords. The prevertebral muscles
deficits. are innervated by Rr. anteriores of the cervical spinal nerves.

M. rectus capitis anterior

The M. rectus capitis anterior (› Table 10.9) has its origin at the
Prevertebral muscles lateral mass of the atlas and runs to the Pars basilaris of the Os oc-
The prevertebral muscles (› Fig. 10.8) are: cipitale. Through its contraction, it assists with tilting the head for-
• M. rectus capitis anterior wards (inclination) and stabilises the Articulatio atlantooccipitalis.
• M. rectus capitis lateralis
• M. longus capitis M. rectus capitis lateralis
• M. longus colli The M. rectus capitis lateralis (› Table 10.9) is a short flat muscle
running from the Proc. transversus atlantis to the Proc. jugularis of

540
 10.3 Cervical fascia and connective tissue spaces

M. rectus capitis anterior

M. rectus capitis lateralis

Articulatio atlantoaxialis lateralis,

Capsula articularis Atlas
M. longus capitis
M. longus colli

M. scalenus medius M. levator scapulae

M. longus capitis M. longus colli

M. scalenus medius
M. scalenus medius
M. scalenus anterior

M. scalenus medius Vertebra cervicalis VI,

Tuberculum caroticum
M. scalenus posterior

M. scalenus medius M. scalenus anterior

M. longus colli
A. subclavia sinistra
A. subclavia dextra
M. scalenus
M. scalenus anterior posterior

V. subclavia dextra

V. brachiocephalica
Truncus brachiocephalicus sinistra
V. cava superior A. carotis communis
sinistra
Fig. 10.8 Prevertebral muscles
I–VII = 1st–7th cervical vertebrae
1–3 = 1st–3rd thoracic vertebrae
and M. longus capitis. Ventral
view.

the Os occipitale (› Fig. 10.8). It supports the lateral flexion of the 10.3 Cervical fascia and connective tissue spaces
head. Michael Scholz

M. longus capitis
The M. longus capitis (› Table 10.9) originates from the Tubercula Skills
anteriora of the transverse processes of cervical vertebrae III–VI
and runs from caudal lateral to cranial medial to the Pars basilaris After working through this chapter, you should be able to:
of the Os occipitale (› Fig. 10.8). A bilateral contraction of the M. • name the various fasciae and anatomical spaces of the
throat area and describe their boundaries
longus capitis leads to a bending forward of the cervical spine and
the head. A unilateral contraction of the muscle causes tilting and
rotation of the head.
The connective tissue of the cervical fascia (Fascia cervicalis) sur-
M. longus colli rounds and connects the muscles, vascular, lymphatic and nervous
The M. longus colli consists of 3 units, giving the muscle as a whole systems and viscera of the neck with each other. Regionally it thick-
its characteristically triangular form (› Fig. 10.8). A Pars obliqua ens into 3 different well-developed sheets. In their course, the re-
superior, running from the transverse processes of the upper cer- spective fascial sheets delimit different transitional anatomical spac-
vical vertebrae III–V to the Tuberculum anterius of the atlas, a Pars es from each other. These anatomical spaces, filled with loose con-
recta, which originates from the anterior side of the lower cervical nective tissue, surround the viscera and vascular, lymphatic and
and upper thoracic vertebral bodies, and attaches at the front of nervous systems, and ensure their ability to move against each oth-
cervical vertebrae II–IV, and a Pars obliqua inferior with its origin er. This is necessary because the neck structures need to follow the
at the front of the thoracic vertebrae I–III, with the attachments at natural movement of the cervical spine and the corresponding loca-
the Tubercula anteriora of the transverse processes of cervical tion changes during swallowing without any friction. The throat
vertebrae V–VII. A unilateral contraction leads to tilting and rota- area structures themselves, like the vascular, lymphatic and nervous
tion of the head on the ipsilateral side. Bilateral contraction assists systems, are also surrounded by their own connective tissue
with the bending forwards of the cervical spine and the head. sheaths.

NOTE
The anatomical spaces created by the fascia of the throat area run
cranially and caudally to the skull base, and pass continually cau-
dally into the mediastinum. Therefore, inflammatory processes or
bleeding can spread virtually freely to the skull base and spread
out into the mediastinum.
541
10 Neck

10.3.1 Neck fasciae la and is attached laterally to the Fascia parotidea. In addition, the
Lamina superficialis is fixed onto the hyoid bone (› Fig. 10.11).
The cervical fascia is divided into a muscle fascia (Fascia cervicalis) Above the hyoid bone, the Lamina superficialis covers the Trigo-
with 3 sheets, a pathway fascia, a general organ fascia and special num submandibulare and the Glandula submandibularis which in
organ fasciae (› Fig. 10.9, › Table 10.10). turn is surrounded by its own capsule (specific organ fascia). The
cutaneous branches of the cervical plexus and the superficial neck
Table 10.10 Neck fasciae. veins (Vv. jugulares externae and anteriores) run over the surface
of the Lamina superficialis.
Fascia Enclosed/ensheathed structures In comparison to the superficial cervical fascia, the middle sheet
Muscle fascia (Fascia cervicalis) of the cervical fascia (Lamina pretrachealis) is a much coarser
• Lamina superfi- • Complete throat area (also referred to as Fascia nuchae
and hence more clearly defined structure. It is tensed bilaterally by
cialis (superficial in the nape of the neck) the Mm. omohyoidei and lies protectively in front of the throat or-
layer) • M. sternocleidomastoideus gans. All infrahyoid muscles are covered by it (› Fig. 10.9, › Fig.
• M. trapezius 10.10); however, there is no direct connection to the trachea. The
• Lamina pretra- • Infrahyoid muscles fascial sheet spans between the hyoid bone and the posterior side
chealis (middle of the Manubrium sterni and of the Clavicula (› Fig. 10.11). At
layer) the point of intersection between the intermediate tendon of the
• Lamina preverte- • Mm. scaleni M. omohyoideus and the carotid sheath, the Lamina pretrachealis
bralis (deep layer) • Prevertebral muscles and the Vagina carotica are fused.
• M. levator scapulae The deep sheet of the cervical fascia (Lamina prevertebralis) is
• Continues into the fascia of autochtonous back mus- fixed on the Lig. longitudinale anterius along the medial cervical
cles
spine. It ensheathes the prevertebral muscles, the M. scaleni and
• Truncus sympathicus, Pars cervicalis
the M. levator scapulae and merges into the fascia of the autoch-
Vascular, lymphatic and nervous systems fascia
tonous back muscles at the nape of the neck (› Fig. 10.9). Cranial-
• Vagina carotica • Aa. carotis communis, carotis interna and carotis externa ly, the Lamina prevertebralis extends to the skull base and caudally
(carotid sheath) • V. jugularis interna it merges into the Fascia endothoracica. The Truncus sympathicus
• N. vagus [X]
is enclosed in the lower neck section up to the C4 level of the Lam-
Organ fasciae ina prevertebralis. In addition, the Lamina prevertebralis covers
• General organ All neck structures together (pharynx, larynx, thyroid the primary strands of the Plexus brachialis, the N. phrenicus and
fascia gland, parathyroid gland, upper part of the trachea, Pars the A. subclavia.
cervicalis of the oesophagus)
• Special organ fas- Each individual neck organ, e.g. Fascia oesophagea Vascular, lymphatic and nervous systems fascia
cia = organ cap- The connective tissue enclosure of the vascular, lymphatic and ner-
sule
vous systems, which ensheathes the neurovascular strand lying to
the side of the neck structures is the Vagina carotica (carotid
sheath;› Fig. 10.10). It extends from the upper thoracic aperture
Muscle fascia to the skull base. Within it, running from caudal to cranial in the
The non-uniformly structured superficial sheet of the cervical area of the Regio sternocleidomastoidea are initially the A. carotis
fascia (Lamina superficialis) in its course lies below the subcuta- communis, the V. jugularis interna with its adjacent deep lateral
neous adipose tissue and under the platysma. The Lamina superfi- cervical lymph nodes and the N. vagus [X]. In the Trigonum
cialis surrounds the entire circumference of the neck and encloses caroticum the A. carotis communis splits into the A. carotis interna
the Mm. sternocleidomastoidei and the upper parts of the Mm. and the A. carotis externa, with the A. carotis interna continuing
trapezii (Partes descendentes) (› Fig. 10.10). Caudally, the super- the course of the A. carotis communis and runs together with the
ficial layer is attached both to the front surface of the Manubrium V. jugularis interna and the N. vagus [X] within the Vagina carotica
sterni and to the Clavicula, and continues into the Fascia pectora- to the skull base.
lis. Cranially the sheet is fixed to the lower margin of the Mandibu-

Mm. infrahyoidei
Glandula thyroidea Trachea Fig. 10.9 Transverse section
Lamina pretrachealis Oesophagus through the neck at the level of
V. jugularis interna the thyroid gland (diagram). The
M. sternocleidomastoideus respective courses of muscle
Platysma
(Fascia oesophagea) fasciae, the pathway fascia and
A. carotis communis
the visceral fascia are marked in
(Vagina carotica) N. vagus [X] colour with their respective con-
Mm. scaleni tent structures. Lamina superfi-
cialis (blue), Lamina pretra-
Lamina chealis (green), Lamina
superficialis Lamina prevertebralis (red), carotid
prevertebralis sheath (purple), general organ
M. trapezius
fascia (yellow), special organ
fascia (brown). [E402]

542
 10.3 Cervical fascia and connective tissue spaces

Fig. 10.10 Muscle fasciae of

the neck. Ventral view. The pla-
tysma has been removed bilat-
erally. To the left, the superficial
Mandibula fascia sheet (Lamina superficial-
is) is intact and ensheathes the
Fascia parotidea M. sternocleidomastoideus. To
Glandula parotidea
the right, the medial portion of
the muscle and the majority of
M. sternocleidomastoideus Lamina superficialis the Lamina superficialis is
removed. As a result, the course
of the middle and deep cervical
M. sternohyoideus
Vagina carotica fascia, as well as the carotid
sheath, can be recognised. The
Lamina pretrachealis General organ fascia medial fenestrated section
makes it possible to view the
Lamina prevertebralis
thyroid cartilage of the larynx
and the M. sternohyoideus,
M. trapezius
which would otherwise be cover­
ed by the lamina pretrachealis
Clavicula and the general organ fascia.
Lamina superficialis (grey),
Lami­na pretrachealis (brown),
Lamina prevertebralis (green),
Vagina carotica (red).

NOTE
The positional relationship between artery, vein and nerve within
from their anatomical/physiological function to enable the freely
the carotid sheath changes in its course from caudal to cranial. At movable nature of the structures of the throat area when swallow-
the start in the Regio sternocleidomastoidea, the vein and nerve ing, breathing and movements of the cervical spine, these spaces
run lateral to the artery, then both migrate dorsally in their course are also clinically relevant, since inflammatory processes can propa-
to the skull base. In the Trigonum caroticum, the vein courses lat- gate along these anatomical spaces.
erodorsally to the artery and the N. vagus [X] runs dorsally between
the vessels. Spatium suprasternale
Within the carotid bifurcation are the Glomus caroticum and the Si-
nus caroticus:
Between the Lamina superficialis and the Lamina pretrachealis
• The Glomus caroticum is a small knot-shaped paraganglion made there is the Spatium suprasternale, due to the different attachment
up of an envelope and main cells. It has a diameter of approx. points of these two sheets of the Fascia cervicalis to the Manubri-
3 mm. Apart from blood vessels, afferent nerve fibres leave the um sterni and the Clavicula, (› Fig. 10.11). This movable space
paraganglion, and these join onto the N. glossopharyngeus [IX] filled with adipose tissue is delimited caudally by the two sternocla-
(R. sinus carotici nervi glossopharyngei). The main cells are vicular joints and by the Lig. interclaviculare which passes over the
­chemoreceptors that measure the partial pressures of oxygen and Manubrium sterni.
carbon dioxide and the pH of the blood.
• The Sinus caroticus contains pressure receptors (baroreceptors)
in its wall that measure the blood pressure in the blood vessels
and register changes of arterial pressure. Via the N. glossopha-
ryngeus [IX] the information from both systems is sent to cardio-
vascular and respiratory centres in the Medulla oblongata. Respi-
ratory rate and depth and heart rate are adjusted by reflexes. Oth-
er glomerulae and sinuses with a similar role are present e.g. in
the wall of the aorta.

Organ fasciae
The organ fasciae are divided into a general and specific organ fas-
ciae (› Fig. 10.9). The connective tissue of the general organ fascia
Spatium
encases all the neck organs, such as the pharynx, larynx, thyroid, retropharyngeum
parathyroid gland, the upper part of the trachea and the Pars cervi-
calis of the oesophagus; the special organ fasciae envelop each indi-
vidual organ of the neck as a connective tissue organ capsule (e.g.
Fascia oesophagea). Spatium periviscerale

Spatium suprasternale

10.3.2 Connective tissue spaces of the neck

Fig. 10.11 Position of the cervical fascia and the resulting connec-
Due to the spatial structure of the individual fascial leaves of the tive tissue spaces in sagittal section (diagram). Lamina superficialis
Fascia cervicalis into a superficial, middle and deep sheet, movable (blue), Lamina pretrachealis (green), Lamina prevertebralis (red),
connective tissue spaces are formed adjacent to each other. Apart general organ fascia (yellow), special organ fascia (brown).

543
10 Neck

NOTE Spatium retropharyngeum

Within the Spatium suprasternale the connection of the two
Vv. jugularis anteriores (› Fig. 10.18) runs at different heights of
The Spatium retropharyngeum (› Fig. 10.11) is the thin slit-like
the Arcus venosus jugularis. Here there is a potential risk of injury connective tissue space between the dorsal pharyngeal wall or the
to the vascular connection during a tracheotomy carried out under cervical part of the oesophagus and the deep layer of the cervical
clinical conditions. fascia (Lamina prevertebralis). The Spatium retropharyngeum
starts at the skull base and continues caudally into the posterior
mediastinum. The boundary with the adjacent Spatium lateropha-
Spatium periviscerale ryngeum is completed by a strong connective tissue plate (Septum
The Spatium periviscerale (previscerale) can be defined as a mov- sagittale) running from cranial to caudal.
able space stretched between the Lamina pretrachealis and the
general organ fascia (› Fig. 10.11). It extends from the Os hyoide-
um to the anterior mediastinum, where it ends at approximately
Clinical remarks
the same level as the base of the heart. Due to the connection of the Spatium retropharyngeum with
the posterior mediastinum, there is here also the risk of trans-
Spatium peripharyngeum mission of inflammatory agents from within the neck to the
The Spatium peripharyngeum dorsolaterally surrounds the throat thorax (retropharyngeal abscess).
(pharynx) and is divided into two parts:
• the Spatium retropharyngeum (Spatium retroviscerale)
• the Spatium lateropharyngeum (Spatium parapharyngeum)

N. vagus [X]
N. accessorius [XI], R. internus
N. glossopharyngeus [IX]
M. constrictor pharyngis superior
Bulbus superior venae jugularis
Sinus transversus Vv. pharyngeae Foramen jugulare
Sinus sigmoideus
Ganglion superius (X)
A. meningea posterior
A. carotis interna
N. caroticus internus
R. auricularis

N. accessorius [XI],
R. externus A. carotis interna

Ganglion inferius (X)

N. hypoglossus [XII]
N. jugularis (Truncus sympathicus)
M. stylopharyngeus
N. glossopharyngeus [IX] Ganglion cervicale superius
(Truncus sympathicus)
R. pharyngealis
M. digastricus, Venter posterior A. pharyngea ascendens

N. laryngeus superior N. glossopharyngeus [IX]

A. carotis externa A. palatina ascendens

R. pharyngealis A. facialis
A. lingualis
A. facialis
A. carotis externa
N. laryngeus superior, R. externus
A. thyroidea superior
N. laryngeus superior, R. internus
N. cardiacus cervicalis superior
M. constrictor pharyngis medius (Truncus sympathicus)
A. thyroidea superior V. jugularis interna
Rr. pharyngeales R. pharyngealis
N. vagus [X]
M. constrictor pharyngis inferior A. carotis communis
Plexus caroticus communis
Truncus sympathicus
Glandula thyroidea
Bulbus inferior venae jugularis
R. pharyngealis

A. thyroidea inferior Ganglion cervicale medium

Ganglion cervicothoracicum [stellatum]

R. cardiacus cervicalis superior N. cardiacus cervicalis medius
Oesophagus
(Truncus sympathicus)

Fig. 10.12 Vessels and nerve pathways in the dorsal compartment of the Spatium lateropharyngeum, after removal of all connective tissue
structures. Left side of image: course of the nerve routes following the removal of the major neck vessels with overlying nerve plexi; dorsal
view.

544
 10.4 Vascular, lymphatic and nervous systems of the neck

Spatium lateropharyngeum Table 10.11 Structures within the two major neurovascular routes of
The Spatium lateropharyngeum like the Spatium retropharyngeum, the neck.
reaches from the skull base into the mediastinum. It is divided into Vessels Nerves Lymph
an anterior and posterior compartment by the course of the Fascia
Lateral cervical region
stylopharyngea, which runs from the Proc. styloideus to the lateral
pharynx wall. The front section of the connective tissue space ex- • A. subclavia • Plexus brachialis • Truncus subclavius
tends to the front into subcutis lying on the M. buccinator and only • V. subclavia

contains the vessels leading to the Tonsilla palatina (Rr. tonsilares of Dorsolateral cervical region
the A. and V. pharyngea ascendens). The section located dorsal of • A. carotis communis • N. vagus • Truncus jugularis
the Fascia stylopharyngea contains the large vascular, lymphatic and • A. carotis externa • Truncus sympathicus
nervous systems of the neck, such as the A. carotis interna, the • A. carotis interna
V. jugularis interna and the N. vagus [X], which are further caudally • V. jugularis interna

covered by the carotid sheath (Vagina carotica). The Truncus sym-

pathicus, the N. glossopharyngeus [IX], the N. accessorius [XI] and
the N. hypoglossus [XII] also run here (› Fig. 10.12). cranial nerves [V, VII, IX, X, XI]. The sensory innervation of the
neck is provided by branches of the Plexus cervicalis and dorsal
branches of the cervical spinal nerves. In addition, the N. hypoglos-
10.4 Vascular, lymphatic and nervous systems sus [XII] and the N. phrenicus (C3–C5) run in their course to their
of the neck respective innervation areas through different regions of the neck.
Michael Scholz

10.4.1 Arteries of the neck

Skills
There are 2 major arteries (A. subclavia and A. carotis communis)
After working through this chapter, you should be able to: running through the neck, which in their course provide the blood
• classify the course of the vascular, lymphatic and nervous supply via their junctions and branches to several areas of the
systems of the throat area and structurally understand the
throat area, the thoracic and abdominal walls and the head.
different areas they innervate or supply

A. subclavia
In the neck there are 2 large neurovascular pathways, which con­ The A. subclavia originates on the right side from the Truncus bra-
tinue in their course to the upper extremities and the head (› Ta- chiocephalicus and on the left side as the last branch from the aor-
ble 10.11). The cervical lymph is carried by superficial and deep tic arch. On both sides, the artery runs in the arch laterally over the
lymph nodes (Nodi lymphodei cervicales) and is drained at the end pleural dome and, together with the primary strands of the Plexus
of the Ductus lymphatic dexter and Ductus thoracicus into the re- brachialis, penetrates the scalene hiatus. In its further course it
spective venous angle. The innervation of the neck muscles and the passes into the Sulcus arteriae subclaviae via the 1st rib and then
muscles of the pharynx and larynx is carried out via the cervical subsequently continues on the lower edge of the 1st rib continuing
spinal nerves (Plexus cervicalis and Plexus brachialis) and via the by definition as the A. axillaris (› Fig. 10.13). Many branches exit

A. vertebralis,
Pars intracranialis
A. vertebralis,
Pars atlantica

A. vertebralis,
Pars transversaria

A. vertebralis,
Pars prevertebralis
A. cervicalis ascendens
A. cervicalis profunda A. carotis communis
Vertebra cervicalis VII (A. cervicalis superficialis, Var.)
Truncus thyrocervicalis
Truncus costocervicalis
A. thyroidea inferior
Vertebra thoracica I A. subclavia
(A. scapularis A. carotis communis
descendens, Var.) A. suprascapularis
A. intercostalis suprema Truncus
brachiocephalicus
Costa I
Clavicula
A. intercostalis posterior II Manubrium sterni
A. axillaris A. thoracica interna Fig. 10.13 Branches of the
A. intercostalis A. subclavia with the Truncus
posterior I thyrocervicalis and Truncus cos-
tocervicalis.

545
10 Neck

Table 10.12 Branches and junctions from the A. subclavia. A. carotis interna, as it runs cranially it supplies the brain and other
structures of the CNS. As it runs through the neck, its small seg-
Arteries Branches
mental branches supply the deep cervical musculature, the verte-
A. vertebralis bral bodies, the spinal cord and the meninges of the medulla.
A. thoracica interna
Truncus thyrocervicalis • A. thyroidea inferior A. thoracica interna
• A. cervicalis ascendens The A. thoracica interna originates caudally from the A. subclavia
• A. suprascapularis and runs lateral to the sternum through the upper thoracic aper-
• A. transversa cervicis (colli) ture. It runs parallel to the sternum caudally to the diaphragm.
Truncus costocervicalis • A. cervicalis profunda
• A. intercostalis suprema Truncus thyrocervicalis
The Truncus thyrocervicalis originates at the medial margin of the
the A. subclavia, which apart from the A. thoracica interna and the M. scalenus anterior (› Fig. 10.15a). Usually 4 arteries arise from
A. intercostalis profunda are all involved in supplying blood to the the short arterial trunk. Due to all these arteries having a high level
neck (› Table 10.12). of individual variability, they can also originate from the A. subcla-
via as stand-alone vessels (› Fig. 10.15b–g). The 4 vessels are:
• A. thyroidea inferior: it rises to the thyroid gland (Glandula
Clinical remarks thyroidea) and supplies the thyroid together with the A. thy-
The atypical outflow of an A. subclavia dextra, which origi- roidea superior from the A. carotis externa. In addition, the
nates as the last branch of the aortic arch instead of originat- A. thyroidea inferior during its course also supplies the parathy-
ing from the Truncus brachiocephalicus, is referred to as the roid glands (Glandulae parathyroidae), the larynx, the pharynx,
A. lusoria. Here, the artery on its way to the right arm runs ei- the oesophagus and the trachea.
ther behind the oesophagus or between the trachea and the
• A. cervicalis ascendens: it runs slightly medial from the
oesophagus. This can affect the oesophageal function by cre-
ating difficulty in swallowing (Dysphagia lusoria) (also N. phrenicus on the M. scalenus anterior in a cranial direction
› Chap. 10.6.6). and supplies the deep cervical muscles (› Fig. 10.16).
A high-grade stenosis in the region of the exit of the A. subcla- • A. suprascapularis: it runs on the dorsal side of the scapula and
via sinistra (less frequently of the A. subclavia dextra) can re- together with the A. axillaris circumflexa scapulae arising from
sult in a retrograde flow into the A. vertebralis of the affected the A. axillaris, forms the Rete scapulare.
side during intense physical activity and load of the arm (sub- • A. transversa cervicis (colli): as it courses through the lateral
clavian steal syndrome). This can lead to reduced perfusion of
cervical region, it divides into 2 branches, the R. superficialis
the brain resulting in dizziness and headaches.
and the R. profundis (› Fig. 10.15a, › Fig. 10.16). The R. su-
perficialis runs together with the N. accessorius [XI] to the
M. trapezius. The R. profundis goes deeper into the lateral cervi-
A. vertebralis cal region together with the N. dorsalis scapulae to the
The A. vertebralis originates as the first branch from the arc-shaped Mm. rhomboidei and the M. latissimus dorsi.
course in the first section of the A. subclavia. It runs almost verti-
cally in a cranial direction and in 90% of cases (› Fig. 10.14) en- A. carotis communis
ters the Foramen transversale of the VIth cervical vertebra under The A. carotis communis dextra originates from the Truncus bra-
the VIth cervical vertebra. From here it runs through the transverse chiocephalicus directly behind the right sternoclavicular joint. The
processes of the cervical vertebra to the atlas. Together with the A. carotis communis sinistra arises directly from the aortic arch
and continues cranially behind the left sternoclavicular joint into
the neck (› Fig. 10.8). The A. carotis communis courses on each
side, together with the V. jugularis interna and the N. vagus [X] en-
CI
cased by the carotid sheath (Vagina carotica) and in its course
CII through the neck, normally no other branches come off. In the
1%
Trigonum caroticum triangle, at the level of the upper edge of the
CIII
Cartilago thyroidea, the A. carotis communis divides into its 2 ter-
CIV 2%
minal branches, the A. carotis externa and the A. carotis interna
CV 5%
(› Fig. 10.17).
CVI 90 % The A. carotis interna continues the course of the A. carotis com-
2%
munis directly without giving off other branches from the Trigo-
CVII
num caroticum through the parapharyngeal space in the direction
of the skull base. It passes via the Canalis caroticus of the petrous
bone (Pars petrosa ossis temporalis) into the inside of the skull in
order to reach its supply areas.
The A. carotis externa provides branches for supplying the organs
of the throat, tongue, face and scalp directly after leaving the
A. carotis communis (› Fig. 10.17):
• A. thyroidea superior
• A. pharyngea ascendens
• A. lingualis
Fig. 10.14 Variations in the levels of entry of the A. vertebralis into • A. facialis
the Foramina transversaria of the cervical spine. • A. occipitalis

546
 10.4 Vascular, lymphatic and nervous systems of the neck

V. retromandibularis
N. hypoglossus V. jugularis interna
R. sternocleidomastoideus [XII]
(A. occipitalis)

A. facialis M. sternocleidomastoideus

Platysma
A. occipitalis
M. mylohyoideus

A. submentalis M. splenius capitis

N. mylohyoideus
M. digastricus,
Venter anterior
N. accessorius [XI]
A. carotis externa
N. laryngeus superior
A. carotis interna
A. laryngea superior
A. thyroidea superior M. levator scapulae
N. vagus [X] N. cervicalis [C5], R. anterior
N. cervicalis [C6], R. anterior
A. carotis communis
(A. cervicalis superficialis, Var.)
Ansa cervicalis (profunda) N. cervicalis [C7], R. anterior
(Plexus cervicalis)
M. omohyoideus, Venter inferior
A. thyroidea inferior

A. cervicalis ascendens A. suprascapularis

Glandula thyroidea
M. deltoideus
A. vertebralis, Pars prevertebralis

N. phrenicus

Truncus thyrocervicalis

A. subclavia

A. thoracica interna

V. jugularis interna V. jugularis externa

a V. brachiocephalica sinistra

30 % 10 % 30 % 8% 1% 4%

b c d e f g

Fig. 10.15 Regio cervicalis lateralis with variations of the vessel branches. a Vessels and nerves of the Regio cervicalis lateralis, deep layer.
Left lateral view after removal of the V. jugularis interna. b–g Variations of the vessel outflows from the A. subclavia and the Truncus thyrocervi-
calis.

• A. auricularis posterior A. pharyngea ascendens

• A. temporalis superficialis The A. pharyngea ascendens courses to the skull base as the second
• A. maxillaris and smallest branch of the A. carotis externa in the posterior com-
partment of the lateropharyngeal space between the A. carotis in-
A. thyroidea superior terna and the pharynx. On its way it supplies the pharynx and the
The A. thyroidea superior arises as the first branch of the A. carotis Tonsilla palatina and with its terminal branch reaches (A. menin-
externa on its anterior side just above the bifurcation of the carotid gea posterior) parts of the meninges.
artery. It courses to the front caudally and supplies the right and
left thyroid lobes. In its course to the thyroid gland, the A. thy- A. lingualis
roidea superior gives off the A. laryngea superior to the larynx. Directly above the outlet of the A. thyroidea superior, the A. lin-
The thyroid gland is also supplied by the A. thyroidea inferior, a gualis courses at approximately the level of the hyoid bone to the
branch of the A. subclavia. front of the A. carotis externa (› Fig. 10.17). It passes behind the
M. stylohyoideus and the Venter posterior of the M. digastricus
into the Trigonum submandibulare, then continues into the Regio

547
10 Neck

N. hypoglossus [XII] N. vagus [X]

N. mylohyoideus A. facialis V. jugularis interna

A. submentalis Rr. communicantes

(Truncus sympathicus) A. occipitalis
A. carotis externa
A. carotis interna R. mastoideus

Ganglion cervicale superius

N. occipitalis minor
(Truncus sympathicus)
A. thyroidea superior N. occipitalis major
R. cardiacus cervicalis superior
(N. vagus) N. accessorius [XI]

Ansa cervicalis (profunda), Radix superior

(Plexus cervicalis) A. cervicalis ascendens

N. cardiacus cervicalis superior

N. phrenicus
(Ganglion sympathicum
A. cervicalis superficialis
accessorium)
(A. transversa colli,
V. thyroidea superior V R. superficialis, Var.)
A. thyroidea inferior VI
M. scalenus anterior
VII
Ganglion
cervicale medium VIII Plexus brachialis,
Pars supraclavicularis
Truncus thyrocervicalis
N. suprascapularis
A. subclavia
N. laryngeus recurrens

Trachea Clavicula

V. thyroidea inferior
M. deltoideus
N. cardiacus cervicalis medius
(Truncus sympathicus) A. thoracoacromialis A. axillaris
A. thoracica interna A. suprascapularis
A. carotis communis V. jugularis externa
V. vertebralis, V. brachio- V. jugularis interna
Pars prevertebralis cephalica sinistra

Fig. 10.16 Nerves and blood vessels of the deep lateral cervical region and axillary area after removal of the M. sternocleidomastoideus, the
major neck vessels and the anterior two thirds of the Clavicula. The Roman numerals V–VIII mark the corresponding cervical nerves.

sublingualis. It provides branches which supply blood to the cranially to the ear muscle, which is supplied by its smaller branches
tongue and other structures within the Regio sublingualis. (Rr. auriculares). In addition it gives off branches to the middle
and inner ear and to the dura mater.
A. facialis
The A. facialis usually leaves the A. carotis externa directly above A. temporalis superficialis and A. maxillaris
the outlet of the A. lingualis. As a variant, both blood vessels can The A. temporalis superficialis and the A. maxillaris are the two ter-
also exit from a common trunk (Truncus linguofacialis) from the minal branches of the A. carotica externa. The A. temporalis super-
A. carotis externa. The A. facialis goes under the M. stylohyoideus ficialis starts dorsally to the Colum mandibulae, and runs between
and stretches along the Venter posterior of the M. digastricus, the rear edge of the Mandibula and cranially in front of the Porus
courses further between the Glandus submandibularis and the acusticus externus to the temple. Here it divides into the R. fronta-
Mandibula, and at the front edge of the M. masseter it crosses the lis and the R. parietalis to supply this region (› Fig. 10.17).
edge of the Mandibula, passing obliquely and forwards to the face The A. maxillaris normally courses as the larger of the two termi-
(› Fig. 10.17). In its course in the Trigonum submandibulare, nal branches dorsal of the Collum mandibulae into the Fossa infra-
more branches are given off to supply the Tonsilla palatina (R. ton- temporalis, and there it branches out into its terminal branches
sillaris of the A. palatina ascendens), the area under the chin (› Chap. 9.2.5).
(A. submentalis) and various other small branches to supply the
Glandula submandibularis (Rr. glandulares).
10.4.2 Veins of the neck
A. occipitalis
The A. occipitalis originates in the Trigonum submandibulare, of- Overview
ten opposite the A. facialis. It courses dorsally to the Os. occipitale, The majority of the venous blood from the head and neck is
where its branches form a dense vascular network. drained through the jugular system, made up of the following
paired veins:
A. auricularis posterior • V. jugularis interna
The A. auricularis posterior is a small branch of the A. carotis ex- • V. jugularis externa
terna, which also originates on the dorsal side and courses dorso­ • V. jugularis anterior

548
 10.4 Vascular, lymphatic and nervous systems of the neck

A. temporalis superficialis,
R. parietalis

A. temporalis superficialis,
R. frontalis

A. maxillaris A. auricularis
posterior

A. occipitalis

A. carotis externa

A. pharyngea ascendens

A. facialis
A. carotis interna
A. lingualis

A. thyroidea superior

A. carotis communis

A. thyroidea inferior

A. transversa colli
A. vertebralis
A. suprascapularis

A. subclavia Fig. 10.17 Course of the A. sub-

Truncus thyrocervicalis clavia and the A. carotis com-
munis. Lateral view.

To a lesser extent, the blood is also drained by the paired V. subcla- Course of the veins
via. The venous network of the throat area is individually extreme- V. jugularis interna
ly variable and the veins are connected with each other by various The paired V. jugularis interna starts at the Foramen jugulare at the
anastomoses. skull base with the Bulbus superior venae jugularis, the extended
The V. jugularis interna and the V. subclavia join together in the continuation of the Sinus sigmoideus. Together with the N. glosso-
right and the left venous angle to the V. brachiocephalica (› Fig. pharyngeus [IX], the N. vagus [X] and the N. accessorius [XI] it
10.19). On both sides of the vein angle the major lymphatic trunks passes through the Foramen jugularis and then runs within the ca-
flow on both sides of the venous angle; on the right side of the Duc- rotid sheath together with the A. carotis interna and the N. vagus
tus lymphaticus dexter and on the left side of the Ductus thoracicus. [X] caudally through the Spatium lateropharyngeum and the
The right and left V. brachiocephalica form the Vena cava superior Trigonum caroticum. In the Regio sternocleidomastoidea it is ac-
(› Fig. 10.19), then flow into the right atrium of the heart. companied by the A. carotis communis and the N. vagus [X]. The
V. jugularis interna widens shortly before its junction with the V.
subclavia into the Bulbus inferior venae jugularis (› Fig. 10.18,
Clinical remarks › Fig. 10.19).
The placing of an intravenous access is the most commonly
used technique in preclinical emergency care. Where the veins NOTE
are in poor conditions, an alternative access point using the The V. jugularis interna collects and drains the venous blood from
V. jugularis externa can also provide a good alternative (car- the brain, scalp, facial region and thyroid gland.
diopulmonary resuscitation guidelines). For central venous
catheters (CVC) thin plastic tubing is introduced under clinical
conditions via a larger vein and advanced to the right atrium
of the heart through the Vena cava superior or the Vena cava V. jugularis externa
inferior. In this way it is possible to introduce drugs and highly The paired V. jugularis externa is formed by the fusing of the V. oc-
concentrated nutritional solutions and to determine the cen- cipitalis and the V. auricularis posterior and it runs epifascially
tral venous pressure (CVP). To insert a CVC, access is prefera- on the M. sternocleidomastoideus to the V. subclavia (› Fig.
bly via the V. jugularis interna or the V. subclavia because they 10.18, › Fig. 10.20) in a caudal direction. It leads blood from the
can be easily located anatomically and sonographically; how-
superficial head and ear areas.
ever, access via other veins is also possible.

549
10 Neck

M. digastricus, Venter M. mylohyoideus

anterior, Tendo
M. hyoglossus
V. jugularis
anterior V. submentalis

V. submentalis A. facialis

Glandula submandibularis V. facialis

V. facialis N. hypoglossus [XII]

V. retromandibularis Glandula parotidea

M. stylohyoideus V. facialis
V. occipitalis
V. occipitalis

V. jugularis interna Prominentia laryngea

V. thyroidea superior
V. thyroidea superior
M. sternocleidomastoideus
V. jugularis externa (Ansa cervicalis profunda), Radix superior
(Plexus cervicalis)
A. carotis communis V. jugularis interna
Isthmus glandulae thyroideae
V. jugularis externa
M. sternocleidomastoideus
V. jugularis anterior
M. trapezius
V. cervicalis
superficialis
M. omohyoideus

V. transversa colli

V. cephalica
V. cephalica

M. pectoralis major

R. perforans (A. thoracica interna) V. thoracoacromialis

R. cutaneus anterior pectoralis

V. axillaris
Rr. perforantes (A.; V. thoracica interna) Arcus venosus jugularis

Fig. 10.18 Veins of the neck after removal of all cervical fasciae. On the left side, the M. sternocleidomastoideus has largely been removed.
Ventral view.

V. jugularis anterior V. brachiocephalica

The V. jugularis anterior is also paired and runs epifascially, begin- The V. brachiocephalica also receives direct inflows from the cervi-
ning in the area of the hyoid bone and draining the venous blood cal region (› Fig. 10.19). The V. thyroidea inferior flows as a sin-
of the floor of the mouth region and the front wall of the throat gle vein or as the Plexus thyroideus impar into the V. brachioce-
area. Shortly before the venous angle (Angulus venosus), it flows phalica sinistra. The V. vertebralis, which previously still largely
into the V. jugularis externa. In the Spatium suprasternale (› Fig. receives venous blood from the V. cervicalis profunda, also flows
10.11, › Fig. 10.18), both Vv. jugulares anteriores are connected into the V. brachiocephalica.
with each other by the Arcus venosus jugularis.

V. subclavia 10.4.3 Nerves of the neck

The V. subclavia collects the venous blood from the cervical spine,
arms and shoulder girdle, a part of the chest wall and the deep cer- The innervation of the skin of the throat area is carried out by
vical muscles. The drainage area of the vein largely corresponds branches of the Plexus cervicalis (ventrolateral skin area) and by
with the supply area of the artery (A. subclavia). The vein runs as a Rr. dorsales of spinal nerves C2–C8. Also involved in the motor in-
continuation of the V. axillaris between the 1st rib and the clavicle nervation of the neck muscles are both cervical spinal nerves
(Clavicula) and between the M. scalenus anterior and the clavicu- (Plexus cervicales; Plexus brachiales; Rr. dorsales C1–C8) and vari-
lar origin of the M. sternocleidomastoideus. In this area it is cov- ous cranial nerves (N. trigeminus [V], N. facialis [VII], N. glosso-
ered by the Fascia pretrachealis and is connected with the sur- pharyngeus [IX], N. vagus [X] and N. accessorius [XI]). Autonom-
rounding structures by connective tissue. In the venous angle it ic nerve fibres of the neck come from the sympathetic trunk of the
combines with the V. jugularis interna to the V. brachiocephalica. neck, (Truncus sympathicus, Pars cervicalis) and the N. vagus [X].

550
 10.4 Vascular, lymphatic and nervous systems of the neck

M. digastricus, Venter anterior M. mylohyoideus

M. hyoglossus Os hyoideum N. lingualis M. digastricus, Venter anterior, Tendo

A. facialis

V. retromandibularis
V. facialis

N. hypoglossus [XII]

Glandula parotidea

V. occipitalis
M. sternohyoideus
M. thyrohyoideus V. thyroidea superior
M. omohyoideus
M. sternocleidomastoideus
A. thyroidea superior
(Ansa cervicalis profunda), Radix superior
Cartilago thyroidea (Plexus cervicalis)
V. jugularis externa
N. vagus [X]
Glandula thyroidea
V. thyroidea media
Plexus thyroideus impar N. accessorius [XI]
N. vagus [X] N. phrenicus
A. transversa colli Plexus brachialis,
Pars supraclavicularis

V. transversa colli M. omohyoideus

V. jugularis anterior Clavicula

A. subclavia A. subclavia;
V. jugularis externa

V. subclavia V. subclavia

V. brachiocephalica V. cephalica
dextra

V. thyroidea inferior V. jugularis interna

V. thoracica interna M. pectoralis major

V. cava superior Costa I
V. brachiocephalica sinistra N. vagus [X] A. carotis communis;
Pars ascendens aortae N. laryngeus recurrens sinister
N. laryngeus
Vv. thymicae recurrens sinister

Fig. 10.19 Vessels and nerves of the neck and the upper thoracic aperture after removal of the sternum, parts of the clavicles and parts of the
M. sternocleidomastoideus, and infrahyoid musculature. Ventral view.

The N. hypoglossus [XII] passes through the neck on its way to the Table 10.13 Rr. posteriores of the spinal nerves of the neck with ori-
tongue, for which it provides the motor innervation. gins, fibre quality and innervation area.

Nerve Origins Quality Supply areas

Cervical spinal nerves
R. posterior C1 Motoric • Deep neck muscles
Like all spinal nerves, the spinal nerves of the neck also include
(N. suboccipitalis) only • M. longus capitis
the R. anterior and R. posterior for the innervation of the different • M. semispinalis capitis
target areas:
R. posterior C2 Mixed • M. semispinalis capitis
• The Rr. anteriores combine to produce 2 large nerve plexi, the
• Lateral branch • M. longissimus capitis
Plexus cervicalis and the Plexus brachialis. In the plexi nerve • Medial branch • M. splenius capitis
fibres from several spinal cord segments combine. (N. occipitalis • Skin of the throat area up to
• By contrast, the Rr. dorsales (C2–C8) which are thinner than the major) the crown
Rr. anteriores, maintain their segmental course. Shortly after ex- R. posterior C3 Mixed • Autochthonous back mus-
iting from the cervical spinal nerves, they divide into a lateral • Lateral branch cles
(R. lateralis) and a medial (R. medialis) branch (› Table 10.13) • Medial branch • Innervation of the skin of
and provide motor innervation of the neck muscles, parts of the (N. occipitalis the nape of the neck
tertius)
autochthonous back muscles, the skin of the nape of the neck
and the occipital region, which supply sensory innervation up to Rr. posteriores C4–C8 Mixed • Autochthonous back mus-
the transition of the supply area of the N. trigeminus [V] • Lateral branch cles
• Medial branch • Overlying skin areas
(› Fig. 10.21).

551
10 Neck

V. auricularis posterior

Platysma
N. occipitalis minor

A. occipitalis
N. facialis [VII], R. colli
V. occipitalis
V. facialis

V. retromandibularis N. occipitalis major

(Ansa cervicalis superficialis =

R. communicans cum nervo faciei) M. splenius capitis
M. levator scapulae
N. auricularis magnus
M. trapezius
V. jugularis externa
N. accessorius [XI]
N. transversus colli
Nodi lymphoidei cervicales
V. jugularis anterior laterales, Nodi lymphoidei superficiales
Nn. supraclaviculares laterales

M. sternocleidomastoideus M. omohyoideus,
Venter inferior
Arcus venosus jugularis
Plexus brachialis
V. transversa colli
Nn. supraclaviculares
intermedii
Nn. supraclaviculares
mediales

Fig. 10.20 Vessels and nerves of the lateral neck region after removal of the Lamina superficialis of the cervical fascia. The platysma is folded
upwards. View from lateral left side.

Table 10.14 Sensory skin branches of the Plexus cervicalis from the
N. trigeminus [V]
Punctum nervosum (ERB's point) with their branches.
N. ophthalmicus [V/1] Nerve Origins
C2
N. occipitalis minor C2–C3
N. maxillaris [V/2] Protuberantia
N. auricularis magnus C2–C3
C2 occipitalis externa
• R. anterior
N. mandibularis [V/3]
C3 Rr. posteriores • R. posterior
(C2–C4)
C3 N. transversus colli C2–C3
Rr. anteriores (C2–C4)
• Rr. superiores
Clavicula Acromion
C4 • Rr. inferiores
C4
Nn. supraclaviculares C3–C4
• mediales
Fig. 10.21 Sensory innervation of the skin of the throat area and
• intermedii
head with segmental arrangement of the skin areas (diagram).
• laterales
[E402]

Plexus cervicalis Rr. cutanei

The Plexus cervicalis is formed from the Rr. anteriores of the spi- The sensory skin branches of the Plexus cervicalis all penetrate at
nal nerves C1–C4. The nerves originating from this plexus inner- the posterior border of the M. sternocleidomastoideus, at about the
vate the skin in the front and side of the throat area, the infrahyoid halfway level of the course of the muscle, through the Lamina su-
muscles and the diaphragm and parts of the serosa skin, such as perficialis to the surface. The position is referred to as the Punc-
the Pleura parietalis, the pericardium in the thorax and the perito- tum nervosum (ERB's point) (› Table 10.14; › Fig. 10.20).
neum in the abdomen. The branches from the Plexus cervicalis are The N. occipitalis minor runs on the posterior border of the
surrounded by the Lamina pretrachealis, and are divided into skin M. sternocleidomastoideus in a cranial direction and crosses over
branches (Rr. cutanei) and muscle branches (Rr. musculares). the N. accessorius [XI]. It supplies sensory innervation to the skin
of the throat area and the head behind the outer ear (› Fig. 10.22).
The N. auricularis magnus is usually the strongest branch from
the Punctum nervosum. It runs from the posterior border of the
M. sternocleidomastoideus diagonally upwards over the muscle to

552
 10.4 Vascular, lymphatic and nervous systems of the neck

N. auriculotemporalis the ear lobe. Its R. anterior supplies the sensory innervation to the
front surface of the outer ear and to the jaw angle (› Fig. 10.22).
N. auricularis magnus
N. occipitalis major The skin on the back of the outer ear is innervated by the R. poste-
rior.
N. transversus colli N. occipitalis minor
The N. transversus colli runs approximately level to the middle of
the N. sternocleidomastoideus, horizontally across the muscle me-
dially into the front throat area. It is covered by the platysma and is
divided into the Rr. superiores (sensory innervation of the skin
Nn. supraclaviculares above the Os hyoideum) and the Rr. inferiores (skin of the throat
area below the hyoid bone). One of the Rr. superiores, together
with the R. colli of the N. facialis [VII], forms an anastomosis (for-
Fig. 10.22 Sensory innervation of the skin of the throat area and merly known as Ansa cervicalis superficialis) and therefore in a
head via the nerves of the Plexus cervicalis and the Nn. occipitalis short section of the fibre course also leads motor fibres to the
major and tertius. ­underside of the platysma (› Fig. 10.20).
The Nn. supraclaviculares are a group of cutaneous nerves radiat-
ing in a fan shape into the lateral triangle of the neck and only pene­
trate the Lamina superficialis and the platysma in the area of the

N. hypoglossus [XII] N. accessorius [XI]

M. sternocleidomastoideus

N. occipitalis major
(R. dorsalis C2)

N. auricularis magnus
C1
N. occipitalis minor
M. geniohyoideus
C2 Rr. musculares (Mm. rectus capitis anterior,
rectus capitis and longus colli)
M. thyrohyoideus M. trapezius
C3
Ansa cervicalis (profunda), Rr. musculares (Mm. longus capitis,
Radix superior longus colli and levator scapulae)
C4
Ansa cervicalis (profunda), Rr. musculares (Mm. longus capitis,
Radix inferior C5 longus colli, levator scapulae,
N. transversus colli scalenus anterior and scalenus medius)
M. omohyoideus, Venter superior N. phrenicus
Ansa cervicalis (profunda)

a
Nn. supraclaviculares mediales,
M. sternohyoideus intermedii and laterales
M. omohyoideus,
M. sternothyroideus Venter inferior
M. sternocleido-
mastoideus

N. occipitalis minor

N. auricularis magnus

Ansa cervicalis (profunda), Ansa cervicalis (profunda),

Radix superior Radix inferior

N. transversus colli
Nn. supraclaviculares mediales,
intermedii and laterales
N. phrenicus

Efferent (motor) fibres Afferent (sensible) fibres Proprioceptive fibres (from the muscles and joints)

Fig. 10.23 Sensory and motor branches of the Plexus cervicalis (diagram). a Anatomical situation. c Functional distinction of the branches.

553
10 Neck

M. digastricus, Venter posterior

N. hypoglossus [XII]
V. retromandibularis
Glandula submandibularis

V. submentalis A. auricularis posterior

N. mylohyoideus N. auricularis posterior (N. facialis)

A. submentalis
M. sternocleidomastoideus
M. stylohyoideus
M. digastricus, N. cervicalis [C2], R. anterior
Venter anterior

M. mylohyoideus N. occipitalis minor

A. lingualis
V. facialis
N. accessorius [XI]
A. carotis externa

A. laryngea superior
Ansa cervicalis (profunda), N. cervicalis [C3], R. anterior
Radix superior

A. thyroidea superior N. cervicalis [C4], R. anterior

R. sternocleidomastoideus (Ansa cervicalis profunda),

V. thyroidea superior Radix inferior

A. cervicalis ascendens Plexus brachialis, Truncus superior

M. omohyoideus, Venter superior

M. trapezius
Glandula thyroidea
A. transversa colli, R. superficialis
(A. cervicalis superficialis, Var.)
N. phrenicus M. omohyoideus,
Venter inferior
M. scalenus anterior
A. transversa colli,
Bulbus inferior venae jugularis R. profundus

A. carotis communis

N. vagus [X] V. jugularis V. subclavia A. subclavia

externa
M. sternocleidomastoideus

Fig. 10.24 Vessels and nerves of the lateral cervical region after removal of the M. sternocleidomastoideus.

Trigonum omoclaviculare. A distinction is made between (› Fig. The Ansa cervicalis (formerly: Ansa cervicalis profunda) is a nerve
10.20, › Fig. 10.22): loop of the cervical nerves C1–C3. It consists of a Radix superior
• Nn. supraclaviculares mediales: sensory innervation of the skin (C1–C2) and a Radix inferior (C2–C3), which lies around the
at the front of the Clavicula with bordering chest skin V. jugularis and is located in the carotid sheath (› Fig. 10.23):
• Nn. supraclaviculares intermedii: sensory innervation of the • The Radix superior in its course is temporarily attached to the
skin in the medial section of the Clavicula with chest skin to the course of the Nn. hypoglossus [XII]. In the place where the
4th rib N. hypoglossus [XII] crosses the Aa. carotides internae and exter-
• Nn. supraclaviculares laterales: sensory innervation of the skin nae, some of the nerve fibres leave it and pass downwards be-
over the acromion of the scapula and above the M. deltoideus tween the major vessels of the throat area. The Radix superior in-
nervates the Venter superior of the M. omohyoideus and the up-
Rr. musculares per portions of the M. sternohyoideus and M. sternothyroideus.
The Rr. musculares of the Plexus cervicalis innervate different • The Radix inferior completes the nerve loop and, as a direct
muscle groups (› Fig. 10.23). branch of the Plexus cervicalis, passes either medial or lateral of
A main motor branch is the N. phrenicus (C3–C5), which inner- the V. jugularis interna in a caudal direction.
vates the diaphragm (Diaphragma) and also sensorily supplies ad- Both roots of the Ansa cervicalis come together individually at dif-
jacent sections of the pericardium and peritoneum. It runs diago- ferent levels ventral of the A. carotis communis and the V. jugularis
nally over the M. scalenus anterior caudally and between the interna (› Fig. 10.24). From here, branches of the Ansa cervicalis
A. and V. subclavia enters through the upper thoracic aperture into course to the Venter inferior of the M. omohyoideus and to the
the mediastinum (› Fig. 10.16, › Fig. 10.24). In its course on the lower parts of the M. sternohyoideus and M. sternothyroideus.
M. scalenus anterior in the direction of the mediastinum, the
N. phrenicus is crossed by 2 arteries, the A. transversa colli and the Plexus brachialis
A. suprascapularis (› Fig. 10.16). The Plexus brachialis is formed by the merging of the Rr. anteri-
ores of spinal nerves C5–C8, as well as the 1st thoracic nerve

554
 10.4 Vascular, lymphatic and nervous systems of the neck

Lig. longitudinale anterius Vertebra cervicalis III

M. longus capitis
Discus intervertebralis
M. scalenus medius
R. interganglionaris
A. vertebralis,
Truncus sympathicus,
Pars transversaria
Ganglion cervicale medium IV
N. phrenicus
Truncus superior
M. scalenus anterior
M. scalenus posterior V Truncus medius Plexus brachialis
V. vertebralis
Truncus inferior
Vertebra cervicalis VII, Proc. transversus VI
A. vertebralis
Truncus thyrocervicalis VII
A.; V. cervicalis profunda VIII

(Nn. phrenici accessorii)

Ganglion cervicothoracicum A. subclavia

[stellatum]

Ansa subclavia N. phrenicus Costa I

A. carotis
communis
M. longus colli

A.; V. thoracica interna Arcus aortae

Pleura parietalis Truncus brachiocephalicus

V. cava superior Vv. brachiocephalicae
dextra and sinistra

Fig. 10.25 Vessels and nerves in the transition zone from the throat area and the thorax to the upper extremity (diagram).

(T1). The Rr. anteriores arise between the origins of the M. scale- • N. thoracicus longus (C5–C7), which further caudally pene-
nus anterior and M. scalenus medius and are the roots of the Plex- trates the M. scalenus medius and courses over the 1st rib to the
us brachialis. At the exit of the scalene hiatus, the Rr. anteriores at- M. serratus anterior, which it innervates (› Fig. 10.16)
tach to the 3 primary strands of the Plexus brachialis (Trunci) • N. subclavius (C5–C6), that courses to the M. subclavius and
(› Table 10.15, › Fig. 10.25). can additionally emit fibres to the N. phrenicus (Nn. phrenici
Prior to entering into the axilla along the Aa. subclavia and axillar- accessorii)
is, the 3 trunks (Trunci superior, medius and inferior), each divide • N. suprascapularis (C4–C6), that courses to the Scapula and
into a ventral and a dorsal branch and then entwine again into 3 runs beneath the Lig. transversum scapulae (in contrast to the
secondary cords (Fasciculi lateralis, medialis and posterior) (see A. suprascapulae, which typically runs above the ligament) pass-
also › Chap. 4.6.2). The peripheral nerve for the innervation of es through the Incisura suprascapulae to innervate the Mm. su-
the upper extremities and parts of the chest wall pass out of the praspinatus and infraspinatus (› Fig. 10.16)
cords. Due to the fibre exchange in the Plexus brachialis, they al-
ways have parts of at least 2 spinal nerves. Cranial nerves
Branches of the N. trigeminus [V], N. facialis [VII], N. glossopha-
ryngeus [IX], N. vagus [X], N. accessorius [XI] , and N. hypoglos-
Clinical remarks sus [XII] run through the throat area (› Table 10.16). The cranial
For local anaesthesia and analgesia in the arm, a clinical nerves IX–XI and the N. hypoglossus [XII], after exiting the inter-
block of the Plexus brachialis (axillary block, axillary Plexus nal surface of skull base, pass through the Spatium lateropharyn­
brachialis block, axillary Plexus anaesthesia) can be per- geum in close relationship to the A. carotis interna (› Fig. 10.12).
formed. It is a simple regional anaesthetic procedure with few As one of the terminal branches of the N. mandibularis [V/3] , the
side effects. A local anaesthetic is mostly injected at the C6
N. mylohyoideus runs forwards in the Sulcus mylohyoideus of the
level into the perineural connective tissue between the
M. scalenus anterior and M. scalenus medius. A disadvantage Mandibula into the Trigonum submandibulare and provides motor
in contrast to the infraclavicular Plexus block is the partly in- innervation to the M. mylohyoideus and Venter anterior of the
sufficient deactivation of the innervation area of the N. radia- M. digastricus (› Fig. 10.15a, › Fig. 10.16). The Venter posterior
lis; however, there is no risk of a pneumothorax caused by of the M. digastricus and M. stylohyoidus are both innervated by
breaching the immediately neighbouring dome of the pleura branches of the N. facialis [VII]. At the lower edge of the Glandula
(› Fig. 10.25, right-hand side).

Table 10.15 Composition and origins of the primary strands of the

Plexus brachialis.
The Pars supraclavicularis of the Plexus brachialis surrounds the
direct motor branches arising from the 3 Trunci. They all leave the Rr. anteriores from Primary strand of the Plexus brachialis
Plexus brachialis in the lateral neck triangle. They include: C5–C6 Truncus superior
• N. dorsalis scapulae (C3–C5) that penetrates through the C7 Truncus medius
M. scalenus medius and runs to its target area, the M. levator
C8–T1 Truncus inferior
scapulae and M. rhomboidei

555
10 Neck

Table 10.16 Cranial nerves IX–XII with side branches and innerva- usually in front of the V. jugularis interna, under the M. sternoclei-
tion areas through the course of the throat area. domastoideus, and in order to supply this and then subsequently
Cranial nerves Innervation areas supply motor innervation to the M. trapezius (› Fig. 10.24).
The N. hypoglossus [XII] courses through the Spatium lateropha-
N. glossopharyngeus [IX] • M. stylopharyngeus ryngeum forward into the Trigonum carotis. Here it crosses over in
• R. musculi stylopharyngei • Plexus pharyngeus
an arch-like manner the A. carotis externa and the A. carotis interna
• Rr. pharyngei • M. constrictor pharyngis superior
• R. sinus carotici • Wall of the Sinus caroticus/Glomus caroticum and continues to run through the Trigonum submandibulare.
From here, it passes between the M. hyoglossus and M. mylohyoi-
N. vagus [X] • Plexus pharyngeus
• R. pharyngeus • M. cricothyroideus
deus to the tongue (› Fig. 10.26).
• N. laryngeus superior • M. constrictor pharyngis inferior
– R. externus
– R. internus
•
•
Mucosa of the upper half of the larynx
Inner laryngeal muscles
Clinical remarks
• N. laryngeus recurrens • Mucosa of the lower half of the larynx Damage to the N. hypoglossus [XII], e.g. due to tumour infil-
• Rr. cardiaci cervicales • Plexus cardiacus
tration of a cervical lymph node metastasis can be easily diag-
superiores/inferiores
nosed: when stretched out, the tongue deviates to the dis-
N. accessorius [XI] • M. sternocleidomastoideus eased side since the tongue muscles pushing out on the
• M. trapezius healthy side can carry out the motion, whereas it is not possi-
N. hypoglossus [XII] • Inner and outer tongue muscles
ble on the diseased side.

parotidea, the R. colli nervi facialis emerges from the glandular tis-
sue and runs diagonally forwards and downwards to innervate the Truncus sympathicus (Pars cervicalis)
platysma (› Fig. 10.20). The sympathetic trunk (Truncus sympathicus) consists of two par-
The N. glossopharyngeus [IX] courses caudally, between the allel nerve cords, running paravertebrally on each side. They ex-
A. carotis interna and the V. jugularis interna through the Spatium tend from the cervical spine to the coccyx. Each of the two sympa-
lateropharyngeum. It is positioned dorsal of the M. stylopharyn- thetic trunks is characterised by the accumulation of neurons (gan-
geus, and continues to run between it and the M. styloglossus to the glions) that thicken in segmental succession. A distinction is made
root of the tongue and its other innervation areas (› Table 10.16). between:
The N. vagus [X] is the main nerve of the parasympathetic nervous • Pars cervicalis
system and also contains visceromotor and viscerosensory fibres • Pars thoracica
(› Chap. 9.3.10). In the throat area, it runs as part of the neuro- • Pars lumbalis
vascular bundle within the carotid sheath through the Spatium lat- • Pars sacralis
eropharyngeum (› Fig. 10.12) in the direction of the mediasti- In its upper section, the Pars thoracica forms a ganglion located on
num. From the throat area section of the N. vagus [X], nerve fibres the head of the rib, each of which is covered by the Fascia endotho-
go out to innervate the pharynx (Rr. pharyngei), larynx (N. laryn- racica. This first chest ganglion is usually fused with the lower cer-
geus superior, N. laryngeus recurrens [the terminal branch of the vical ganglion, forming the Ganglion cervicothoracicum (stella-
N. laryngeus recurrens is also referred to as the N. laryngeus inferi- tum) with a length of up to 2 cm. It is located above the dome of
or]) and the heart (Rr. cardiaci cervicales superiores and inferiores) the pleura behind the A. subclavia at the level where the A. verte-
(› Table 10.16). bralis exits. The Pars cervicalis trunci sympathici continues from
The N. accessorius [XI] also courses through the Spatium latero- here embedded in the deep layer (Lamina profunda) of the Fascia
pharyngeus and enters in the top angle of the Trigonum caroticum, cervicalis in front of the Mm. longus colli and capitis and behind

R. marginalis mandibularis

M. stylohyoideus
V.; A. facialis Glandula
submandibularis
Glandula parotidea
N. mylohyoideus

M. mylohyoideus
N. hypoglossus [XII]
M. digastricus,
N. accessorius [XI] Venter anterior

Ansa cervicalis, M. hyoglossus

Radix superior
N. hypoglossus [XII]
A. lingualis
A. lingualis
N. vagus [X]

V. jugularis externa M. digastricus,

Tendo intermedius
M. sternocleidomastoideus Fig. 10.26 Vessels and nerves
Os hyoideum in the upper region of the Trigo-
V. jugularis interna
num caroticum and Trigonum
A. carotis externa
A. laryngea superior;
submandibulare after removal
A. thyroidea superior of all fascia. View from right lat-
N. laryngeus superior
eral below.

556
 10.4 Vascular, lymphatic and nervous systems of the neck

the carotid sheath cranially (› Fig. 10.12, › Fig. 10.16). Approxi- Ganglion cervicale medium
mately at the level of the IV cervical vertebra the sympathetic trunk The Ganglion cervicale medium is frequently poorly developed
penetrates the deep sheet of the cervical fascia and now, resting be- and can be either entirely absent as an individual variability, it can
hind the carotid sheath, runs towards cranial. At the level of the IIIrd be replaced by several smaller ganglia, or it can be fused with the
cervical vertebra, the sympathetic trunk once again thickens on Ganglion cervicale inferius. When present, it is found at the level of
both sides, to the Ganglion cervicale superius. Between the Gan- the VIth cervical vertebra, in close proximity to the A. thyroidea
glion stellatum and the Ganglion cervicale superius, infrequently inferior. The Rr. communicantes grisei for the spinal nerves C5–C6
there is a Ganglion cervicale mediale (at the level of the VIth cervi- and branches to the thyroid gland, parathyroid gland and the heart
cal vertebra). Connections between spinal nerves and the sympa- come from the ganglion.
thetic trunk usually run via the Rr. communicantes albi to the sym-
pathetic trunk and back to the respective spinal nerve via the Ganglion cervicale inferius
Rr. communicantes grisei; however the Rr. communicantes albi The Ganglion cervicale inferius is usually fused together with the
only occur in the Pars thoracica and the Pars lumbalis. In the Pars first chest ganglion of the Truncus sympathicus to the Ganglion cer-
cervicalis they are absent! In the ganglia, ascending preganglionic vicothoracicum (Ganglion stellatum). The ganglion is located ven-
parasympathetic fibres are interlaced; these then continue as post- trally on the head of the 1st rib and in front of the Proc. transversus of
ganglionic fibres to a variety of target areas in the chest, throat area the VIIth cervical vertebra (C7). The Rr. communicantes grisei run
and head. from the ganglion to spinal nerves C7–C8 and T1. Other branches
course as the N. vertebralis and in the Ansa subclavia to the vessels,
Ganglion cervicale superius and as the Nn. cardiaci inferiores to the heart. Thus the fibres reach
The Ganglion cervicale superius is positioned before the transverse the oesophagus, larynx, trachea, bronchi, pharynx and the heart.
processes of the IInd and IIIrd cervical vertebrae, and at about 3 cm
in size, it is the largest sympathetic ganglion in the throat area. It is
also the last switching station onto postganglionic parasympathetic 10.4.4 Lymph nodes of the neck
fibres that go from here to their innervation areas in the head. The
Rr. communicantes grisei run from the Ganglion cervicale superi- In the throat area there are approximately 200–300 lymph nodes,
us to spinal nerves C1–C4. Additionally, the fibres form a Plexus strung together like a chain, running mainly along the V. jugularis
around the Aa. carotis interna and externa, and its branches reach interna. This large number (approximately 30% of the lymph nodes
the parasympathetic cranial ganglia (Ganglia ciliare, pterygopalati- of the entire body) is explained by the immediate proximity of the
num, submandibulare, oticum), through which they pass to the oral and nasal cavities, providing entry for potential pathogens and
end organs without being switched. Other fibres run down to the antigens. Running along a horizontal line from the chin via the man-
heart. dibular edge to the Occiput is a series of lymph nodes which serve as

Nodi lymphoidei parotidei

superficiales

Nodus lymphoideus buccinatorius

Nodi lymphoidei
Nodi lymphoidei faciales mastoidei

M. digastricus, Venter anterior

Nodus lymphoideus
Nodi lymphoidei submandibulares jugulodigastricus
Nodi lymphoidei
Nodi lymphoidei submentales occipitales

Nodi lymphoidei cervicales laterales, M. sternocleidomastoideus

Nodi lymphoidei profundi superiores M. splenius capitis
M. omohyoideus, Venter superior Nodi lymphoidei cervicales laterales,
Nodi lymphoidei superficiales
Nodi lymphoidei cervicales laterales,
Nodi lymphoidei profundi inferiores M. levator scapulae
Nodus lymphoideus juguloomohyoideus N. accessorius [XI]
A. carotis communis M. scalenus medius

V. jugularis interna M. trapezius

M. scalenus posterior
Nodus lymphoideus cervicalis lateralis,
Plexus brachialis,
Nodus profundus inferior
Pars supraclavicularis
M. scalenus anterior
M. omohyoideus, Venter inferior

Fig. 10.27 Lymph vessels with superficial and deep Nodi lymphodei of the lateral head and throat regions. Child, lateral view from the left
after the removal of the skin and fascia.

557
10 Neck

Table 10.17 Lymph nodes of the neck with course and catchment areas.

Lymph nodes Course Lymph inward circulation

Nodi lymphoidei cervicales anteriores
• Nodi lymphoidei cervicales anteriores superficiales Along the V. jugularis anteri- • Skin of the anterior cervical region; drainage goes to the anterior deep
– Nodi lymphoidei submentales or lymph nodes
• Lower lip, floor of the mouth, teeth, tongue, oral mucosa
• Nodi lymphoidei cervicales anteriores profundi Along the lower respiratory
tract; both collecting and
– Nodi lymphoidei infrahyoidei • Upper half of the larynx
regional lymph nodes
– Nodi lymphoidei prelaryngei • Lower half of the larynx
– Nodi lymphoidei thyroidei • Thyroid gland
– Nodi lymphoidei pretracheales and paratracheales • Trachea and larynx
– Nodi lymphoidei retropharyngeales • Hypopharynx, Tuba auditiva, rear sections of the nasal cavity

Nodi lymphoidei cervicales laterales

• Nodi lymphoidei cervicales laterales superficiales On the M. sternocleidomas- • Regional lymph nodes for: ear lobe, floor of the external acoustic meatus,
toideus, along the V. jugu- skin above the mandibular angle and the lower part of the Glandula
laris externa parotidea
• Drainage to the lateral deep lymph nodes
• Nodi lymphoidei cervicales laterales profundi superiores • Intersection of V. jugularis • Regional lymph nodes for:
– Nodus lymphoideus jugulodigastricus cervicalis interna and M. digastricus, – Tonsilla palatina
– Nodus lymphoideus lateralis Venter posterior – Base of the tongue
– Nodus lymphoideus anterior – Tongue
– Nodi lymphoidei submentales
• Nodi lymphoidei cervicales laterales profundi inferiores • Intersection of the inter-
– Nodi lymphoidei submandibulares
– Nodi lymphoidei juguloomohyoidei mediate tendon of the
– Skin of the anterolateral throat area
– Nodus lymphoideus lateralis M. omohyoideus with the
– Chest wall (mammary gland)
– Nodi lymphoidei anteriores V. jugularis interna
– Nape of the neck, shoulder, skin of the lateral throat area
• Nodi lymphoidei supraclaviculares • Along the A. transversa – Retroauricular lymph nodes
cervicis – Occipital lymph nodes
• Nodi lymphoidei accessorii • Nape of the neck

regional lymph nodes for the lymph coming from most of the re- Clinical remarks
gions of the head. Other lymph node stations, consisting of chain-
like rows of Nodi lymphoidei, run vertically in the throat area along The lymph outflow of the throat area and its organs is compli-
the Vv. jugularis and the neck organs; these are the main drainage cated, from a clinical perspective; however, the majority of
passages of the head and throat area (› Fig. 10.27). As a general lymph nodes of the neck are easily palpated and suited to the
histological diagnosis of tissue (biopsy). In general, an en-
rule, they are divided according to their location into frontal Nodi largement of multiple cervical lymph nodes (cervical lymph-
lymphoidei cervicales anteriores and lateral cervical lymph nodes adenopathy) can have a variety of causes not necessarily re-
(Nodi lymphoidei cervicales laterales). In their respective regions, stricted to disease processes of the head and throat area (e.g.
they appear both as superficial (Nodi lymphoidei superficiales) and lymphoma, viral infections). In case of doubt or where lym-
deep nodes (Nodi lymphoidei profundi) (› Table 10.17). phatic metastasis of malignant tumours is present (e.g. in thy-
The deep anterior cervical lymph nodes transfer the lymph they con- roid cancer) the compartmental divisions of the AJCC (› Fig.
trol from the larynx, thyroid gland and trachea to the lateral deep 10.29) are used for the elective surgical removal of the cervi-
cal lymph nodes (neck dissection).
cervical lymph nodes (› Fig. 10.28). Analogous to the classification
of the American Joint Committee on Cancer (AJCC), on each side of
the neck the lymph nodes of the throat area are divided regionally on
either side into 6 compartments (I–VI) (› Fig. 10.29).

Nodi lymphoidei Nodi lymphoidei

submentales submandibulares

Nodi lymphoidei Nodi lymphoidei cervicales laterales,

prelaryngei Nodi lymphoidei profundi

Nodi lymphoidei Nodi lymphoidei

pretracheales paratracheales
Fig. 10.28 Lymph outflow of
the neck organs and the upper
airways to the deep lateral cer-
vical lymph nodes (diagram).
[E460]

558
 10.5 Thyroid and parathyroid glands

during a thyroid resection. If this occurs (or if it is also simply

mechanically irritated), postoperative hoarseness may arise or
voice and language formation could be altered. Therefore, nowa-
days in these operations intraoperative neuromonitoring is used
to locate the nerve and identify it with certainty. This is particu-
I larly important in cases of enlargement of the thyroid gland (e.g.
M. digastricus goitre), because here the normal topography of the N. laryngeus
recurrens is elevated (although it maintains its close proximity to
II the thyroid gland and the A. thyroidea inferior, even though it is
V. jugularis interna
VI no longer as easy to locate). Goitre operations are still the most
III common causes for paralysis of the laryngeal muscles.
V
IV M. omohyoideus

The parathyroid glands (epithelial bodies, Glandula parathyroi-

dae) are generally 4 lentil-sized individual organs (2 superior and 2
inferior) located on the rear side (but with exceptionally wide vari-
Fig. 10.29 Classification of the head/throat lymphatic drainage ability) of the thyroid gland. They can also occur within the thyroid
areas in 6 compartments (AJCC).
gland or the thymus gland (ectopic epithelial bodies). The weight
of an epithelial body is approximately 40 mg.
From the lymph vessels coming from the deep cervical lymph The thyroid and parathyroid glands are part of the endocrine, hor-
nodes (Vasa efferentia) and along the V. jugularis interba, the mone-forming organs. The hormones produced here act on the
Trunci jugulares dexter and sinister arise. Via these lymph vessels, complete metabolism and intervene to regulate the iodine and cal-
the lymph drains to the right via the Ductus lymphaticus dexter cium balance of the body:
into the right venous angle and to the left via the Ductus thoracicus • The thyroid hormones triiodothyronine (T3) and tetraiodothy-
into the left venous angle. ronine (thyroxine, T4) increase the basic metabolic rate and
stimulate energy metabolism and growth and differentiation
processes.
10.5 Thyroid and parathyroid glands • The hormone produced by the parafollicular cells (C-cells) of the
Michael Scholz thyroid, calcitonin is the functional antagonist of the parathor-
mone, which is synthesised in the parathyroid glands. Calcitonin
lowers the blood calcium levels, whereas the antagonist parat­
Skills hormone raises it.

After working through this chapter, you should be able to:

• explain the embryological development of the thyroid and 10.5.2 Development
parathyroid glands
• explain the structure and function of thyroid and parathy-
roid glands Thyroid gland
From around the 24th day after fertilisation, the site of the thyroid
gland is recognisable as a medial thickening of the entoderm at the
level of the 2nd pharyngeal arch at the floor of the ectodermal sto-
modeum (› Fig. 10.31a). The epithelial thickening, from which
10.5.1 Location and function the thyroid bud arises, sprouts caudally lengthwise and stretches as
it continues its development passed the hyoid bone in order to reach
The thyroid gland (Glandula thyroidea) and the parathyroid glands its final position just below the thyroid cartilage (› Fig. 10.31b). The
(Glandulae parathyroideae, epithelial bodies) are in the anterior
throat area below the larynx (› Fig. 10.30).
The thyroid gland (Glandula thyroidea) is a large, H-shaped, un- Cornu minus Os hyoideum, Corpus
paired gland (weight in adults 20–25 g). It consists of 2 lateral lobes
Cornu majus
(Lobus dexter and Lobus sinister), which are connected to each oth-
er by the unpaired isthmus. This is adjacent to the trachea at ap- Cartilago thyroidea,
Membrana thyrohyoidea
proximately the level of the 2nd–3rd tracheal cartilage. The lateral Cornu superius
lobes surround the side surfaces of the trachea and are tightly at- Prominentia laryngea
Cartilago thyroidea,
tached to it by the connective tissue of the organ capsule (Capsula Lamina dextra
fibrosa). Thus the thyroid gland can follow the movements of the Lig. cricothyroideum
medianum
larynx and trachea during swallowing. The lateral lobes of the thy- M. cricothyroideus
roid gland reach the groove between the trachea and oesophagus Glandula thyroidea,
dorsomedially, where the N. laryngeus recurrens courses. Dorsolat- Glandula thyroidea, Lobus sinister
erally the thyroid is adjacent to the carotid sheath (Vagina carotica). Lobus dexter
Isthmus glandulae
thyroideae
Clinical remarks
Trachea
In its course the N. laryngeus recurrens is in close proximity to
the A. thyroidea inferior. As a result it can be damaged, e.g. Fig. 10.30 Location of the thyroid gland below the larynx. Ventral
view.

559
10 Neck

ingrown tissue forms an elongated, medially located duct with a NOTE

In almost 50% of people, the distal rudiments of the Ductus thyro-
narrow lumen (Ductus thyroglossus), which is connected to the glossus do not fully recede, remaining as the Lobus pyramidalis
surface of the tongue. The duct continues to exist up until the 6th running cranially from the isthmus of the thyroid gland. This can
week. At this point in time, the still undivided thyroid bud begins even be connected with the hyoid bone via connective tissue fibres
its histological differentiation, even before the formation of the and smooth muscles (› Fig. 10.32).
right and left lobes, lateral of the organ system. The median central
section (the actual thyroid bud) subsequently remains behind in
terms of its growth, later on forming the isthmus of the thyroid Clinical remarks
gland, while the two side lobes extend somewhat cranially.
For the entire length of the Ductus thyroglossus, from the Fora-
In about the 7th week of embryonic development, the thyroid gland men caecum at the floor of the tongue up to the isthmus or the
achieves its final shape and its position in the throat area. The isthmus Lobus pyramidalis, the lumen of the duct may persist and lead
and the lower margins of the two side lobes lie in front of the 2nd and to the formation of a median neck cyst or (where it connects to
3rd cartilage rings of the later trachea. At this point, the Ductus thy- the neck surface) a median neck fistula (› Fig. 10.33a). Both
roglossus has already receded; its proximal opening at the base of the have no clinical significance, as long as they are not inflamed
tongue, however, remains as a small medial cavity (Foramen cae- (but can be cosmetically disfiguring). Median neck cysts and
fistulas should be differentiated from lateral neck cysts and
cum) behind the Sulcus terminalis of the tongue (› Fig. 10.31b).
fistulas. The latter arise when the brachial sulcus or the Sinus
cervicalis (a furrow occurring during embryogenesis, which
represents the joint opening of the 2nd–4th brachial sulci) are
not fully obliterated. Lateral neck cysts are noticeable as
4th week ­liquid-filled bulges on the side of the throat area; lateral neck
fistulas usually open at the anterior border of the M. sterno-
Bud of the cleidomastoideus (› Fig. 10.33b).
Ductus thyroglossus

Lingua

a Parathyroid gland
Unlike the site of the thyroid gland, the parathyroid glands develop
as derivatives of the 3rd and 4th pharyngeal pouches. Approxi-
5th week
mately in the 6th embryonic week the left and right dorsal buds of
Foramen caecum the 3rd and 4th pharyngeal pouches are each differentiated into an
epithelial body, which are located on the dorsal side of the thyroid
Ductus
thyroglossus gland.
Glandula thyroidea
NOTE
b Due to the descent of the upper epithelial bodies (3rd pharyngeal
pouch) jointly with the thymus, they continue caudally on the pos-
Fig. 10.31 Development of the thyroid gland. a Formation of the thy- terior of the thyroid gland as the epithelial bodies of the 4th pha-
roid gland bud as an epithelial thickening on the base of the ectoder- ryngeal pouch. The epithelial bodies of the 4th pharyngeal pouch
mal Stomodeum in the 4th embryonic week. b Descent of the thyroid are thus found at the upper thyroid pole originating from the 3rd
bud caudally and formation of the Ductus thyroglossus with persisting pharyngeal pouch at the lower thyroid pole. This means that their
connection to the base of the tongue. Growth of the two side lobes of position on the posterior side of the thyroid gland is extremely vari-
the thyroid gland up to the end of the 7th embryonic week. [E838] able.

Glandula
submandibularis
M. digastricus,
Venter anterior

Glandula M. stylohyoideus
submandibularis
Os hyoideum

M. omohyoideus,
A.; V. laryngea superior;
Venter superior
N. laryngeus superior
M. sternohyoideus
Membrana thyrohyoidea
M. thyrohyoideus
Cartilago thyroidea
M. constrictor pharyngis inferior

Glandula thyroidea, (Lobus pyramidalis, Var.)

Lobus dexter

Fig. 10.32 Clearly formed Lobus

M. cricothyroideus M. sternothyroideus pyramidalis of the thyroid gland
with connection to the hyoid
Cartilago cricoidea bone (Os hyoideum). Ventral
view.

560
 10.5 Thyroid and parathyroid glands

10.34). It courses in an arch shape around the neurovascular

cord running to the head (A. carotis communis, N. vagus [X],
V. jugularis) medially to its supply area.
Foramen caecum The 4 parathyroid glands are supplied by branches of the Aa. thy-
Cyst of the ductus
roideae inferiores.
Os hyoideum
thyroglossus

Opening of a Cartilago thyroidea Clinical remarks

thyroglossal fistula
Glandula thyroidea About 10% of the population have an A. thyroidea ima, mostly
a arising from the Truncus brachiocephalicus rising in front of
the trachea. Individually, their size can vary greatly and can
lead to clinical complications within the context of a tracheos-
Location of
ear fistulas
tomy or thyroidectomy.

Location of
inner opening
Tonsilla palatina of neck fistulas
Veins
Cervical cyst Remains of a The venous blood from the upper half of the thyroid gland is
pharyngeal arch drained on both sides by the V. thyroidea superior into the
Location of external
M. sternocleido- V. jugularis interna (› Fig. 10.36). This contains other venous in-
opening of neck fistulas
mastoideus flows from the Vv. thyroideae mediae which are also paired. The
b vessels of the Plexus venosus thyroideus impar form a venous
plexus on the lower poles of the thyroid lobes and the isthmus
Fig. 10.33 Cysts and neck fistulae. a Possible location of cysts of the
Ductus thyroglossus. The arrows represent the course of the descent
(› Fig. 10.36). They take the blood via the Vv. thyroideae inferi-
of the thyroid gland bud from the Foramen caecum to under the thy- ores along the front of the trachea into the V. brachiocephalica
roid cartilage of the larynx. b Lateral neck fistulas usually perforate sinistra. Running caudally, these veins also take with them smaller
through the skin at the leading edge of the M. sternocleidomastoide- venous vessels from the trachea and oesophagus.
us. [E581]
NOTE
The thyroid hormones leave the thyroid gland and the parathyroid
10.5.3 Vascular, lymphatic and nervous systems glands via the veins!

Arteries
The thyroid gland as an endocrine organ, is very well perfused Lymph vessels
(› Fig. 10.34, › Fig. 10.35). It is supplied on both sides by two The lymph from the thyroid and parathyroid glands is drained via
arteries coming from different origins: the Nodi lymphoidei thyroidei along the venous blood vessels to
• The A. thyroidea superior runs as the first branch of the A. the lateral deep cervical lymph nodes. From the top half of the thy-
carotis externa to the upper pole of each thyroid lobe and roid gland, lymphatic vessels lead to the Nodi lymphoidei prela-
branches out on the front surface of the thyroid gland. ryngei. From the lower half, lymphatic vessels run ventrally either
• The A. thyroidea inferior originates from the Truncus thyrocer- via the Nodi lymphoidei pretracheales or directly to the caudal
vicalis (› Fig. 10.13) and supplies branches to the lower pole Nodi lymphoidei cervicales laterales profundi (› Table 10.17;
and for the supply of the posterior of the thyroid gland (› Fig. › Fig. 10.28).

A. sublingualis N. hypoglossus [XII]

A. lingualis V. lingualis

M. hyoglossus M. hyoglossus

A. thyroidea superior A. carotis externa

A. carotis externa N. laryngeus superior,

R. internus
M. geniohyoideus
Bifurcatio carotidis
Os hyoideum
A. laryngea superior
Membrana thyrohyoidea
A. thyroidea superior
Glandula thyroidea,
A. carotis communis
Lobus dexter
Cartilago thyroidea
A. thyroidea superior,
R. glandularis anterior Glandula thyroidea,
Lobus sinister
M. cricothyroideus
Lig. cricothyroideum medianum
A. thyroidea inferior,
Rr. glandulares Isthmus glandulae thyroideae Fig. 10.34 Supply areas and
Trachea course of the arteries of the thy-
roid gland. Ventral view.

561
10 Neck

10.6 Larynx
Friedrich Paulsen

A. thyroidea
superior
Glandula parathyroidea Skills
superior

Glandula parathyroidea After working through this in this chapter, you should be able to:
A. thyroidea inferior • describe the essential functions of the larynx, the blood
inferior
Truncus thyrocervicalis
supply, lymph drainage and innervation
• name the skeletal elements and ligaments of the larynx
• present the joints and muscles of the larynx and their func-
A. subclavia tion and innervation
sinistra N. laryngeus • explain terms such as tensioning and adjustment appara-
recurrens dexter tus, the subdivision of the larynx and limits of the entrance
N. laryngeus to the larynx
recurrens sinister • relate the larynx, its blood vessels and nerves to the sur-
rounding structures, and name the important landmarks
• describe the principles of laryngeal development
Fig. 10.35 Aa. thyroideae superior and inferior and Nn. laryngei
recurrentes sinister and dexter. Dorsal view. [E402]

Clinical case
Carcinoma of the larynx
Case study
A 53-year-old roofer is referred to an ear nose and throat (ENT)
specialist by a general practitioner. In patient case history the
M. thyrohyoideus A.; V. thyroidea man says he has been hoarse for some time. He can't say ex-
superior actly how long it has been. When asked, he admits to smoking
at least one pack of cigarettes a day for about 30 years. His
alcohol intake is ‘normal’, without being more specific.
V. thyroidea
A. thyroidea inferior media Initial examination
Plexus thyroideus In the laryngoscopy, the ENT specialist sees a large supraglottic
impar Truncus tumour in the area of the right vestibular fold, passing continu-
thyrocervicalis ously into the epiglottis and concealing the anterior commis-
N. laryngeus
recurrens dexter sure and part of the glottis. On the right side of the throat area,
N. vagus [X] sinister he can also clearly palpate a clearly enlarged hard tumour, not
N. vagus [X] dexter
painful under pressure, which he classified as enlarged lymph
Vv. thyroideae inferiores N. laryngeus nodes. He then immediately arranges an appointment at the
recurrens sinister
neighbouring university ENT clinic for the patient. He informs
the patient that for the purposes of further diagnosis tissue
Fig. 10.36 Drainage areas and course of the veins of the thyroid
samples need to be taken to rule out a malignant tumour; how-
gland. Ventral view. [E402]
ever, he must consider the possibility of laryngeal cancer.

Further diagnosis
Nerves In the university clinic, several tissue biopsies are taken with
The thyroid and parathyroid glands are innervated by the auto- the patient under local anaesthesia from various superficial
nomic nervous system. Postganglionic parasympathetic fibres sections of the tumour and sent to the pathology department.
The histopathological findings in several of the samples con-
come from the 3 upper sympathetic trunk ganglia (Ganglia cervi-
firm the diagnosis of a non-keratinised squamous cell carci­
calia superius, medius and inferius or Ganglion cervicothoracicum noma. Now a comprehensive tumour staging is undertaken for
= Ganglion stellatum → fusion of Ganglion cervicale inferius with the patient. This shows a supraglottic malignancy, which has
the first or the first two thoracic ganglia) and course with the ves- already grown into the fatty material in front of the epiglottis
sels to their target organs. The parasympathetic fibres come from and on the right side has spread to the level of the vocal folds.
the N. vagus [X] and reach the thyroid and parathyroid glands with The anterior commissure and the thyroid cartilage have al-
the N. laryngeus superior (› Fig. 10.34) and the N. laryngeus re- ready been penetrated. The tumour has grown further caudally
currens (› Fig. 10.35). than the doctors had expected. Ipsilaterally there are already
other lymph node metastases, as well as the palpable en-
larged lymph nodes. No remote metastases are detectable.
NOTE
The thyroid gland has a close spatial relationship with the Nn. laryn- Clinical picture
gei recurrentes (Nn. laryngei inferiores). After its loop around the Malignant laryngeal tumours, at about 40%, are the most
arterial vessels (left: courses around the aortic arch, to the right: common cancers of the head and neck area, with an incidence
cour­ses around the A. subclavia dexter) the nerves run in the of 8 out of 100,000 inhabitants per year. They are 5–10 times
groove between the trachea and the oesophagus cranially to the more common in men than in women. The peak age is 55–65
larynx, where they innervate the inner laryngeal muscles. years old. In 95% of cases they involve squamous cell carcino-
ma, 60% of laryngeal carcinomas develop in the area of the
glottis and 40% are supraglottic tumours. The main causes
are exogenic noxious agents, especially tobacco.

562
 10.6 Larynx

Treatment and follow-up Phonation

Due to the extensive findings, in this patient the larynx cannot For articulation many mechanisms, such as the mass, tension and
be preserved. This means that he will be informed about the length of the vocal cords, as well as the pressure of blowing, are in-
extensive treatment to be carried out and after giving his ap- volved. When doing so, the pitch depends on the frequency of vi-
proval he will be operated on the following day. In the course
bration of the vocal folds and the volume of the airflow strength,
of the operation, the entire larynx is removed (laryngectomy).
The transition to the pharynx is closed and the patient re- which in turn is caused by the tension of the diaphragm and the
ceives a continuous tracheostome in the region of the Fossa respiratory muscles (blowing pressure).
jugularis. On the right side, a neck dissection is carried out If one presses the index finger on the Adam's apple and swallows,
(removal of the lymph nodes of the throat area) of zones II, III, the upward movement of the larynx can be felt; similarly, one can
V and VI according to the classification of the American Acade- feel the larynx migrating cranially when a sound is generated and it
my of Otolaryngology Head and Neck Surgery. continues to rise.
After the operation there is close monitoring, and elaborate
speech therapy is planned to learn to speak using the oeso­
phagus (belching speech), as the patient no longer has a larynx. Breathing
However, 5 days after the operation, the patient is seen once The width of the lumen of the windpipe can be modified in the lar-
again with a cigarette in his hand in front of the hospital en- ynx by changing the position of the vocal folds.
trance. This time, he is not smoking through the mouth, but
through the tracheostome.
10.6.2 Development

Prenatal
10.6.1 Overview The development of the larynx is closely linked with the develop-
ment of the base of the tongue and pharyngeal arches and takes
The larynx functionally provides the reflective protection for the place in the 4th–10th weeks.
lower respiratory tract against intrusion by foreign objects and Between the 2nd and 4th pharyngeal arches, at the end of the 4th
articulation and voice projection (phonation). In addition, it week, the hypobranchial eminence (Eminentia hypobranchialis) is
plays a part in abdominal prelum. As part of the airway, the larynx differentiated from the buccopharyngeal bud. Its lower end over-
sits between the throat (pharynx) and the windpipe (trachea). Oth- grows onto the laryngotracheal groove lying medial between the
er neck structures such as the thyroid gland, gullet (oesophagus) 4th and 5th pharyngeal arches and is differentiated to the epiglot-
and neurovascular cord are in close proximity. The larynx is fixed tic eminence.
by ligaments and muscles in the throat area in such a way that its Lateral to the laryngotracheal groove, the arytenoid bulges devel-
location can be changed in the connective tissue spaces of the neck op due to rapid growth from a tracheobronchial bud. They con-
when swallowing and speaking. This is possible due to its close re- strict the developing lumen of the trachea from the already sepa-
lationship with the hyoid bone (Os hyoideum), with which it is rated oesophagus into a T-shape. At this stage (6th week) the epi-
connected by ligaments. glottis and arytenoid bulges are adjacent to each other and are only
separated from each other by a narrow slit (entrance to the larynx)
NOTE (top bar of the T). There remains between the arytenoid bulges a
The lower respiratory tract includes the larynx, trachea and bron- slit-shaped gap (primitive glottis; lower vertical line of the T). Due
chial tree (Arbor bronchialis). to the very rapid growth of the arytenoid bulges, a short-term clo-
sure of the lumen of the larynx occurs.
In the 10th week the rest of the laryngeal growth has caught up and
Structure the larynx is recanalised again. This creates mucosal pockets on
The larynx consists of a cartilage skeleton that partially ossifies both sides of the larynx (Sinus MORGAGNI ), whose upper and
over the course of life. The skeletal elements are connected to each lower limits differentiate to the pocket folds and vocal folds.
other by true joints or by connective tissue and are moved by mus-
cles. Some muscles are part of the adjustment apparatus, which ex-
pands the glottis, while the other muscles are part of the tensioning
Clinical remarks
apparatus which regulates the length and the tension of the vocal Degenerative disorders of what is usually the short-term clo-
folds in phonation (› Chap. 10.6.3). sure of the lumen of the larynx can lead to life-threatening par-
tial or complete closure (congenital stenoses and dia-
Functions phragms). Additionally, malformations of the epiglottis are
possible (epiglottic hypoplasia or aplasia, double or split epi-
Protection
glottis).
During swallowing, as well as when coughing and sneezing, there
is a coordinated interaction of the larynx with all it surrounding
structures:
• When swallowing the glottis is closed, narrowing the structures The arytenoid cartilage is differentiated from the arytenoid bulges;
lying above, the epiglottis is moved over the entrance to the lar- the epiglottic bulge becomes the epiglottis. Its lateral parts develop
ynx, and the larynx is pulled forwards and upwards. Thus the into the Plicae aryepiglotticae. Thyroid and ring cartilage originate
airway through the larynx is sealed and protected from the in- from the 4th and 5th pharyngeal arches, the inner laryngeal mus-
gress of liquids and food. cles differentiate from the 6th pharyngeal arch. The suspension de-
• When coughing and sneezing the vocal ligaments and the high- vice develops from the surrounding mesenchyme, the epithelium
er structures are narrowed for a short time, the larynx is pulled originates from the entoderm of the foregut.
forward and upwards and the glottis is suddenly pulled open by
an explosive respiratory breath (cough reflex, › Chap. 10.6.6).

563
10 Neck

NOTE Table 10.18 Cartilage of the laryngeal skeleton.

Due to the different origins of the upper and lower parts of the lar-
ynx from a buccopharyngeal and a tracheobronchial bud, which Cartilage Amount Cartilage Occurrence
fuse together at the level of the Ventriculus laryngis, the glottis (the histology
area between the vocal folds) is the boundary for vascular supply,
Epiglottic cartilage (Cartilago epi- Unpaired Elastic Regular
innervation and lymph drainage.
glottica)
Thyroid cartilage (Cartilago thy- Unpaired Hyaline Regular
roidea)
Postnatal
The infant is able to breathe and drink at the same time, because Cricoid cartilage (Cartilago cri- Unpaired Hyaline Regular
coidea)
the larynx is still located relatively high up, and so the epiglottis
reaches the nasopharynx. The maternal milk flows through the Re- Arytenoid cartilage (Cartilago ary- Paired Hyaline (excep- Regular
cessus piriformes (› Chap. 10.6.3) of the larynx into the oeso­ tenoidea) tion: tip of the
Proc. vocalis:
phagus, and at the same time, breathing can take place. In the course,
elastic)
due to longitudinal growth, the larynx becomes increasingly caudal
Corniculate cartilage (Cartilago Paired Elastic Variable
(laryngeal descent). Now the airway has to be closed when swal-
corniculato, SANTORINI's carti-
lowing, in order to prevent aspiration. lage)
During puberty, there is an extensive gender divergent growth
Cuneiform cartilage (Cartilago Paired Elastic Variable
spurt of the whole larynx. As a result, the larynx grows significant-
cuneiformis, WRISBERG's carti-
ly within a relatively short time period, in boys much more signifi- lage)
cantly than in girls, with the laryngeal structures being affected to
varying degrees. In boys, the length of the vocal fold increases by
an average of 1 cm, in girls by ‘only’ 3–4 mm. This results in voice Thyroid cartilage
changes, which are significantly more pronounced in boys than in The thyroid cartilage (Cartilago thyroidea, › Fig. 10.37a) consists
girls (voice break, voice change, mutation). The cause of the voice of 2 plates, Lamina dextra and Lamina sinistra, sitting like a pro-
break is essentially disruption in the coordination between the dif- tective shield in front of the voice-producing part of the larynx.
ferent rapidly growing structures involved in phonation. They join together ventrally at a right angle (in men) and at a
slightly larger angle (approx. 120° in women). The interface with
the Incisura thyroidea superior is retracted cranially, and goes up
10.6.3 Laryngeal skeleton to the furthest point of the ventral side, the Prominentia laryngea
(Adam's apple). The connection point of the two plates with the In-
The laryngeal skeleton (› Fig. 10.37, › Fig. 10.38) is composed of cisura thyroidea inferior is retracted on the lower edge. On the out-
epiglottic cartilage, thyroid cartilage, ring cartilage, arytenoid carti- er side, bulging at the posterior of the thyroid cartilage are a Tu-
lage, corniculate cartilage and sphenoid cartilage (› Table 10.18). berculum thyroideum superius and a Tuberculum thyroideum
inferius, which are connected via the Linea obliqua. All protruber-
Cartilage of the laryngeal skeleton ances serve as zones for tendon insertion. The posterior edges of
Epiglottis the side plates each merge cranially into the slightly longer superior
The foundation of the epiglottis (epiglottis, › Fig. 10.37b) is an horn, the Cornu superius, and caudally into the inferior horn, the
apertured plate made of elastic cartilage (Cartilago epiglottica). Cornu inferius. On the inside of the Cornu inferius is the articular
Blood vessels, nerves and excretory ducts of subepithelial glands surface, the Facies articularis cricoidea, for articulation with the
pass through these holes. The cartilage goes downwards to the cricoid cartilage.
front in the stalk of the epiglottis (Petiolus epiglottidis).

Os hyoideum, Cartilago
Cornu minus epiglottica Os hyoideum, Cartilago epiglottica
Cornu majus Os hyoideum Membrana thyrohyoidea
Lig. thyrohyoideum Bursa infrahyoidea Cartilago thyroidea,
laterale Cartilago triticea Cornu superius
Lig. hyoepiglotticum
Membrana Cartilago thyroidea,
Cartilago thyroidea, Lig. thyrohyoideum Lamina dextra
thyrohyoidea Cornu superius medianum
(Lig. corniculopharyn-
Corpus adiposum geum)
Cartilago thyroidea, Lig. thyrohyoideum preepiglotticum
Cartilago arytenoidea
Lamina dextra medianum
Lig. thyroepiglotticum
Lig. cricoaryteno-
Incisura thyroidea ideum
Lig. vestibulare
superior
Cartilago thyroidea,
(Lig. corniculopharyn-
Lig. cricothyroideum Cornu inferius Lig. vocale
geum)
medianum [(conicum)]
Lig. cricothyroideum
Cartilago cricoidea
medianum
Cartilago cricoidea Pharynx, Tunica mucosa
Ligg. anularia
Lig. cricotracheale Trachea, Paries
membranaceus
a b

Fig. 10.37 Laryngeal skeleton and ligament arrangement. a Ventral view. b Medial view of the sagittal planes of the larynx.

564
 10.6 Larynx

Incisura thyroidea superior

Cartilago thyroidea

Lig. vocale
Cartilago cricoidea

Conus elasticus
Conus elasticus

Proc. vocalis
Cartilago Articulatio
arytenoidea cricothyroidea
Proc. muscularis

Cartilago thyroidea,
Cornu superius
Cartilago corniculata Fig. 10.38 Laryngeal skeleton
Lig. cricoarytenoi-
Cartilago cricoidea deum (without epiglottis) with Conus
elasticus. Cranial view.

Cricoid cartilage age of 60 years, with very few exceptions the cartilage has al-
Cricoid cartilage (Cartilago cricoidea, › Fig. 10.37) forms the most completely mineralised and ossified; in women only
base of the laryngeal skeleton. It is shaped like a signet ring, with parts of the laryngeal skeleton ossify. Therefore, in men over
the seal being the Lamina cartalaginis cricoideae pointing dorsal- the age of 50 years the hyaline cartilage should be called
ly and carries articular surfaces to the right and left side and on the bone. Thus, fractures of the laryngeal skeleton can occur (e.g.
following traffic accidents), accompanied by life-threatening
upper edge: above is the Facies articularis arytenoidea to articu-
obstruction of the airway, phonation disorders and danger of
late with the respective arytenoid cartilage, and on the side a Facies asphyxiation. Due to the ossification, the operative excision of
articularis thyroidea surface to articulate with the thyroid cartilage. bone tissue (e.g. in the case of a hemilaryngectomy due to
At the front, the ring forms a narrow arch, the Arcus cartilaginis cancer of the larynx) or following a fracture, the fracture ends
cricoideae. and/or the remaining parts can be splinted with material used
for osteosynthesis.
Rarely, at birth the laryngeal cartilage is too soft (laryngomala-
NOTE
cia). This can be associated with respiratory disorders.
In adults the cricoid cartilage is at the level of the VI cervical verte-
bra (C7).

Ligaments of the larynx

Arytenoid cartilage The laryngeal cartilages (bone) are joined together by joints and a
The arytenoid cartilage (Arytenoid cartilage, Cartilago aryte- connective tissue suspension system. The connective tissue appa-
noidea, › Fig. 10.37b) are comparable to three-sided pyramids. ratus made up of ligaments and membranes, together with the la-
This means that each cartilage has 4 areas: ryngeal muscles, other muscles and the fascia of the throat area, is
• Facies anterolateralis (with Colliculus, Crista arcuata, Fovea essential for the functioning of the mobility of the larynx with
triangularis and Fovea oblonga) breathing, phonation and when swallowing. The ligament appara-
• Facies medialis tus can be divided into outer and inner laryngeal ligaments
• Facies posterior (› Table 10.19, › Table 10.20, › Fig. 10.37, › Fig. 10.38).
• Base, Basis cartilaginis arytenoideae (with Facies articularis for
articulation with the cricoid cartilage). Ligaments between the larynx and hyoid bone
Furthermore, each arytenoid cartilage has 3 processes: Top edge of the thyroid cartilage and lower edge of the hyoid bone
• Anterior Proc. vocalis, at its peak consisting of elastic cartilage are connected by the Membrana thyrohyoidea which are rein-
• Lateral Proc. muscularis forced in the area of the Incisura thyroidea superior to the Lig. thy-
• Above the tip, Apex cartalaginis arytenoideae rohyoideum medianum and in the area of Cornua majora of the
hyoid bone at the Lig. thyrohyoideum laterale (› Fig. 10.37a). In
Corniculate and cuniform cartilage each Lig. thyrohyoideum laterale a triangular cartilage (Cartilago
The corniculate cartilage (Cartilago corniculata, SANTORINI's triticea) consisting of elastic cartilage can be embedded.
cartilage) has a hook-shaped structure and can also be absent. It
sits on the arytenoid cartilage and protrudes under the mucous Suspension of the epiglottis
membrane as the Tuberculum corniculatum. The cuniform carti- The Lig. thyroepiglotticum originates below the Incisura thy-
lage (Cartilago cuneiformis, WRISBERG's cartilage) also may oc- roidea superior on the inside of the thyroid cartilage, which attach-
cur as a variation. It protrudes into the Plica aryepiglottica (see be- es the epiglottic stalk (Petiolus epiglottidis) to the thyroid carti-
low) as the Tuberculum cuneiforme (› Fig. 10.43). lage (› Fig. 10.37b). The frontal surface of the epiglottis facing the
hyoid bone is attached via the Lig. hyoepiglotticum to the inner
surface of the hyoid bone. Between the Membrana thyrohyoidea
Clinical remarks and epiglottis, and also at the side of the epiglottis, is the Corpus
From about the age of 20 years, the hyaline laryngeal cartilag- adiposum preepiglotticum, a fatty body which carries out an im-
es (thyroid, cricoid and arytenoid cartilage) start to ossify very portant role in the distortion of the epiglottis during swallowing by
slowly and differently according to gender. In men, after the protecting the lower respiratory tract.

565
10 Neck

Table 10.19 Outer laryngeal ligaments. Ligaments of the cricoid cartilage

In the ventral section, the thyroid and cricoid cartilages are con-
Ligament/ Connects Remarks
membrane nected by the Lig. cricothyroideum. This is a syndesmosis, the
middle part of which is reinforced by the Lig. cricothyroideum
Membrana thyro- Hyoid and thyroid cartilage
medianum (Lig. conicum) (› Fig. 10.37). Caudally the cricoid
hyoidea
cartilage is attached via the Lig. cricotracheale to the first tracheal
Lig. thyrohyoide- Hyoid and thyroid cartilage Reinforcement of the Membra- ring. Dorsally the Lig. cricopharyngeum radiates into the pharyn-
um medianum in the median plane na thyrohyoidea
geal wall.
Lig. thyrohyoide- Hyoid and thyroid cartilage Reinforcement of the Membra-
um laterale at the rear edge of the na thyrohyoidea
Membrana thyrohyoidea
NOTE
Above the Prominentia laryngea (Adam's apple), the Incisura thy-
Lig. cricotra- Cricoid cartilage and tra- Fixes cricoid cartilage to the roidea superior and the Membrana thyrohyoidea can be palpated.
cheale chea trachea When the person carrying out the test runs their finger from the
Lig. cricopharyn- Cricoid cartilage and lower Fixes the cricoid cartilage to Prominentia laryngea along the thyroid cartilage in a caudal direc-
geum part of the anterior wall of the pharynx tion, they reach the clinically significant Lig. conicum.
the pharynx

Clinical remarks
Table 10.20 Inner laryngeal ligaments. If the upper respiratory tract is shifted causing breathless-
ness, the Lig. cricothroideum medianum (Lig. conicum) serves
Ligament/ Connects Remarks
as a physical landmark. In an emergency measure it can be cut
membrane
through (coniotomy), together with the underlying Conus
Lig. thyroepiglot- Thyroid cartilage and stalk Fixes the epiglottis to the thy- elasticus (see below) in order to reach the inner space of the
ticum of the epiglottis roid cartilage larynx just below the vocal folds.
Lig. cricothyroide- Thyroid and cricoid carti-
um lage
Lig. cricothyroide- Thyroid and cricoid carti- Reinforcement of the Lig. cri-
Laryngeal joints
um medianum lage cothyroideum
(Lig. conicum)
Thyroid cartilage and cricoid cartilage are linked via the paired Ar-
ticulatio cricothyroidea. Each arytenoid cartilage articulates with
Lig. ceratocri- Cornu inferior of the thy- Reinforces the joint capsule of
the cricoid cartilage via the Articulatio cricoarytenoidea. These
coideum roid cartilage and outer the Articulatio cricothyroidea
surface of cricoid cartilage joints are diarthroses (true joints); however, in a smaller percentage
of people, the Articulatio cricothyroidea can also be a synchondro-
Lig. cricoarytenoi- Posterior of the arytenoid Contains much elastic materi-
deum (posterius) cartilage and lateral poste- al and is used to reset the ary-
sis.
rior of the cricoid cartilage tenoid cartilage in the starting
position Articulatio cricothyroidea
Membrana fibro- Runs within the wall of the These include the Conus elas- The Articulatio cricothyroidea (› Fig. 10.37a) is a ball joint. The
elastica supraglottic and subglottic ticus, Ligg. vocalia, Membrana concave Facies articularis thyroidea of the lateral surface of the cri-
space and includes the quadrangularis and Ligg. ves- coid cartilage articulates with the convex Facies articular cricoidea
vocal cords and vestibular tibularis at the lower inner side of the Cornu inferius of the thyroid carti-
folds lage. The joint capsule is taut and is reinforced by the Lig. cerato-
Conus elasticus Upper edge of the sides of Strong elastic membrane in cricoideum on the outside. The joint enables shifting movements
(› Fig. 10.38) the cricoid ligaments and the wall of the subglottic to take place along the sagittal plane as well as rotational move-
Lig. vocale space; the upper edge of the
ments around a transverse axis. During rotation, the cricoid carti-
Conus elasticus thickens
towards the Ligg. vocalia, with
lage comes close to the thyroid cartilage (› Fig. 10.39). The tilting
its width depending on the movement leads to tension of the vocal cords (see below; coarse
position of the vocal folds; in tension of the vocal cords).
phonation, it concentrates
and focuses the airstream Articulatio cricoarytenoidea
onto the vocal folds
In the cricoarytenoid joint the base of the arytenoid cartilage artic-
Lig. vocale Thyroid cartilage (via vocal Thickened upper edge of the ulates with the posterior side of the upper edge of the cricoid carti-
ligament and Nodulus Conus elasticus in the glottis lage (› Fig. 10.37b). The articular surface of the arytenoid carti-
elasticus anterior) and
lage is more round and concave; the articular surfaces of the cri-
Proc. vocalis (via the
­No­dulus elasticus posterior)
coid cartilage are convex and oval (cylinder-shaped). Parallel to the
of the arytenoid cartilage cylindrical axis, hinging and sliding movements can be carried out
Membrana quad- Inside the wall of the Thinner elastic membrane in
in the cricoarytenoid joint; these serve to open and close the vocal
rangularis supraglottic space, pulls it the wall of the supraglottal ligaments and maintain the tension of the vocal folds (› Fig.
from the edges of the epi- space 10.37b). When the arytenoid cartilage is guided outwards as part of
glottis to the vestibular a hinge movement, this leads to the raising and abduction of the
folds Proc. vocalis, and thus the opening of the glottis. A rotation along
Lig. vestibulare Connects the thyroid carti- Thickened lower margin of the the hinge inwards in combination with the lowering and adduction
lage with the respective Membrana quadrangularis in of the Proc. vocalis leads to the closure of the glottis. The hinge
arytenoid cartilage, cranial the vestibular folds movements can be combined with sliding motions. By doing so,
of the vocal folds
the arytenoid cartilage moves in abduction and adduction ventrally

566
 10.6 Larynx

Clinical remarks
The complete paralysis of all the laryngeal muscles leads to
Cartilago thyroidea
the so-called cadaveric position of the vocal folds due to the
pulling strength of the Ligg. cricoarytenoideae posteriora on
the arytenoid cartilages.
Lig. vocale Following endotracheal intubation and extubation, laryngos-
copy or bronchoscopy, the arytenoid cartilage can be shifted
Nodulus
elasticus in a dorsolateral or medioventral direction, which is called
anterior ary­tenoid dislocation. Because the Lig. vocale on the affected
side is unmovable, the patient has a hoarse voice. Causes for
Vocal Cartilago
arytenoidea
this are internal bleeding in the joint cavities or the formation
tendon
of a reactive effusion after damaging the synovial membranes.
Proc. vocalis Muscle contractures can cause the joint surfaces to subse-
Pars
M. crico- obliqua Nodulus quently adhere and ankylosis can occur. An arytenoid disloca-
thyroideus Pars elasticus tion should be distinguished from a nerve lesion.
recta posterior The cricoarytenoid joints are constructed like the large limb
joints. That means that here degenerative cartilaginous chang-
es in advanced age are possible (osteoarthritis), affecting the
closure of the vocal folds in phonation and thus the quality of
Cartilago Rotational axis of the the voice, as well as joint infections (arthritis) or rheumatoid
cricoidea Articulatio cricothyroidea diseases (rheumatoid arthritis).

Fig. 10.39 Outer laryngeal muscles, M. cricothyroideus. Medial view

of a lateral sagittal plane of the larynx. Contraction of the M. cricothy-
roideus tilts the ring cartilage using synchronous movements in the Laryngeal muscles
cricothyroid joints. The vocal ligament is extended and is roughly The laryngeal muscles derived from the pharyngeal arches are sub-
stretched because the arytenoid cartilage sitting on the cricoid carti- divided according to their origin, location and innervation, into
lage is tilted dorsally. outer and inner laryngeal muscles. The striated muscles are ex-
tremely densely innervated and very well perfused. Functionally,
or dorsally. The joint capsule (Capsula articularis cricoarytenoide- they serve to open and close the vocal ligaments and maintain the
ae) is broad and taut due to the complex movement options and it tension of the vocal folds (by lengthening and shortening). Muscles
has no influence on the joint alignment; however, dorsally the joint that change the shape of the vocal ligaments belong to the actuator
capsule is reinforced by the Lig. cricoarytenoideum (posterius) apparatus; muscles that affect their tension are collectively called
made from highly elastic connective tissue (› Fig. 10.37b), which the tension apparatus.
functionally aids the alignment of the arytenoid cartilage and
counteracts the elastic forces of the Lig. vocalis. Outer laryngeal muscles
Apart from the M. cricothyroideus sitting directly on the larynx,
the M. constrictor pharyngis inferior belonging to the muscles of
the pharynx (pharyngeal muscles) as well as the M. thyrohyoideus

Table 10.21 Outer laryngeal muscles.

Innervation Origins Attachment Function

M. cricothyroideus, Pars interna (› Fig. 10.39)
N. laryngeus superior, Anterior inner surface of the cricoid carti- Inside of the thyroid cartilage and Tenses the vocal folds (coarse tension) by tilting the
R. externus lage Conus elasticus cricoid cartilage
M. cricothyroideus, Pars externa with a Pars recta and a Pars obliqua (› Fig. 10.39)
N. laryngeus superior, Anterior inner surface of the cricoid carti- Lower edge of the thyroid cartilage Tenses the vocal folds (coarse tension) by tilting the
R. externus lage plate (Pars recta), Cornu inferius of cricoid cartilage
the thyroid cartilage (Pars obliqua)
M. constrictor pharyngis inferior, Pars thyropharyngea
N. laryngeus superior, Outer margin of the thyroid cartilage Pharyngeal wall Raises the larynx during swallowing, participates in
R. externus, Plexus pharyn- tensing of the vocal folds
geus
M. constrictor pharyngis inferior, Pars cricopharyngea
N. laryngeus superior, Outer margin of the cricoid cartilage Pharyngeal wall Unclear at the larynx
R. externus, Plexus pharyn-
geus
M. thyrohyoideus
Radix superior of the Ansa Lower edge of the thyroid cartilage, outer Hyoid body, Cornu majus ossis Raises the larynx during swallowing, fixes the larynx
cervicalis (profunda) of the surface of the thyroid cartilage hyoidei during phonation
Plexus cervicalis

567
10 Neck

Vocal ligament
Os hyoideum
Pars interna
M. thyroary-
Nodulus elasticus (M. vocalis)
Membrana
tenoideus Ventriculus laryngis
anterior Pars externa thyrohyoidea [MORGAGNI's sinus]

Membrana
quadrangularis
Cartilago thyroidea
Cartilago
thyroidea (Linea arcuata superior) Plica vestibularis
(ventricularis)
Lig. vocale M. thyroarytenoideus,
pars interna (M. vocalis) Glandulae
Nodulus laryngeales
elasticus
posterior M. thyroarytenoideus,
pars externa Lig. vestibulare
Articulatio
REINKE’s space
cricothyroidea Ossified
Cartilago thyroidea Lig. vocale
Proc. vocalis Pars obliqua M. aryteno-
Conus elasticus (Linea arcuata
Pars transversa ideus
inferior)
M. cricoarytenoideus Cartilago M. cricothyroideus
posterior arytenoidea Glandulae
laryngeales

Fig. 10.40 Inner laryngeal muscles, Mm. laryngis. View from above.
Ossified
[L238]
Cartilago cricoidea

belonging to the infrahyoid muscles are assigned to the outer la- Cartilago cricoidea
ryngeal muscles (› Fig. 10.39, › Table 10.21).

Inner laryngeal muscles

Fig. 10.42 Frontal section through sagittally bisected larynx (dia-
The central switching points of the inner laryngeal muscles are in gram). [L126]
the arytenoid cartilage, in which all internal laryngeal muscles at-
tach or originate (› Fig. 10.40, › Fig. 10.41, › Fig. 10.42, › Fig. vocal folds. The M. cricothyroideus regulates the length and ten-
10.43, › Table 10.22). sion of the Lig. vocale and Conus elasticus and leads to coarse ten-
sion of the vocal folds (› Fig. 10.39). The Pars thyropharyngea of
Tensioning apparatus the M. constrictor pharyngis inferior contributes to this. The M.
The tensioning apparatus includes the laryngeal joints and the la- cricoarytenoideus posterior (posticus) and Lig. cricoarytenoide-
ryngeal muscles, apart from the skeletal elements of the larynx. It um (posterius) stabilise the arytenoid cartilage, so that it cannot
influences the volume, shape and length of the vibrating part of the tilt forward. The fine tension is regulated by the M. vocalis (Pars
interna of the M. thyroarytenoideus › Fig. 10.40, › Fig. 10.42).
Its muscle fibres run parallel to the vocal fold and the vocal liga-
Cartilago corniculata
[SANTORINI's cartilage] ment (Lig. vocale) and are partly attached to the vocal cord. The
tension can be strengthened by isotonic muscle contractions and
Cornu Cartilago thyroidea modified even further by isometric contraction, so that the muscle
superius has a decisive impact on tone quality in voice projection. The Pars
Lig. vocale cricopharyngea of the M. constrictor pharyngis inferior (› Ta-
Nodulus elasticus
ble 10.23) is able to actively diminish the vocal fold tension.
anterior
NOTE
Tension apparatus: structures affecting the volume, shape and
Vocal ligament length of the vibrating section of the vocal folds: skeletal elements
Apex of the larynx, laryngeal joints, laryngeal muscles

Pars interna
(M. vocalis) M. thyroary- Clinical remarks
tenoideus
Pars externa
Voice overloading leads to a loss of tension in the M. vocalis.
It is called laryngeal paralysis. The glottis can no longer be
M. cricoarytenoideus closed properly, the voice is hoarse. This is also a reduction in
lateralis mucus production of the laryngeal glands due to voice over-
Cartilago load (› Chap. 10.6.5).
cricoidea M. cricoarytenoideus
posterior

Pars Pars
obliqua transversa Actuator apparatus
M. arytenoideus The M. cricoarytenoideus posterior (posticus) is the main muscle
of the actuator apparatus (› Fig. 10.39, › Fig. 10.40, › Fig.
Fig. 10.41 Inner laryngeal muscles, Mm. laryngis. Dorsal oblique 10.43) since it enables opening of the vocal folds and thus inspira-
view. Thyroid cartilage partially resected. [L238] tion (› Fig. 10.44a) by the abduction and elevation of the Proc.

568
 10.6 Larynx

Table 10.22 Inner laryngeal muscles.

Innervation Origins Attachment Function

M. thyroarytenoideus, Pars interna (M. vocalis) (› Fig. 10.40, › Fig. 10.41, › Fig. 10.42)
N. laryngeus inferior Lower third of the angle of the thyroid carti- Proc. vocalis, lateral to the Lig. Closes the Pars intermembranacea of the vocal liga-
lage (radiates over the vocal ligament in vocale and Nodulus elasticus pos- ments (shortening or lengthening the vocal folds, iso-
thyroid cartilage) terior, Fovea oblonga of arytenoid tonic contraction), regulates vocal fold tensioning
cartilage (vibrating section of the vocal folds, isometric contrac-
tion)
M. thyroarytenoideus, Pars externa (› Fig. 10.40, › Fig. 10.41, › Fig. 10.42)
N. laryngeus inferior Lower third of the angle of the thyroid carti- Crista arcuata of the arytenoid Closes the Pars intermembranacea of the vocal liga-
lage, lateral to the vocal ligament cartilage ments by adduction and sinking of the Proc. vocalis
M. arytenoideus transversus (› Fig. 10.40, › Fig. 10.41, › Fig. 10.43)
N. laryngeus inferior Lateral edge and posterior surface of the Lateral edge and posterior surface Closes the Pars intermembranacea of the vocal liga-
arytenoid cartilage of the contralateral arytenoid carti- ments by bringing together both arytenoid cartilages
lage
M. arytenoideus obliquus (› Fig. 10.41)
N. laryngeus inferior Base of the posterior surface of the aryte- Tip of the contralateral arytenoid Closes the Pars intercartilaginea by adduction of the
noid cartilage cartilage arytenoid cartilage; minor lateral rotation of the Proc.
vocalis with a slight opening of the Pars intermembra-
nacea
M. arytenoideus obliquus, Pars aryepiglottica (› Fig. 10.43)
N. laryngeus inferior Arytenoid cartilage tip Lateral edge of the epiglottis Slightly lowers the epiglottis
M. cricoarytenoideus lateralis (› Fig. 10.40, › Fig. 10.41)
N. laryngeus inferior Lateral upper border between Arcus and Proc. muscularis of the arytenoid Closes the Pars. intermembranacea of the epiglottis by
Lamina of the cricoid cartilage cartilage adduction and elevation of the Proc. vocalis of the
artytenoid cartilage, opens the Pars intercartilaginea
(whisper triangle)
M. cricoarytenoideus posterior (posticus) (› Fig. 10.40, › Fig. 10.41, › Fig. 10.43)
N. laryngeus inferior Posterior surface of the lamina of the cricoid Proc. muscularis of the arytenoid Opens the epiglottis for abduction and elevation of the
cartilage cartilage Proc. vocalis (up to a maximum opening) for inspiration

vocalis of the arytenoid cartilage; however, the M. cricoarytenoi- Mm. cricoarytenoideus lateralis and thyroarytenoideus and the
deus lateralis can also open the glottis to a limited extent: its iso- mucosa on the arytenoid cartilage are also involved. The fine ten-
lated contraction leads to the formation of the whisper triangle sion of the vocal folds that is vital for phonation is undertaken by
(triangular gap in the posterior region of the glottis). To improve the Pars interna of the M. thryroarytenoideus (M. vocalis), which
gaseous exchange, in calm expiration the glottis is only opened just therefore not only affects the tension but also the actuator appara-
enough to allow the exhaled air to escape. It lasts much longer than tus. The Pars externa of the M. thyroarytenoideus has a functional
the short inspiration phase with a wide open glottis. With calm effect on the convergence of the vocal folds. All the muscles can
breathing, the width of the glottis is therefore constantly changing. also be contracted so strongly that they ensure the fixed closure of
For phonation (› Fig. 10.44b) the Procc. vocales are brought to- the glottis when there is abdominal pressure (e.g. when defecating)
gether and so the glottis is loosely closed. To do this, the Mm. ary- or coughing.
tenoidei transversus and obliquus contract. Furthermore the

Margo superior epiglottidis

Epiglottis
Os hyoideum, Cornu majus
Cartilago triticea
Cartilago thyroidea,
Cartilago cuneiformis
Cornu superius
M. arytenoideus obliquus,
M. thyroarytenoideus, Pars aryepiglottica
Pars thyroepiglottica
Cartilago corniculata
M. thyroarytenoideus
Cartilago arytenoidea
M. arytenoideus
M. arytenoideus
obliquus
transversus
Cartilago thyroidea,
Capsula articularis Cornu inferius
cricothyroidea
M. cricoarytenoideus
posterior
Cartilago cricoidea, Lamina
Cartilago trachealis
Trachea, Paries
membranaceus Fig. 10.43 Inner laryngeal mus-
cles, Mm. laryngis. Dorsal view.

569
10 Neck

Table 10.23 Pharyngeal constrictors.

Innervation Origin Attachment Function

M. constrictor pharyngis superior
Rr. pharyngeales of the • Pars pterygopha- Lamina medialis of Membrana pharyngobasilaris, Together with the M. palatopharyngeus, a bulge arises
N. glossopharyngeus [IX] ryngea: the Proc. pterygoi- Raphe pharyngeus due to contraction, which blocks the nasopharyngeal
(= Plexus pharyngeus) deus and Hamulus space (PASSAVANT's ridge) when swallowing
pterygoideus
• Pars buccopha- Raphe pterygoman- Membrana pharyngobasilaris, Constriction of the throat, transport of food bolus
ryngea: dibularis Raphe pharyngeus
• Pars mylopharyn- Linea mylohyoidea
gea: of the Mandibula
• Pars glossopha- Internal muscles of
ryngea: the tongue
M. constrictor pharyngis medius
Rr. pharyngeales of the • Pars chondropha- Cornu minus ossis Raphe pharyngeus Constriction of the throat, transport of food bolus
N. glossopharyngeus [IX] ryngea: hyoidei
and the N. vagus [X]
• Pars ceratopha- Cornu majus ossis
(= Plexus pharyngeus)
ryngea: hyoidei
M. constrictor pharyngis inferior
Rr. pharyngeales of the • Pars thyropharyn- Linea obliqua of the Raphe pharyngeus Constriction of the throat, transport of food bolus
N. vagus [X] (= Plexus pha- gea: thyroid cartilage
ryngeus)
• Pars cricopharyn- Cartilago cricoidea
gea:
– Pars obliqua
– Pars transversa

Epiglottis Epiglottis

Commissura anterior

Nodulus elasticus anterior

Ventriculus laryngis Plica
(Macula flava anterior)
vestibularis
Plica vestibularis Plica vocalis

Plica vocalis Recessus Plica

piriformis aryepiglottica
Nodulus elasticus posterior
(Macula flava posterior) Tuberculum
cuneiforme Incisura inter-
Plica interarytenoidea arytenoidea
Tuberculum
a corniculatum b

Fig. 10.44 Direct imaging of the larynx (laryngoscopy). a Respiration position. b Phonation position. Plica interarytenoidea. [T719]

For phonation air flow is also important; it functions according to Clinical remarks
the BERNOULLI principle (see textbooks of physiology) on the
opening width of the glottis. Since the glottis has a smaller diame- In isolated, unilateral paralysis of the posticus, the vocal fold
ter than the trachea, the air coming from the lungs up to the level on the affected side is in the paramedian position; bilateral pa-
of the glottis is accelerated and swirled. This results in the mucosa ralysis leads to a tightened glottis due to the predominance of
the glottis closer and is associated with shortness of breath.
of the vocal folds being set in motion. The vibration can be made Dysphonia refers to all disease-related changes in sound for-
visible using stroboscopy (using light flashes creates a virtual slow mation. This also includes hoarseness (hoarseness is a rela-
motion image for the observer's eye). As a rule the vocal folds vi- tively common dysphonia of the voice, recognisable by a
brate in harmony. Through the loose connective tissue of REIN- rough, broken, husky or silent voice) in unilateral paralysis of
KE's space (see below), where there is sufficient basic tension of the posticus. Complete loss of voice is referred to as aphonia.
the vocal folds edge displacements occur; these are achieved It can occur particularly in women due to weakness in the
through the wave-shaped rolling of the mucosa at the free edge of M. arytenoideus transversus (transversus weakness) with the
whisper triangle and the resulting breathy voice.
the vocal folds (› Fig. 10.45). Due to the back migration of the
mucosal wave towards the subglottis, the mucous membranes on
both sides meet each other for a short period and completely stop
the air flow. The air flow then forces them away from each other NOTE
again. This means that there is a permanent alternation between Actuator apparatus: structures that change the shape of the vocal
the interruption and liberation of the air flow (vibration), making ligaments.
the vocal folds swing in the air flow.

570
 10.6 Larynx

cuneiforme, which are raised by the underlying cartilage of the

same name.
• The gap between the two arytenoid cartilages (Incisura interary-
tenoidea, › Fig. 10.44b): its width varies depending on the po-
sition of the arytenoid cartilage; the mucosal folds between the
a b c
arytenoid cartilages are called Plica interarytenoidea, › Fig.
10.44a.
On the right and left of the inlet of the larynx the laryngeal mucosa
goes deeper between the aryepiglottal folds on the medial side, as
well as between the hyoid bone, Membrana thyrohyoidea and thy-
d e f roid cartilage on the lateral side to form the Recessus piriformis.
Within the Recessus the Plica nervi laryngei superioris arising
from the N. laryngeus superior can be seen.

Clinical remarks
g h i
The structures delimiting the larynx serve as a guide for intu-
Fig. 10.45 Edge displacements of the vocal fold mucosa during the bation. Swallowed foreign matter can become caught in the
opening and closing phase. a At the starting position, the vocal folds Recessus piriformis.
are closed. b–d By increasing the subglottic pressure, a threshold
level is reached, pushing the vocal folds apart. This then separates
the lower edges. The separation continues further upwards until both
vocal folds are completely separated from each other. e–h The breath
can now pass through the supraglottis and the pharynx as if through
10.6.4 Laryngeal levels
a nozzle. The air flow laterally causes a suction effect (BERNOULLI
effect), resulting in edge displacement. In doing so, the epithelium Anatomically, the larynx is divided into
and the loose connective tissue in the REINKE’s space of the vocal • Laryngeal vestibule (Vestibulum laryngis); from the edge of
folds are sucked in and pulled together. The lower margins close and the epiglottis up to the vocal folds
the upper edges follow, as soon as the subglottic air flow is cut off. • Mid-larynx level (glottis); includes the area between the vocal
Overall it looks like a rolling of the epithelium on the substrate (Lig. folds (glottis)
vocale and M. vocalis) from bottom to top. i The vocal folds are close
together and closed. As a consequence, subglottic pressure begins
• Lower larynx level (Cavitas infraglottica); below the vocal
again, and this starts the phonation cycle again. Repeated cycles folds to the lower edge of the cricoid cartilage
lead to regular vibrations. [L126] Clinically the larynx is divided into (› Fig. 10.46)
• Supraglottis (supraglottic space); from the edge of the epiglot-
tis up to the vestibular folds
Transition between larynx and base of the tongue • Transglottic space (glottic space); of the vestibular folds, in-
The upper edge of the epiglottis (Margo superior epiglottidis) and cluding the Ventriculi laryngis up to underneath the vocal folds
the base of the tongue are interconnected by the Plica glossoepi- • Subglottis (subglottic space); from below the vocal folds to the
glottica mediana and the paired Plicae glossoepiglotticae laterales. lower edge of the cricoid cartilage
The paired Valleculae epiglotticae lie between the folds (this area
belongs to the Pars oralis pharyngis, › Fig. 10.47).

Clinical remarks
Swallowed foreign matter can get into the Valleculae epiglotti-
cae and, by putting pressure on the epiglottis, can displace Supraglottic space
(Supraglottis)
the entrance to the larynx and thus the airway. Or it can trigger
a bolus death via a reflexive cardiac arrest due to vagal stimu-
lation of the sensitive pharyngeal and laryngeal plexus when
swallowing large, poorly chewed bits of food (bolus), so that
they become jammed in the laryngopharynx, and cannot even
be ejected by strong coughing. Fish bones or pieces of chicken
Transglottic space
bones and other sharp-pointed foreign bodies most often get (glottic space, Glottis)
stuck in the Tonsillae palatinae.

Subglottic space
(Subglottis)
Laryngeal inlet
The laryngeal inlet (Aditus laryngis, › Fig. 10.43) is delimited by:
• The upper edge of the epiglottis (Margo superior epiglottidis;
› Fig. 10.50): it extends into the oropharynx.
• Aryepiglottic folds (Plicae aryepiglotticae): they range from the
lateral edge of the epiglottis up to the arytenoid cartilage tips and
each contains a Tuberculum corniculatum and a Tuberculum Fig. 10.46 Levels (compartments) of the larynx.

571
10 Neck

Supraglottis (supraglottic space) like a cylinder and at the top correspondingly tapers to the shape of
It extends from the inlet of the larynx (Aditus laryngis) up to the the Conus elasticus. The anterior boundary is the Lig. cricothyroi-
level of the vestibular folds (Plicae vestibulares) and includes the deum medianum (Lig. conicum); the posterior is the glottis.
epilarynx (laryngeal surface of the epiglottis, Plicae aryepiglotticae
and cusps of the arytenoid cartilage).
Clinical remarks
Clinical remarks The lumen of the larynx is for the most part observable by
means of various techniques (examination under laryngosco-
Allergic reactions at the laryngeal inlet can lead to acute oe- py, direct laryngoscopy, indirect endolaryngoscopy) and
dema with pronounced shortness of breath, as they can ex- therefore, accessible for examination.
pand greatly in the loose connective tissue. Acute bacterial The division of the larynx into levels is carried out in clinical
infections of the epiglottitis, which particularly occur in chil- imaging for determining the extent (staging) of a tumour-relat-
dren, can very quickly become life-threatening by shifting the ed disease. Although magnetic resonance imaging (MRI) has
airways. the highest sensitivity for tumour staging of all imaging tech-
niques, the standard procedure for image-based diagnostics
of the larynx is spiral computer tomography (CT) using very
thin layers, as with a highly mobile larynx MRI can be associat-
Transglottic space (glottic space) ed with significant movement artefacts.
Included in the transglottic space are
• The paired vestibular folds (Plicae vestibulares or Plicae ventric-
ulares)
• The Tuberculum epiglotticum 10.6.5 Structure of the Plicae vocales und Plicae
• Rima vestibuli (space between the vestibular folds) vestibulares
• The paired MORGAGNI's ventricules (Ventriculi laryngis);
both end in an individually large Sacculus laryngis (Appendix Components
ventriculi laryngis) In the central area the Plica vocalis (› Fig. 10.42) is made up of:
• The paired vocal folds (Plicae vocales), which are also referred to • Multilayered non-keratinised squamous epithelium
as the Labia vocales; they represent the central element of the • Lamina propria made of loose connective tissue
glottis (glottis, Rima glottidis, voice-forming part of the larynx) • Lig. vocale (extends cranially into the Membrana quadrangularis
When viewed from above, the vocal folds protrude even further and caudally to the Conus elasticus)
into the lumen of the larynx than the overlying vestibular folds. • M. vocalis
Due to their covering with squamous epithelium, they appear The Plica vestibularis is composed of:
whitish compared to the red-shimmering vestibular folds. • Multirow respiratory ciliated epithelium
The glottis includes the area of the free edge of the vocal folds. • Lamina propria from loose connective tissue which contains nu-
They are contrasted with the transglottic space which includes the merous seromucous glands and a lot of lymphatic tissue, which
space in the area of the glottis, the lower section of the vestibular belongs to the mucous-associated lymphoid tissue (LALT =
folds and the laryngeal ventricules. The anterior area of the glottis ­larynx-associated lymphatic tissue)
with the anterior commissure, (Commissura anterior, see below) is • Lig. vestibulare (can be viewed as a thickening of the Membrana
referred to as the Pars intermembranacea (constitutes around two quadrangularis, in which it is embedded)
thirds of the length of the vocal folds); the posterior section of the • Striated muscle fibre bundles
glottis between the arytenoid cartilages is called the Pars intercar-
tilaginea. The vocal folds end at the transition of the Pars intercar- Epithelium and Lamina propria
tilaginea into the Plica interarytenoidea. Multilayered non-keratinised squamous epithelium is regularly
found at the free margin of the vocal cords, on the Plicae aryepi-
glotticae, on the Plica interarytenoidea, as well as on the top edge
Clinical remarks of the epiglottis. All other sections of the larynx are covered with
An extension of the Sacculus laryngis is referred to as a laryn- multirow respiratory ciliated epithelium.
gocele. If the extension protrudes to such an extent that the
Membrana thyrohyoidea is broken, the laryngocele can usual-
ly be palpated and visualised from outside (outer laryngo- Clinical remarks
cele). Complications are infections of the laryngocele and dis-
In advanced age, increasing amounts of multirow respiratory
placement phenomena of the throat area structures.
ciliated epithelium are replaced by squamous epithelium, so
that in old people large parts of the mucous membranes are
made up of squamous epithelium. Exogenous noxious agents
(especially tobacco consumption and alcohol) contribute to
Subglottis (subglottic space, Cavitas infraglottica)
squamous cell carcinoma originating from here.
The subglottis ranges from below the vocal folds to the lower rim
of the cricoid cartilage. It is a conically shaped space between the
free margin of the vocal folds, the vocal folds, and the lower mar- The physiological transitions of the squamous epithelium of the
gin of the cricoid cartilage. The upper boundary is the microscopi- Plica vocalis into the ciliated epithelium of the Ventriculus laryngis
cally locatably Linea arcuata inferior of the Plica vocalis (› Fig. and the subglottis are referred to as Linea arcuata superior and
10.42, › Chap. 10.6.5) which can be localised under a microscope. Linea arcuata inferior (› Fig. 10.42). Below this epithelial transi-
The caudal limit is the lower margin of the cricoid cartilage. Crani- tion, the Lamina propria is fixed in place by solid collagen connec-
al to the side are the Conus elasticus and further caudal of the cri- tive tissue at the offshoots of the Lig. vocale, so that the very loose
coid cartilage is the boundary. Below, the subglottic space is shaped connective tissue below the squamous epithelium of the Plica vo-

572
 10.6 Larynx

calis forms a closed (virtual) space (REINKE'S space) (› Fig. Clinical remarks
10.42). Beyond the Linea arcuata superior is the Lamina propria,
Changes in the area of the vocal folds (benign or malignant)
also made from loose connective tissue and containing many im-
lead to the incomplete closure of the glottis in phonation and
mune cells, lymph follicles and, particularly in the Plica vestibu- are accompanied by hoarseness and at an advanced stage by
laris, numerous seromucous glands, which secrete their products shortness of breath. Benign changes can be caused by over-
to the surface of the mucous membranes via fine excretory ducts. use (speaking professions) or misuse of the voice and lead to
Below the Linea arcuata inferior in the loose Lamina propria there the formation of nodules from shouting or singing. They can
are also numerous smaller seromucous glands in the subglottic re- also occur due to mechanical irritation during intubation as
gion. intubation granulomas. The most frequently observed benign
tumors of the vocal fold are polyps; the most common malig-
nant ones are squamous cell carcinomas.
Attachment structures of the Plica vocalis Accumulation of fluid in the REINKE's space (common in fe-
Ventrally the vocal folds end in the anterior commissure; dorsally male smokers) are associated with vocal swelling and hoarse-
the Pars intercartilaginea goes into the Plica interarytenoidea. The ness and dyspnoea (REINKE’s oedema). Fluid accumulation in
Ligg. vocalia insert in the area of the anterior commissure via 2 the Lamina propria of the supraglottis can also appear as glot-
structures (› Fig. 10.39, › Fig. 10.40, › Fig. 10.41): tic oedema, e.g. in allergic reactions. These are also associat-
• via the Noduli elastici anteriores (are visible in examination of ed with hoarseness and respiratory sounds up to severe short-
ness of breath.
the larynx as yellowish thickenings)
• via the vocal ligament (BROYLES' tendon) inserted at the thy-
roid cartilage
The insertion of the Lig. vocale at the Proc. vocalis of the cricoid
cartilage is carried out via a Nodulus elasticus posterior (also visi- 10.6.6 Vascular, lymphatic and nervous systems
ble when examining the larynx as a yellowish thickening, › Fig.
10.39, › Fig. 10.40). This continuously goes into the elastic carti- Arteries
lage of the Proc. vocalis which in turn continues into the hyaline The main blood vessels of the larynx (› Fig. 10.47) are the:
cartilage of the Proc. vocalis. The various structures in the area of • Aa. laryngeae superiores
the attachment of the vocal ligament serve to attenuate stretching • Aa. laryngeae inferiores
in the vibration of the vocal folds and also enable great mobility • Rr. cricothyroidei
within the context of phonation and respiration. The paired A. laryngea superior usually exits close to the upper
border of the thyroid cartilage from the A. thyroidea superior

Rr. linguales Papillae vallatae

N. glossopharyngeus [IX]
N. glossopharyngeus [IX]

Rr. tonsillares
A. palatina ascendens,
R. tonsillaris

Tonsilla palatina
Os hyoideum, Cornu majus

Epiglottis
N. laryngeus superior,
R. internus

A. laryngea superior Vallecula epiglottica

Cartilago thyroidea, N. laryngeus superior,

Cornu superius Rr. interni

Aditus laryngis Membrana thyrohyoidea

Incisura interarytenoidea
Ansa GALENI

Pars obliqua
Cartilago thyroidea M. arytenoideus
Pars transversa

Cartilago thyroidea, M. cricoarytenoideus

Cornu inferius posterior

Glandula thyroidea
A. laryngea inferior

Rr. tracheales Glandula parathyroidea

superior

A. thyroidea inferior
Glandula parathyroidea inferior
N. laryngeus recurrens,
Rr. oesophageales Trachea N. laryngeus recurrens Fig. 10.47 Arteries and nerves
of the larynx. Dorsal view.

573
10 Neck

(branch of the A. carotis externa) (however, it can also directly exit N. laryngeus superior (› Fig. 10.47)
as a stand-alone vessel from the A. carotis interna, the A. lingualis The N. laryngeus superior exits at the level of the Ganglion inferius
or the A. facialis) and then finally penetrates the membrana thyro- of the N. vagus [X], runs medially from the A. carotis interna and
hyoidea with the R. internus of the N. laryngeus superior (see be- branches off at the level of the hyoid bone into an outer (R. exter-
low). Rarely it reaches the inner larynx also through a Foramen nus) and an inner (R. internus) branch:
thyroideum in the thyroid cartilage plate. In the larynx it courses • The R. externus of the N. laryngeus superior runs caudal along
below the mucosa of the Recessus piriformis. Its branches supply the side wall of the pharynx to the M. constrictor pharyngis inferi-
the Aditus laryngis and the Vestibulum laryngis. or. It penetrates it, innervates it and courses further caudally and
The blood supply of the glottis is undertaken by the paired R. cri- ventrally up to the M. cricothyroideus, which it also innervates.
cothyroideus, a branch of the A. laryngea superior. Together with • The R. internus of the N. laryngeus superior passes together
the branch of the opposite side it forms an arch-shaped arcade be- with the A. laryngea superior through the Membrana thyrohy-
fore the Lig. cricothyroideum and may, in rare cases, completely oidea (› Chap. 10.6.3) into the larynx. Here, it runs under the
replace the A. laryngea superior. mucosa of the Sinus piriformis (Plica nervi laryngei). It inner-
The paired A. laryngea inferior is a branch of the A. thyroidea in- vates the whole mucosa of the Aditus laryngis, Vestibulum la­
ferior (from the Truncus thyreocervicalis) and, together with the ryngis and the dorsal part of the vocal folds. In most cases it
N. laryngeus inferior (see below) rises in the groove between the forms an anastomosis (R. communicans cum nervo laryngeo
oesophagus and trachea, These nerves course cranially to the Ar- inferiori; GALEN's anastomosis).
ticulatio cricothyroidea. Here it enters in the space between the
thyroid and cricoid cartilages and mainly supplies the dorsally ly- N. laryngeus inferior (› Fig. 10.47)
ing muscles (M. cricoarytenoideus posterior and M. arytenoideus). The N. laryngeus inferior is the terminal branch of the N. laryn-
There are many anastomoses between all the laryngeal arteries. geus recurrens. The latter branches off from the N. vagus [X] on
the left side at the level of the Pars decendens of the aortic arch,
Veins runs dorsally beneath the Lig. arteriosum (BOTALLI) and rises in
The veins draining the larynx accompany the arteries. They form an the groove between the trachea and the oesophagus, coursing cra-
extended mucosla plexus. The blood of the V. laryngea superior, nially to the larynx (Fig. 9.40). On the right side, it already leaves
together with the blood from the venous R. cricothyroideus, reaches the N. vagus [X] at the level of the A. subclavia dextra, crossing be-
the V. thyroidea superior and from here flows into the V. jugularis. neath it from front to back and so also runs in the groove between
The V. laryngea inferior drains into the V. thyroidea inferior, the trachea and the oesophagus (Fig. 9.40). At the level of the lower
which reaches the Plexus thyroideus impar mostly via the left horn of the Cartilago thyroidea and the M. cricoarytenoideus pos-
V. brachiocephalica. terior it divides into anterior (R. anterior) and posterior (R. poste-
rior) branches:
Lymph • The R. anterior innervates the M. thyroarytenoideus and the
The Lamina propria of the laryngeal mucosa is infiltrated by a dense, M. cricoarytenoideus lateralis.
fine mesh network of lymph capillaries, which join together to major • The R. posterior innervates the M. cricoarytenoideus posterior
lymph collectors. Lymph vessels above the vocal folds run with the (posticus) and the Mm. arytenoidei transversus and obliquus. It
A. laryngea superior and reach the Nodi lymphoidei infrahyoidei also provides sensory innervation of the front part of the vocal
(Nodi lymphoidei cervicales profundi). Lymph vessels below the Pli- folds, the subglottis and parts of the hypopharynx, the oesopha-
cae vocales drain into the prelaryngeal (Nodi lymphoidei prelaryn- gus and the trachea.
gei; DELPHIAN lymph nodes) and to the Nodi lymphoidei cervi-
cales profundi superiores and inferiores close to the A. thyroidea
inferior (› Fig. 10.27). Lymph drainage in the vocal folds is primari­ly
Clinical remarks
directed dorsally; however there is no separation between the supra- Damage to the N. laryngeus superior leads to paralysis of the
glottic and subglottic drainage area and between right and left. M. cricothyroideus. As a result, the coarse tension of the vocal
The regional lymph nodes drain via intermediate collection lymph fold is insufficient and results in an incomplete closure of the
nodes into the Trunci jugularis dexter and sinister. glottis with hoarseness and dysphonia. In addition, sensory
disturbances on the inlet of the larynx and in the supraglottis
can arise, which can lead to frequent swallowing.
Innervation Recurrens paresis refers to damage to the N. laryngeus recur-
The sensory and motor innervation of the larynx (› Fig. 10.47) is rens or the N. laryngeus inferior. There are many causes for this
taken care of by two branches of the N. vagus [X], the N. laryngeus (e.g. malignant tumors, intubation nerve damage due to thyroid
superior and the N. laryngeus inferior. surgery). Due to the paralysis of the inner laryngeal muscles,
the vocal cords are held on the affected side in a paramedian
position (cadaveric position). It results in hoarseness. Bilateral
NOTE
damage may result in a life-threatening shortness of breath.
The cough reflex is an involuntarily occurring polysynaptic protec-
An A. lusoria, occurring with a frequency of 0.4–2.6% is a ves-
tive reflex, which is intended to clear the lower respiratory tract of
sel variant, with the A. subclavia dextra arising as the last
foreign bodies, excess secretions and other potentially harmful
branch from the aortic arch and which in different variants
stimuli (irritation of the throat). There are many receptors for trigger-
passes behind the oesophagus, between the oesophagus and
ing the reflex in the laryngeal mucosa among other places. The in-
the trachea or in front of the trachea on the right side of the
formation is passed via viscerosensory nerve fibres of the N. vagus
body. In cases of A. lusoria, the N. laryngeus recurrens is miss-
[X] to the cough centre in the Medulla oblongata. The stimulus re-
ing on the right side. Instead, the N. laryngeus inferior leaves
sponse is switched to the efferent limb in the Nucleus ambiguus
the N. vagus directly at the level of the larynx and this region is
(motor core area of N. vagus [X] and the N. glossopharyngeus [IX])
at risk during surgery.
and is directed to the laryngeal muscles and respiratory muscles,
causing a short-term closure of the glottis and explosive exhalation.
Ideally the intruding foreign body is thus expelled to the outside.

574
 10.7 Pharynx

10.7 Pharynx • Upper level (Pars nasalis, nasopharynx or epipharynx): it is con-

Wolfgang H. Arnold nected with the nasal cavity through the Choanae and the mid-
dle ear via the Tuba auditiva.
The throat (Pharynx) is a muscular tube which is attached via the • Middle level (Pars oralis, oropharynx or mesopharynx): it is the
Membrana pharyngobasilaris to the outer surface of the skull base of junction between the superior and inferior pharyngeal levels and
the Os occipitale. It sits in front of the cervical spine and extends to connects with the oral cavity through the Isthmus faucium.
the level of the VIth cervical vertebra and cricoid cartilage, where it • Lower level (Pars laryngea, laryngopharynx or hypopharynx): it
merges into the oesophagus. Its lumen, the pharyngeal cavity (Cavi- stands at the front, connected with the larynx via the Aditus lar-
tas pharyngis), is connected to the nasal cavity, the middle ear, the yngis and runs caudally into the gullet (Oesophagus).
oral cavity, the larynx, and the oesophagus. Within the pharyngeal
cavity, respiratory and digestive pathways cross. Functionally, the Epipharynx
pharynx is used to transport air, transport food, perceive taste and The choanae (Choanae nasales) open out from the nose into the
for immune defence (WALDEYER's tonsillar ring, › Chap. 10.7.7 ). epipharynx. Upwards the epipharynx forms the pharyngeal fornix
(Fornix pharyngis). Here, the pharyngeal wall consists of taut con-
nective tissue (Fascia pharyngobasilaris), which is fixed to the
10.7.1 Development skull base. It used by the M. constrictor pharyngis as attachment
zone. The fascia is attached dorsally at the Tuberculum pharynge-
The muscles of the throat originate from the 3rd to 5th pharyngeal um (› Fig. 9.5). From here the connective tissue extends as a me-
arches and are in contact with the skeletal elements which previ- dian strip of connective tissue, Raphe pharyngis, which serves as
ously originated from these pharyngeal arches. the attachment zone for the inferior pharyngeal constrictor muscle
and reaches caudally to the Pars cricopharyngea. Under the mucosa
(respiratory ciliated epithelium) of the rear area, located on the
10.7.2 Levels of the pharynx roof of the epipharynx under the skull base, there is lymphatic tis-
sue that bulges forward, particularly in children, known as Tonsilla
The pharynx is structured, corresponding to its openings into 3 pharyngea. In front of the tonsils, the pharyngeal hypophysis
levels: (Hypophysis pharyngealis) may be present in the connective tis-

Plica salpingopalatina

Ostium pharyngeum tubae auditivae;

Torus tubarius

Tonsilla pharyngea

Torus levatorius
Maxilla
Palatum molle
Plica salpingopharyngea
M. genioglossus
Arcus palatopharyngeus
Tonsilla lingualis

M. geniohyoideus

M. mylohyoideus
Tonsilla palatina

Os hyoideum Pharynx

Lig. thyrohyoideum medianum

Spatium retropharyngeum
Lig. hyoepiglotticum
Cartilago epiglottica Tuberculum cuneiforme
Corpus adiposum preepiglotticum
Lig. thyroepiglotticum Tuberculum corniculatum
Cartilago thyroidea
Lamina cartilaginis cricoideae
Plica vestibularis; Plica vocalis
R. cricothyroideus (A.; V. thyroidea superior);
Dura mater spinalis
Lig. cricothyroideum medianum

Arcus cartilaginis cricoideae Fascia cervicalis,

Lamina prevertebralis
Fascia cervicalis, Lamina superficialis
(Spatium
Fascia cervicalis, Lamina pretrachealis retrooesophageum)
Oesophagus
Isthmus glandulae thyroideae
(Spatium oesophagotracheale)
M. sternothyroideus
Trachea

Fig. 10.48 Overview of the structure of the pharynx and larynx.

575
10 Neck

sue on the under surface of the cuneiform bone as an embryologic ents pass through here going from the base of the tongue to the
relic of the RATHKE's pouch. The Tuba auditiva opens in the later- ­inlet of the oesophagus.
al wall on both sides, connecting the pharynx to the middle ear.
The Ostium pharyngeum tubae auditivae is delimited from the
back and the top by the Torus tubarius. The T ­ orus tubarius is
Clinical remarks
­extended downwards and to the rear through the Plica salpingo- Swallowed foreign matter can irritate the delicate neuronal
pharyngea (› Fig. 10.48). It is elevated by the M. salpingopharyn- network of the pharynx and larynx and may lead to a vagal re-
geus. Beneath the orifice of the Tuba auditiva is the Torus levatori- action with reflex cardiovascular arrest (bolus death) when
us, in which the Levator veli palatini courses (› Fig. 10.48). Under swallowing large, poorly chewed bits of food (bolus), so that
they become jammed in the laryngopharynx, and cannot be
the epithelium of the tubal opening is lymphatic tissue known
ejected even by strong coughing and gagging.
collectively as the Tonsilla tubaria. The Tonsilla pharyngea and
Tonsillae tubariae are part of the lymphatic pharyngeal ring known
as (WALDEYER's tonsillar ring, › Chap. 10.7.7 ).

Clinical remarks 10.7.3 Pharyngeal wall

In childhood, a hyperplasia of the pharyngeal tonsils fre- The pharyngeal wall is thin and can be divided into 4 layers:
quently occurs (adenoids, adenoid vegetation, commonly • Tunica mucosa (mucous membrane): in the nasopharynx this is
known as ‘polyps’). This can lead to the pharyngotympanic largely made up of respiratory ciliated epithelium, while in the
tube being displaced, reducing the aeration of the middle ear. oropharynx and laryngopharynx it is multilayered, non-kera-
This results in recurrent middle ear inflammation, which reduc-
tinised squamous epithelium. It contains small salivary glands,
es hearing and developmental delays ensue. The treatment of
choice in these cases is removal of the tonsils (adenectomy). Glandulae pharyngeales, and a lot of lymphatic tissue that be-
Sometimes the pharyngeal roof hypophysis (Hypophysis pha- longs to the mucosa-associated lymphoid tissue.
ryngea) is to be found on the under surface of the cuneiform • Tela submucosa (submucosal connective tissue): it connects
bone, in the connective tissue in front of the Tonsilla pharyn- with the Tunica adventitia to the Fascia pharyngobasilaris.
gea. It is left behind during development and in young people • Tunica muscularis (musculature): it surrounds the pharyngeal
can constitute a starting point for a craniopharyngioma. constrictor muscles (Mm. constrictores pharyngis) and the leva-
Beneath the mucosa between the Tonsilla tubaria and the Ton-
tor pharyngeal muscles (Mm. levatores pharyngis).
silla palatina, there is lymphatic tissue referred to as lateral
strands. Especially after removal of the Tonsillae palatinae • Tunica adventitia (adventitia): it creates the connection to the
(tonsillectomy) bacterial infections can occur here as a form of surroundings, dorsally to the Spatium retropharyngeum, a virtual
inflammation of the throat area, pharyngitis. Commonly, gap attaching the pharynx to the cervical spine, laterally to the
those affected suffer from ear ache and headache, and have Spatium parapharyngeum, virtual spaces creating the connec-
difficulty swallowing. tion to the lateral structures of the neck. Virtual means that con-
nective tissue fibres create the connection to neighbouring
structures (cervical spine, neck structures), but in the context of
pathological processes they can be dissolved, which then creates
Mesopharynx gaps which can go cranially as far as the skull base and caudally
The mesopharynx (Pars oralis pharyngis) is connected by the Isth- into the mediastinum.
mus faucium with the oral cavity. The base of the tongue, together
with the Tonsilla lingualis presses into the mesopharynx (› Fig. NOTE
10.48). The epiglottis is movably connected with the base of the Unlike the gastrointestinal tract, the pharyngeal wall has no Lami-
tongue via the Plica glossoepiglottica mediana and the Plicae glos- na muscularis. In the cranial section, a Tunica muscularis is also
soepiglotticae laterales. Between the folds are 2 depressions (Val- absent; here, submucosal connective tissue and adventitia merge
leculae epiglotticae). During swallowing, the Pars oralis is separat- together with the Fascia pharyngobasilaris.
ed from the Pars nasalis by displacement of the soft palate to the
posterior pharyngeal wall.

Hypopharynx 10.7.4 Pharyngeal musculature

The hypopharynx (Pars laryngea pharyngis) is the longest section
of the pharynx. At the front it is connected to the laryngeal inlet The pharynx is a long outstretched muscle tube consisting of 3
(Aditus laryngis) and ends caudally behind the cricoid cartilage of sphincter muscles (pharyngeal constrictors, Mm. constrictores
the larynx, where it joins the oesophagus. This is the location of the pharyngei) and 3 longitudinal muscles (pharyngeal levators, Mm.
first narrowing of the gullet (Constrictio pharyngea oesophagea- levatores pharyngei).
lis). The laryngeal inlet is surrounded by the epiglottis and the Pli-
cae aryepiglotticae. In the lower area, the posterior surfaces of the Pharyngeal constrictor muscles
arytenoid cartilage and subglottis stand out with their muscles. Be- All 3 pharyngeal constrictor muscles (Mm. constrictores pharyn-
tween the arytenoid cartilages is the Incisura interarytenoidea. The gis) originate in the anterior region on the structures of the oral
Plica glossoepiglottica lateralis runs from the lateral edge of the cavity wall and the larynx, enclosing in a circular way the lumen of
epiglottis to the side wall of the larynx. The N. laryngeus superior the pharynx, overlapping like roof tiles and coming together dor-
and the blood vessels of the same name bulge out caudally from the sally in the centre in the fibrous Raphe pharyngis (› Fig. 10.49,
Plicae glossoepiglotticae laterales, towards the Plica nervi laryngei. › Table 10.23). The Raphe pharyngis runs from the Tuberculum
The Recessus piriformis is located between the thyroid cartilage pharyngeum of the Os occipitale to the oesophagus. The lowest
and Plica aryepiglottica, and particularly liquids and liquid nutri- part (Pars cricopharyngea) of the lower pharyngeal constrictor

576
 10.7 Pharynx

(M. constrictor pharyngis inferior) consists of 2 muscle units (Pars Pharyngeal levator muscles
obliqua and Pars transversa = Pars fundiformis = KILLIAN’s The paired pharyngeal levator muscles (Mm. levatores pharyngis)
bundle), which form the weakly muscular KILLIAN's triangle are the M. stylopharyngeus (› Fig. 10.49), the M. salpingopha-
(› Fig. 10.49). Below the Pars transversa, another muscle triangle ryngeus, and M. palatopharyngeus (› Fig. 10.50, › Table 10.24).
arises (LAIMER’s triangle) from the obliquely radiating oesopha- They pass between the constrictor muscles under the mucosa of
geal muscles. In comparison to KILLIAN's triangle it stands on its the larynx, where they are attached.
head. The Pars transversa forms the basis of both triangles.

Clinical remarks 10.7.5 Vascular, lymphatic and nervous systems

Within the weak muscle of KILLIAN's triangle a pulsion diverti­ Arteries and veins
culum = hypopharyngeal diverticulum (ZENKER’s diverticulum) The pharynx is supplied with blood by 4 arteries (› Table 10.25):
frequently occurs in aged men. It involves protrusions of the • The A. pharyngea ascendens from the A. carotis externa lies on
wall of the pharynx into the retropharyngeal space. If chyme col- the lateral pharyngeal wall and runs up to the skull base.
lects in the increasingly expanding diverticulum, it can lead to
• The A. palatina ascendens from the A. facialis supplies the ante-
the regurgitation of undigested food. Problems with swallowing
may also occur. A rupture with a life-threatening infection into rior section of the pharynx.
the peripharyngeal space (peripharyngeal abscess) may occur, • The A. sphenopalatina from the A. maxillaris also supplies the
which can spread to the skull base and into the mediastinum. anterior section of the pharynx.
The same propagation paths also apply to inflammation, which • The A. thyroidea inferior supplies the lower part of the pharynx
can easily penetrate the thin pharyngeal wall. (› Fig. 10.49).

N. vagus [X]
N. accessorius [XI], R. internus
N. glossopharyngeus [IX]
M. constrictor pharyngis superior
Bulbus superior venae jugularis
Sinus transversus Vv. pharyngeae Foramen jugulare
Sinus sigmoideus
Ganglion superius
A. meningea posterior
A. carotis interna
N. caroticus internus
R. auricularis
Proc. mastoideus Ganglion inferius (IX)
N. accessorius [XI],
R. externus A. carotis interna
Proc. styloideus Ganglion inferius (X)
N. hypoglossus [XII]
N. jugularis (Truncus sympathicus)
M. stylopharyngeus
N. glossopharyngeus [IX] Ganglion cervicale superius
(Truncus sympathicus)
R. pharyngealis
M. digastricus, Venter posterior A. pharyngea ascendens
N. laryngeus superior N. glossopharyngeus [IX]
A. carotis externa
A. palatina ascendens
R. pharyngealis
A. facialis
A. facialis A. lingualis
N. laryngeus superior, R. externus A. carotis externa
N. laryngeus superior, R. internus A. thyroidea superior
M. constrictor pharyngis medius N. cardiacus cervicalis superior
(Truncus sympathicus)
A. thyroidea superior V. jugularis interna
Rr. pharyngeales R. pharyngealis
N. vagus [X]
M. constrictor A. carotis communis
pharyngis inferior Plexus caroticus communis

Glandula thyroidea Truncus sympathicus

Bulbus inferior venae jugularis
*
R. pharyngealis
A. thyroidea inferior
Ganglion cervicale medium
**
Ganglion cervicothoracicum [stellatum]
R. cardiacus cervicalis superior
N. cardiacus cervicalis medius
Oesophagus
(Truncus sympathicus)

Fig. 10.49 Overview of the constrictors of the pharynx. ∗ KILLIAN'S TRIANGLE, ∗∗ LAIMER'S triangle

577
10 Neck

Tonsilla pharyngea Cartilago tubae auditivae;

Ostium pharyngeum tubae auditivae
Truncus nervi accessorii, R. internus Fascia pharyngobasilaris
N. hypoglossus N. vagus [X]
N. vagus [X] [XII]
Recessus
N. glossopharyngeus [IX] N. accessorius [XI]
pharyngeus
Bulbus superior venae jugularis
Sinus transversus
Sinus sigmoideus A. carotis interna
N. accessorius [XI],
Ganglion inferius (X) R. externus
N. hypoglossus [XII] A. occipitalis

Torus tubarius Ganglion cervicale superius

(Truncus sympathicus)
M. uvulae M. tensor veli palatini

Plica salpingopharyngea M. constrictor pharyngis superior

M. salpingopharyngeus
Tonsilla palatina
M. palatopharyngeus
Arcus palatopharyngeus Sulcus terminalis
Plica aryepiglottica Dorsum linguae, Pars posterior
Cartilago thyroidea,
Cornu superius Epiglottis

Tuberculum cuneiforme N. laryngeus superior; A.; V. laryngea superior

Tuberculum corniculatum N. vagus [X]

Recessus piriformis, M. arytenoideus transversus;

Plica nervi laryngei superioris M. arytenoideus obliquus

M. cricoarytenoideus posterior
N. vagus [X] Truncus sympathicus, Plexus caroticus communis
Oesophagus, Tunica muscularis N. laryngeus inferior
Ganglion cervicale medium Glandula parathyroidea inferior
A. thyroidea inferior Truncus thyrocervicalis

Bulbus inferior venae jugularis N. vagus [X],

R. cardiacus cervicalis superior
Truncus thyrocervicalis
Bulbus inferior venae jugularis

A.; V. subclavia
N. vagus [X]
Ganglion cervicothoracicum
[stellatum] N. laryngeus recurrens
V. brachiocephalica sinistra
V. brachiocephalica dextra
A. carotis communis
Trachea, Paries membranaceus
N. laryngeus recurrens
N. vagus [X] Truncus brachiocephalicus
Pars descendens aortae V. cava superior

Fig. 10.50 Pharyngeal levator muscles at the open pharynx, as well as vessels and nerves of the pharynx and the parapharyngeal space,
Spatium lateropharyngeum. Dorsal view.

Table 10.24 Pharyngeal levator muscles.

Innervation Origins Attachment Function

M. stylopharyngeus
Rr. pharyngeales of the Proc. styloideus Cartilago thyroidea radiates into Raising of the pharynx during swallowing
N. glossopharyngeus [IX] the side wall of the pharynx
(= Plexus pharyngeus)
M. palatopharyngeus
R. musculi stylopharyngei Aponeurosis palatinae, Hamulus pterygoi- Cartilago thyroidea radiates into Raising of the pharynx during swallowing
of the N. glossopharyngeus deus the side wall of the pharynx
[IX]
M. salpingopharyngeus
Rr. pharyngeales of the Posterior edge of the Ostium tubae auditi- Radiates into the side wall of the Raising the pharynx during swallowing opens the Tuba
N. glossopharyngeus [IX] vae pharynx auditiva
(= Plexus pharyngeus)

578
 10.7 Pharynx

Table 10.25 Overview of the arterial blood supply to the pharynx. Clinical remarks
Arterial trunk Terminal branch Supply area Perfusion disorders in the catchment area of the A. vertebra-
lis that supplies the brain stem with blood, are often accom-
A. carotis externa A. pharyngea ascendens Lateral and posterior pharynge-
al wall
panied by swallowing disorders, including volley-like hiccups.
For those affected, this can be life-threatening as the gag and
A. maxillaris A. sphenopalatina Superior anterior section of the defensive reflex does not function correctly.
pharynx
A. facialis A. palatina ascendens Medial anterior section of the
pharynx
A. subclavia A. thyroidea inferior Lower section of the pharynx
10.7.6 Swallowing

Under the mucosa and the pharyngeal muscles is the venous Plex- In infants, the epiglottis reaches from far cranial up to the naso-
us pharyngeus, the blood from which drains into the Vv. pharyn- pharynx. Breast milk passes directly into the Sinus piriformis. To
geae, which lead to the V. jugularis interna. do so, the larynx must not be closed, and the soft palate must not
to be drawn to the pharynx.
Lymph vessels In children and adults, the airway and gullet cross over each other,
The entire mucous membrane of the pharynx is interfused with which is why when swallowing the airway must be briefly separat-
lymph follicles belonging to the mucosa-associated lymphoid tis- ed from the gullet. To do this, the soft palate is drawn up to the
sue. The lymph is discharged from here via the Nodi lymphoidei pharyngeal wall and the larynx is briefly closed.
retropharyngeales into the Nodi lymphoidei cervicales profundi.
NOTE
Innervation Infants can breathe and drink at the same time.
The sensory, motor and secretory innervation of the pharynx is
performed by branches of the N. glossopharyngeus [IX] and the
N. vagus [X] (N. laryngeus superior). The branches form the Plex- Swallowing takes place in 3 phases:
us pharyngeus, together with postganglionic sympathetic fibres of • Oral phase: this is the voluntary phase of food communition
the Truncus sympathicus. Fibres from the N. maxillaris [V/2] (R. and salivation within the oral cavity. The tongue is pressed
pharyngeus of the Nn. pterygopalatini, › Fig. 10.51) also make a against the palate by contraction of the muscles of the floor of
contribution. the mouth, with the food bolus being transported in the direc-
tion of the Isthmus faucium.
NOTE • Pharyngeal phase: this is the reflex phase, coordinating the safe-
Afferent and efferent fibres of the Plexus pharyngeus are part of the guarding of the respiratory tract and the transportation of food.
swallowing, gag and defensive reflex, which is also maintained Here, initially the M. tensor veli palatini and the M. constrictor
during sleep. The coordination centre for this lies in the Medulla pharyngis superior contract to form the PASSAVANT's bar
oblongata. which closes the access to the nasopharynx. The way back to the
oral cavity is barred by the sphincter system of the muscles of
the Isthmus faucium and the tongue. In addition, the Aditus lar-
yngis and the glottis are closed.
• Oesophageal phase: this is characterised by a peristaltic con-
traction of the pharyngeal muscles from cranial to caudal. At the
same time the contraction of the pharyngeal levator raises the
larynx, which to a certain extent, draws the pharynx over the
­bolus. Solid food components are transported by waves of peri-
N. maxillaris [V/2] staltic contraction; when standing, liquids are passed by jerking
contraction of the floor of the mouth and the upper constrictor
muscles into the stomach by taking gulps.
N. glossopharyngeus [IX]

10.7.7 Lymphatic pharyngeal ring

The lymphoid ring (WALDEYER's tonsillar ring) is understood

as a group of lymphatic epithelial tissues, which are located at the
N. vagus [X] transition of the oral and nasal cavities to the pharynx. In its en-
tirety, the tissues form a ring which serves the immune system and
belongs to the mucosa-associated lymphoid tissue (MALT). The
elements of WALDEYER's tonsillar ring are:
• Lingual tonsil (Tonsilla lingualis, unpaired)
• Palatine tonsil (Tonsilla palatina, paired)
• Lateral cord (paired)
• Tube tonsil (Tonsilla tubaria, paired)
Fig. 10.51 Sensory innervation of the throat. • Nasopharyngeal tonsil (Tonsilla pharyngea, unpaired)

579
This page intentionally left blank
 NEURO­
ANATOMY
11 General neuroanatomy
12 Special neuroanatomy
13 Functional systems
11 General neuroanatomy
11.1 Embryology . . . . . . . . . . . . . . . 584 11.4 Ventricular system
11.1.1 Overview . . . . . . . . . . . . . . . . . 584 and adjacent structures . . . . . 607
11.1.2 Further brain development . . 586 11.4.1 Overview and structure . . . . . 607
11.1.3 Development 11.4.2 Embryology . . . . . . . . . . . . . . . 608
of the spinal cord . . . . . . . . . . 591 11.4.3 Inner cerebrospinal
11.1.4 Development of the fluid space . . . . . . . . . . . . . . . . 609
peripheral nervous ­system . . 593 11.4.4 External subarachnoid
fluid spaces – ­Spatium
11.2 Structure of the subarachnoideum . . . . . . . . . . 610
nervous system . . . . . . . . . . . 593 11.4.5 Cerebrospinal fluid . . . . . . . . . 610
11.2.1 Overview . . . . . . . . . . . . . . . . . 593 11.4.6 Circumventricular organs . . . 611
11.2.2 Structure of the CNS . . . . . . . 593
11.2.3 Morphology of the CNS . . . . . 594 11.5 Cerebral vessels . . . . . . . . . . . 612
11.2.4 Distribution of 11.5.1 Overview . . . . . . . . . . . . . . . . . 612
grey matter in the CNS . . . . . 599 11.5.2 A. carotis interna
11.2.5 Distribution of and its branches . . . . . . . . . . . 617
white matter in the CNS . . . . . 599 11.5.3 Aa. vertebrales/A. basilaris
and their branches . . . . . . . . . 619
11.3 Meninges . . . . . . . . . . . . . . . . . 603 11.5.4 Central blood supply . . . . . . . 622
11.3.1 Overview . . . . . . . . . . . . . . . . . 603 11.5.5 Vascular supply
11.3.2 Embryology . . . . . . . . . . . . . . . 604 of the spinal cord . . . . . . . . . . 623
11.3.3 Pachymeninx – Dura mater . . 604 11.5.6 Topography and supply
11.3.4 Leptomeninx . . . . . . . . . . . . . . 604 areas of the arteries . . . . . . . . 624
11.3.5 Neurovascular pathways 11.5.7 Clinical description
of the meninges . . . . . . . . . . . 606 of the vascular sections . . . . . 628
11.5.8 Venous sinuses of the brain . 628
11.5.9 Presentation
of the vasculature . . . . . . . . . . 630
11 General neuroanatomy

11.1 Embryology as ‘free blastocysts’ between the 5th and 6th day to the mucous
Tobias M. Böckers membrane of the uterus.

Implantation (syn.: Nidation)

Skills The embryoblast cells ‘migrates’ first of all to the attachment point,
the trophoblast cells dividing very dynamically and merging at the
After working through this chapter, you should be able to: penetration point into large giant cells (syncytiotrophoblasts,
• present the principles of development of the nervous sys- › Fig. 11.1). Remaining attached to the embryoblast, the sin-
tem, based on the structure of the neural tube in the alar,
gle-layered cytotrophoblast replenishes through rapid cell division
base, roof and floor plate
• explain the morphological classification of the brain and for the further formation of the syncytiotrophoblasts. In this way,
spinal cord according to the embryonic differentiation steps blastocysts penetrate in the direction of the Zona compacta of the
endometrium until finally ending in the epithelial tissue of the en-
dometrium above the implanted embryo. At the site of implanta-
tion, surface defects are covered by a final formation of the coagu-
lum (approx. day 7–8). In addition to the invasive growth dynam-
11.1.1 Overview ics of the trophoblasts, the production and secretion of important
molecules also begins. Therefore, among other factors, the human
Both the central nervous system (CNS) as well as the peripheral chorionic gonadotropin (hCG) is secreted, an analogue of luteinis-
nervous system (PNS) are derived from the ectoderm of the ing hormone (LH), which binds to the LH-receptors in the Corpus
three-layered germinal disc. This folds into the primitive neural luteum and induces their conversion into Corpus luteum gravidi-
tube, which subsequently forms the brain and spinal cord. Here, tatis. This produces more progesterone, maintaining the pregnancy
the cranial section of the neural tube becomes enlarged and thick- and preventing the onset of menstrual bleeding. In addition, differ-
er, to form the so-called brain vesicles, which later form the output ent signalling molecules are given out that suppress the immune
structures for the brain parts which differentiate further. The neu- response of the maternal immune system.
roblasts (neural crest cells) migrate from the primitive neural
tube, forming the PNS, among other structures. Germinal disc development
The 2nd week of development further differentiates the embryo-
Early development blast. It creates the two layers of the germinal disc (epiblast and
After fertilisation, the zygote remains for about 30 hours in a quies- hypoblast, › Chap. 2.4.1), and the blastocyst cavity becomes the
cent stage before the cells within the surrounding Zona pellucida primary yolk sac, lined with hypoblast cells. There is a gap be-
divide in a predominantly synchronous manner (cleavage stages/ tween the trophoblasts and epiblasts that becomes increasingly
division without growth phase, › Chap. 2.3.1). The compaction larger (primary amniotic cavity) and which is lined with an epi-
and morula stage follow these cleavage stages (› Chap. 2.3.1). thelium of further differentiated epiblast cells (definitive amniotic
The morula reaches the uterus mucosa and the penetrating fluid cavity, › Fig. 11.2b, › Fig. 2.7). Finally, between the germinal
expands the intercellular spaces. These intercellular spaces coalesce system and the rapidly growing trophoblasts, new intercellular
on one side of the embryo where they form so-called blastocyst spaces are created that become increasingly larger and merge to-
cavities. An outer layer of surrounding trophoblast cells are visi- gether. This newly created space is referred to as the extra-embry-
ble (these will form the foetal portion of the placenta), which are onic coelom, also called the chorionic cavity. The yolk sac splits
differentiated from the inner embryoblast cells (the inner cell apart under the growth traction and then closes again to form a
mass which forms the embryo) (› Chap. 2.3.2). Blastocysts finally secondary yolk sac; an exocoelomic cyst (remnant of the primary
leave the surrounding Zona pellucida (hatching) and are attached yolk sac) often remains behind in the chorionic cavity.

Endometrium glands

Connective tissue
of the endometrium

Endometrium
capillary Glands with
secretions

Endometrium
Embryonic pole Syncytiotrophoblast
epithelial
Epiblast
Embryoblast
Blastocyst [inner cell mass] Cytotrophoblast
cavity
Trophoblast Hypoblast
a b
Blastocyst cavity

Uterine lumen

Fig. 11.1 Start of implantation and differentiation of embryoblasts. a Attachment of the blastocyst to the endometrium. b Formation of syncy-
tiotrophoblasts and penetrations into the endometrium. [E347-09]

584
 11.1 Embryology

Epiblast Cutting edge of the amnion Primitive groove

in primitive streak
Yolk sac with coverage from
extra-embryonic mesoderm Primitive nodes Cutting edge
of the amnion
Primitive nodes Fig. 11.2 Germinal disc devel-
Epiblast
opment. a Formation of the
Primitive trench primitive streak (view after
Section plane of b removal of the amniotic cavity).
b Cross-section of the germinal
Primitive groove disc, growth movements in the
in primitive streak area of the primitive streak, for-
a b Hypoblast Migrating
Body stalk mesoderm cells mation of intra-embryonic
mesoderms. [E347-09]

At the start of the 3rd week a strip-shaped thickening, the primitive • Lateral folding: The lateral edges of the germinal disc grow ven-
streak, is visible on the epiblasts (› Fig. 11.2, › Chap. 2.4.2). It trally towards the yolk sac and then merge ‘below’ the embryo.
forms from the caudal to the cranial and ends about halfway, where The lateral and front body wall are thus formed (› Fig. 11.3,
it displays a round enlargement, the primitive node. Primitive › Chap. 2.8.2). In addition, this growth movement displaces
streaks and primitive nodes form depressions, so that it is possible parts of the definitive yolk sac (entoderm) into the inside of the
for the primitive groove to be distinguished from the primitive pit. embryo. These cell layers also merge with each other. This cre-
These morphological structures suggest dynamic cell migration, di- ates a tube structure (primitive intestinal tube) on the inside of
rected by in-depth epiblasts (invagination). Epiblast cells detach here the embryo, which extends from the pharyngeal membrane to
from the cell complex and slide between epiblasts and hypoblasts. the cloaca membrane.
The resulting germinal layer is thus called the intra-embryonic me- • Craniocaudal curvature: Due to the very rapid growth and fur-
soderm. The remaining epiblast cells continue to differentiate from ther differentiation of the neural tube (› Fig. 11.3, › Chap.
the ectoderm. From the primitive node, a cell complex cranially 2.8.1), the embryo ‘bends’ into a C-shape and the tail fold can be
grows as an axial structure and reveals a primitive axis rod, the distinguished from the head fold.
Chorda dorsalis (mesoderm), which is of particular importance for • Neuronal folding (primary neurulation): under the influence
many subsequent development stages. The hypoblast is also replaced of messenger substances, which are secreted from the cells of the
by cells of the epiblasts (in particular in the area of the primitive pit); Chorda dorsalis, a development of a thicker ectodermal cell layer
this cell layer is now called the endoderm. In 2 positions in the em- (neural plate) in the above-lying ectoderm is induced. Such sig-
bryo, the ectoderm and endoderm lie directly next to each other as nal molecules include growth factors such as TGFβ or inhibitors
there is no intra-embryonic mesoderm. Cranially, this is the so-called such as chordin or noggin. Via these mediators, specific tran-
pharyngeal membrane (prechordal plate = later the opening of the scription factors such as neurogenin are activated, which then,
mouth) and caudally, the cloaca membrane (= later the anus). for example, induce the differentiation of ectoderm cells in neu-
rons or glial cells. Over the further course of the neurulation, a
Folding shallow groove (neural groove) forms on the neural plate with
Dynamic changing in shape in early embryos is described as fold- lateral raised areas, the neural cleavage (› Chap. 2.5.2 ). At this
ing, which ultimately changes the flat embryoblast (germinal disc) point in time, you can already see a cranio-caudal limit: the sec-
into a three-dimensional structure. tion above the 4th somite later becomes the brain, and the sec-

Ca Midgut
up ud
g
Amnion Foregut Intra-embryonic
n

al

Dermo-
ldi

fol

(cutting edge) coelom

Cranial fo

myotome
ding up

in g u p

Section plane
fold

of c
al

Hindgut
er

L
at

Vitelline duct Yolk sac

End bud Extra-embryonic coelom Yolk sac

a b c

Allantoi diverticulum
Dorsal Spinal
mesenterium ganglion
Umbilical cord
Dermo-
Amnion myotome

Section plane Side Medium

of f abdominal wall gut
Fig. 11.3 Embryonic folding in
the 4th week. The craniocaudal
Amnion bend (b, e) and the lateral fold-
d e f
ing are visible (c, f ). [E347-09]

585
11 General neuroanatomy

Section edge
of the amnion

Neural fold

Neural groove

Section plane Neural fold Neural crest

Somite from b

Primitive nodes

Neural groove
Primitive streak Chorda process

a b
Convergence of
the neural folds Surface
ectoderm

Neural crest
Neural groove
Neural groove

c d

Future
epidermis

Neural crest

Neural tube Central channel Neural tube Future

spinal ganglion
e f Chorda dorsalis

Fig. 11.4 Formation of neural grooves, neural folding, neural tube and neural crests; diagram. [E347-09]
a View from above after removal of the amniotic cavity. b–f Illustrated are the cross-sections through embryos in consecutive stages of devel-
opment. [E347-09]

tion below becomes the spinal cord. The neural folding first be-
NOTE
The CNS and PNS are ectodermal in origin. The sections of the CNS
gins at the level of the 4th–6th somites to merge with each other evolve from the neural tube, which at both ends opens into the am-
and thereby, through the cranial and caudal merger process, niotic cavity (Neuroporus anterior and Neuroporus posterior). The
form the neural tube (› Fig. 11.4). At the respective ends, there closure of these openings takes place on the 24th day (anterior) or
are still small openings that are called Neuroporus anterior on the 26th day (posterior). The PNS differentiates itself from the
(rostralis) and posterior (caudalis). Through these openings, neural crest cells, which develop early on from the neural tube.
the lumen of the neural tube is connected with the amniotic cav-
ity, before the Neuroporus anterior closes on the 24th day and
the Neuroporus posterior on the 26th day. The location of the
Neuroporus anterior corresponds to the Lamina terminalis in 11.1.2 Further brain development
the adult brain. The Neuroporus posterior is localised in the area
of the Filum terminale or at the level of the 31st somite pairs, Further development of parts of the CNS from the neural tube
from which sacral vertebrae I and II are formed. The sections of have similarities in all sections, based on an early separation of the
the spinal cord lying caudally further than S1, are formed by a neural tube into a dorsal and ventral half:
secondary sprouting of the neural epithelium of the already • The dorsal half consists of the alar plates, which are linked with
formed neural tube. This process is also known as secondary each other through the narrow roof plate.
neurulation. At the edge of the neural plate, in the transition to • The ventral half includes the base plates, which are linked to
the surface ectoderm, the neural crest system develops, which is each other via the ventrally located floor plates.
formed from cells that migrate laterally from the neural tube and Alar and base plates are separated from each other by the Sulcus
then dorsally into a thin layer of connective tissue between the limitans. To a large extent this morphological structure also re­
surface ectoderm and the closed neural tube. The neural crest presents a functional structure, insofar as primarily afferent (gener-
cells, among other things, form the future PNS. al somato/visceral afferents or specific somato/visceral afferents)

586
 11.1 Embryology

4th week 4th week

Flexura mesencephalica
Prosencephalon

Flexura cervicalis
Mesencephalon

Rhombencephalon

Telencephalon

a Primary brain vesicles b Primary brain vesicles

5th week 6th week

Telencephalon
Ventriculus tertius Diencephalon Mesencephalon Metencephalon
Diencephalon Myelencephalon
Optic cup Mesencephalon
Telencephalon
Metencephalon
Ventriculus quartus
Myelencephalon

c Secondary brain vesicles d Secondary brain vesicles

Fig. 11.5 Development of the brain. a Formation of primary brain vesicles; 4th week; horizontal section. b The mesencephalic flexure (Flexura
mesencephalica) and the cervical flexure (Flexura cervicalis) are visible; 4th week lateral view. c Development of secondary brain vesicles; 5th
week, horizontal section. d secondary brain vesicles; 6th week, the pontal flexure is visible; lateral view. [E838]

nuclei form in the alar plates; in the base plates, efferent (general ferentiated in the area of the mesencephalon. The cervical flexure
somato/visceral efferents or specific visceral efferents) nuclei are later lies approximately at the level of the Foramen magnum or at
preferred. the outlet of the 1st spinal nerve (› Fig. 11.5b).
This basic structure is the foundation for further development in
all sections of the brain. Histologically speaking, the first homoge- Development of the pons and Medulla oblongata
neous neuroepithelial part of the neural tube changes to a If you change the perspective from the outer structure of the neural
three-layered structure: tube to the development processes, which can be observed in a
• the outer marginal zone (rich in Substantia alba) cross-section, it can be seen that the development of the pons and
• the intermediate mantle zone (rich in Substantia grisea) Medulla oblongata (parts of the brainstem) is relatively comparable
• the ventricular zones lying next to the neural canal (preferen- with the myelencephalon vesicles: the Canalis centralis extends in
tially forming macroglia forms, such as oligodendrocytes, astro- this section in which the dorsal alar plate opens out like a book and
cytes and ependymal cells) only the thin roof plate as the cover of the canal or the later IVth
At the beginning of the 4th week the cranial part of the neural tube ventricle persists (› Fig. 11.6b). Thus the alar and base plates end
is certainly already significantly different from the caudal section. up lying next to each other, separated by the Sulcus limitans.
Above the 4th somites, after the closure of the Neuroporus anteri- Through these dynamics, the later core areas of the cranial nerves
or, 3 cerebral vesicles, the so-called primary brain vesicles, can be are positioned side by side: nuclei of efferent nerve fibres lie para-
detected (from cranial to caudal, › Fig. 11.5a): median with a total of 3 groups (general somato/visceral efferent,
• prosencephalon vesicles specific visceral efferent), afferent, the afferent core areas laterally
• mesencephalon vesicles of it (general and specific visceral afferent, general and specific so-
• rhombencephalic vesicles matoafferent). Neurons of the alar plate migrate in ventrally and
In the 5th week of development, 5 secondary brain vesicles develop form there, for example, the Nuclei olivares, the olive core, or the
from the 3 primary vesicles. There are 2 extra paired protuberances Formatio reticularis. Also from the alar plates, the so-called rhom-
on the prosencephalon vesicles (telencephalic vesicles or end- bic lips are formed, from which the cerebellum is developed in a
brain/cerebrum vesicles), the unpaired ‘vesicle remnant’ later be- further step (› Fig. 11.6, › Chap. 12.4).
comes the interbrain (diencephalon or diencephalon vesicles). The
rhombencephalon vesicles can later be divided into a cranial me- Development of the mesencephalon
tencephalon and a caudal part, the myelencephalon (› Fig. Mesencephalon vesicles undergo the fewest changes during fur-
11.5c, d). ther development. The lumen of the neural tube narrows due to
With further development, the lumen of the neural tube is extend- enhanced growth of the lateral walls and it forms the finely sized
ed or tapers into the later ventricular system of the CNS. The rapid Aqueductus mesencephali (SYLVII), which connects the IIIrd and
brain growth and craniocaudal folding of the embryo bend the IVth ventricles. The mesencephalon is divided into a roof plate
neural tube so that a cephalic flexure, a ventrally convex pontine (tectum) and a section that covers the ventral two-thirds, the so-
flexure (emerging a little later and located in the area of the called tegmentum, to which the anterior portion, the Pars basilar-
rhombencephalon), and a cervical flexure (located in the transi- is mesencephali, connects. Neuroblasts migrate from the alar plate
tion between the myelencephalon and the spinal cord), can be dif- to the Tectum mesencephali and form the paired Colliculi superi-

587
11 General neuroanatomy

Section plane of b
Arachnoidea mater Ependymal roof
Cerebellum structure
Somatoafferent Structure of the
cerebellum
General
visceroafferent
IVth ventricle
Specifically
visceroefferent Bridge core
a b Somatoefferent
Pons and Medulla oblongata structures

Capillaries
Lobus posterior
Primordium of the Lobus (Neocerebellum)
Mesen- anterior cerebelli
Fissura prima Nucleus
cephalon Nodulus
Fig. 11.6 Development of the
dentatus brain. a Schematic drawing of
Tela choroidea Lobus anterior the brain in the 5th week. b
Lobus floccu-
(Paleocerebellum) Cross-section through the
lonodularis
(Archi- rhombencephalon on which the
IVth ventricle cerebellum) derivatives of the base plate and
Aqueductus alar plate can be seen. c, d Sag-
mesencephali Medulla ittal sections of a 6- (c) and 17-
c d oblongata (d) week-old rhombencephalon.
The ongoing development of the
Pons Plexus Medulla Pons Plexus choroideus
choroideus oblongata pons and cerebellum is clearly
evident. [E347-09]

ores and inferiores (› Fig. 11.7b–e). Neuroblasts of the former structure of the mesencephalon has already reached its final form
base plate in turn form motor core groups in the Tegmentum mes- (› Fig. 11.7c–e).
encephali (e.g. Nucleus nervi oculomotorii). What is controversial
is the origin of the Nucleus ruber and/or the Substantia nigra, Development of the diencephalon
which were formed from neuroblasts from either the alar plate or The diencephalon vesicles are the origin of the diencephalon to
the base plate. Approximately in the 11th week of development the which the hypothalamus belongs, along with the hypophysis, epi-

Structures of the
Colliculi mesencephali
Section plane of b
Mesencephalon

Rhombencephalon

Substantia nigra Crus cerebri

(cerebral crus)
b

Nucleus mesencephalicus
a nervi trigemini
Colliculus
inferior
Nucleus trochlearis
(somatoefferent)
Aqueductus
mesencephali
Endbrain vesicles
(cerebral hemisphere)
Intersection of fibres Substantia nigra
in the Pedunculus
cerebelli superior d
Section planes
from: Fossa interpeduncularis Crus cerebri
e
d
Colliculus inferior Nucleus mesencephalicus
nervi trigemini
Cerebellum Colliculus
superior
Nucleus ruber
Nucleus nervi
oculomotorii
c Fig. 11.7 Development of the
Substantia nigra
mesencephalon. a, b 5th week
Pons Medulla oblongata Crus cerebri
e of development. c–e 11th week
of development. [E347-09]

588
 11.1 Embryology

Epithalamus

Cerebral hemisphere Thalamus Mesencephalon Sulcus Ependymal roof

Cerebral Midbrain epithalamicus
hemisphere Alar plate
Cerebellum Epi-
Sulcus limitans thalamus
Rhombic lip
Base plate
IIIrd Thalamus
Cerebellum ventricle

Sulcus
hypothalamicus Hypo-
thalamus
a b c
Bulbus olfactorius N. opticus [I] Hypothalamus Corpus mamillare
Chiasma opticum Infundibulum

Fig. 11.8 Development of the brain in the 7th week. a Surface view of the brain. b Corresponding median section with prosencephalon and
mesencephalon. c Cross-section through the diencephalon, on which the epithalamus can be seen dorsally, the thalamus laterally, and the
hypothalamus ventrally. [E347-09]

thalamus, thalamus and the subthalamus (› Fig. 11.8b, c). The the thalamus and hypothalamus. The medial cores of the thalamus
structure of the eye also grows from the diencephalon. Due to the often bulge in the IIIrd ventricle, so that both touch in the Adhesio
further growth dynamics of the adult brain – in particular the mas- interthalamica in approximately 70% of people. On the roof plate
sive expansion of the telencephalon – diencephalon components the Plexus choroideus is formed for CSF formation and protrudes
are only visible on the basal side of the brain. into the IIIrd ventricle. On the floor plate, the Chiasma opticum lies
The inside of the neural canal will be extended during the early de- immediately next to the IIIrd ventricle (› Fig. 11.8b).
velopment to the IIIrd ventricle. Through massive cell divisions in All neurovascular pathways running to or from the telencephalon
the lateral wall of the neural tube, the epithalamus, thalamus and have to pass through the diencephalon. Some of these pathways
hypothalamus are formed. The Sulcus epithalamicus lies between combine to form white matter for the Capsula interna, which
the epithalamus and thalamus; the Sulcus hypothalamicus between pushes the subthalamus away laterally. These lateral parts of the di-

RATHKE’s Diencephalon
pouch
Structure of the neurohypophysis Infundibulum

Endbrain
vesicles Floor of diencephalon
RATHKE’s
pouch

Ectoderm of the
Chorda oral cavity
a b c

Primitive oral cavity Position of the former

(stomodeum) pharyngeal membrane

Chiasma opticum Eminentia mediana

Pars infundibularis
Pars intermedia Pituitary stem
(Infundibulum)
Lobus anterior
Lobus anterior Colloidal
(Pars tuberalis) deposits

Structure of the Lobus posterior

Os sphenoidale (Pars nervosa)

Pars intermedia
Pharyngeal roof Fig. 11.9 Development of the
pituitary gland. a Overview in
d e
the median section with back of
Remnants of the connection of the
RATHKE’s pouch with the oral cavity the throat and floor of the dien-
cephalon. b–d Folding of the
Remaining residues of restriction of the
RATHKE’s pouch in the cranial cavity, bone
epithelium in the top of the
or pharyngeal roof throat (RATHKE’s pouch, later
adenohypophysis) and fusion
Pituitary bag (cranially directed Infundibulum of the diencephalon (caudally with the infundibulum (later
indent of the pharyngeal roof) directed annex of the floor of the diencephalon) neurohypophysis). e Position of
the pituitary gland. [E347-09]

589
11 General neuroanatomy

encephalon are called Globus pallidus (pallidum). The Globus The rapid growth of the respective hemispheres is C-shaped,
pallidus thus lies in the telencephalon, but originates from the di- whereby the pallium initially grows ventrally and rostrally and thus
encephalic base plates and is integrated into the efferent, precise forms the Lobus temporalis. This growth movement is also known
motor functions or control mechanisms. as hemisphere rotation whereby the rotation axis is located in the
The pituitary gland is of ectodermal origin, whereby its tissue sec- later island (insula) region. The island region is displaced due to
tions originate from 2 different ectodermal sources: the anterior the growth of the hemispheres of the surface anatomy in the depth
pituitary develops from the ectoderm of the oral cavity (RATHKE's of the fissure, or the Sulcus lateralis. At the telencephalon itself, dif-
pouch) the neurohypophysis from the ectoderm of the diencepha- ferentiation can already be made between the Lobus frontalis, the
lon. The oral epithelium folds on approximately the 36th develop- Lobus parietalis and the Lobus temporalis. The occipital lobes
ment day into a duplication (the so-called RATHKE's pouch), which can only be delineated after completion of the hemisphere rotation.
grows on the neurohypophysis system, the infundibulum, and fi- In the described rotation, the deeper lying brain structures such as
nally merges with this to form the pituitary gland (› Fig. 11.9). the ventricular system, the hippocampus, the fornix, the Gyrus cin-
guli, the Nucleus caudatus and the Corpus callosum are included,
Development of the telencephalon which explains their macroscopic C-shaped structure.
The telencephalic vesicles consists of a median section and 2 later-
al attachments that will evolve into the later cerebral hemispheres. Gyrification
Because the roof plate grows more slowly in comparison to the At first, the surface structures of the telencephalons are smooth. In
hemispheres, it sinks into the depths of the Fissura longitudinalis later stages of development, the gyri and sulci are formed which
superior and then lies in the area of the later Corpus callosum. significantly increase the surface area of the cortex. Gyrification
Developing from the floor and alar plate or the intermediate zone starts around the 26th week, whereby first the gyri and sulci are
of the neural tube, is the Substantia grisea, i.e. the telencephalic formed, which are almost identical in all people (e.g. Sulcus cingu-
cortex, also known as the pallium. In the area of the base plate, the li, Sulcus centralis and lateralis). At the end of the 8th development
parenchyma thickens. Here, at the base of the lateral ventricles, the month all important primary flutes are created. In the 9th month,
existing neurons form the basal ganglia. Telencephalon impar re- the secondary and tertiary gyri and sulci develop, very often exhib-
fers to the median-located endbrain section with the Lamina ter- iting quite large inter-individual variations (› Fig. 11.11).
minalis and the commissural pathways in the area of the former
roof and floor plates. In addition, the floor plate of the telencepha- Cortex types
lon grows significantly more slowly than the walls of the hemi- According to the phylogenetic development, different cortex types
spheres, which are divided into a ventral, lateral or dorsal pallium. can be identified:
The medial and dorsal pallium grow outwards and form the neo-­ • The neocortex is phylogenetically the youngest part of the cere-
(iso-)cortex. As soon as the hemispheres clash medially, further bral cortex. It is found only in mammals. In humans, the neo-
growth is inhibited, causing the flattened shape of the hemispheres cortex forms the majority of the surface of the cerebrum (around
in the Fissura longitudinalis cerebri (› Fig. 11.10). 90%). Opposite it are the phylogenetically older cortical regions,
described as the archicortex or ‘paleocortex’.

Lobus parietalis
Section plane of c
Thalamus Ependymal roof
Section plane of b
of the IIIrd ventricle
Foramen Lobus occipitalis
interventriculare Plexus choroideus
Commissura habenularum
Commissura Foramen
Epiphysis interventriculare
fornicis Pallium
(Corpus pineale)
(hippocampi)
Lateral
Commissura
ventricle
Lobus frontalis posterior

Quadrigeminal Corpus
Corpus callosum
plate striatum
Lamina terminalis
Cerebellum Thalamus
a Bulbus olfactorius Pons
b
Hypothalamus Fig. 11.10 Development of the
Commissura anterior Corpora mamillaria IIIrd Ventricle
prosencephalon. a Schematic
diagram of the medial surface
Chiasma opticum Infundibulum anatomy of the prosencephalon
in the 10th week. b Cross-sec-
tion of the mesencephalon at
Cortex cerebri the height of the Foramina inter-
Nucleus caudatus
ventriculari that shows the Cor-
Plexus choroideus pus striatum and the Plexus
of the lateral ventricles and The projection fibres of the choroideus of the lateral ventri-
of the IIIrd ventricle Capsula interna cles. c Comparable section in
the 11th week. Through the
Thalamus Putamen growth of the Capsula interna,
Merger zone between
the Corpus striatum divides into
c Hypothalamus
di- and telencephalon the putamen and Nucleus cau-
datus. [E347-09]

590
 11.1 Embryology

14th week 26th week

Cerebrum Sulcus centralis

hemisphere
Sulcus lateralis

Dience-
phalon
Insula Lobus
occipitalis
Cranial nerves

Stem of the
Infundibulum Pons
Posterior
a b characteristic

30th week 38th week

Gyri
Sulcus Fig. 11.11 Progression of the
Insula lateralis development of gyri and sulci
Lobus (gyrification) in the schematic
frontalis
side view. As part of the growth
processes, the island region
falls and the Fissura lateralis
Lobus narrows; the lobi of the cere-
temporalis Cerebellum brum are increasingly delineat-
ed. [E347-09]
Cerebellum
a 14th week, b 26th week.
c Spinal cord d [E347-09]
c 30th week. d 38th week.
[E347-09]

• In a division that takes into account the number of differentiable Postnatal maturation
layers, the isocortex (classic 6-layer) is differentiated from the The brain is one of the few organs which is not yet fully matured
allocortex (3 layers) and from the mesocortex (transition zone). after birth. It still has to ‘mature’ postpartum and later enters a
• The paleopallium (Pallium = cortex plus white matter) describes ­process of further maturation and ageing. The maturation process
the oldest cerebrum section, in particular the rhinencephalon includes the increasing myelination of axons and a dynamic change
(olfactory brain). From the archipallium, which exhibits a 3-layer in the structure and number of synaptic connections. At 3 years of
archicortex, portions of the limbic system are formed, such as the age, every brain cell has approximately 15,000 contact points (syn-
hippocampus, Indusium griseum or the fornix. apses) to other nerve cells, while only 2,500 existed at the time of
birth. The maturation process manifests itself, among other things,
Inner cerebrospinal fluid space in that up to the age of 18 years the links between nerve cells – de-
The inner cerebrospinal fluid space (› Chap. 11.4.3) originates pending on the type of neurons and brain region – are reduced to
from the lumen of the neural tube. Above the 4th somites, the lu- approximately 10,000 synapses/nerve cells.
men expands to the brain vesicles, so that lateral ventricles (I and
II) in the area of the telencephalon can be differentiated, and which
are connected via the Foramina interventricularia with the IIIrd 11.1.3 Development of the spinal cord
ventricle of the diencephalon. The IIIrd ventricle, in turn, tapers
towards the Aqueductus mesencephali. This passes through the In the embryonic and foetal development of the caudal portion of
mesencephalon and extends in turn into the area of the metelen- the neural tube, there is a noticeable thickening of the lateral alar
cephalon and the myelencephalon to the IVth ventricle, which is and base plates. Later on, these take on different functions: from
in contact with the outer subarachnoid spaces via median and lat- the base plate (or the ventral horn) the efferent fibres exit and form
eral openings. The ventricles contain the Plexus choroidei respon- the Radix anterior. Afferent fibres converge towards the alar plate
sible for CSF production, also following the rotational movement (the sensory dorsal horn) and form the subsequent Radix posteri-
of the hemispheres. The often closed (obliterated) Canalis centra- or (› Fig. 11.12). The base and the roof plates clearly lag behind in
lis remains in the section of the Medulla spinalis. terms of growth and are eclipsed by other structures or shifted
backwards into the depths. In this way, the Fissura mediana ante-
NOTE rior or the Sulcus medianus posterior are differentiated. In the area
The inner subarachnoid spaces of the CNS emerge from the lumen of the base and roof plates, fibres cross from one side of the spinal
of the neural tube. Due to the different growth dynamics of the cord to the opposite side. As a result of the depicted proliferation
brain sections, the respective diameter of the subarachnoid spaces processes, the neural canal visibly narrows and from the 9th/10th
is very different. The structure of the Ist and IInd ventricles in the development week becomes a narrow central canal (Canalis centra-
telencephalon is the result of the C-shaped direction of growth of
the two cerebral hemispheres. In the spinal cord, the lumen be-
lis).
comes smaller towards the central canal, which is often completely
closed.

591
11 General neuroanatomy

Structure of the Roofplate Septum medianum dorsale

spinal ganglion Afferent neuroblasts Dorsal
Marginal zone in the spinal ganglion horn
Central channel
Neural tube
Alar plate Ventral
horn Fissura
Sulcus mediana
Neural limitans anterior
channel Motor-
neurons
Basal plate
White
matter
a b c
Motor neuroblasts Floorplate
Stem of the Ventral spinal
spinal nerve nerve root

Membrana Neuroepithelial cell in division

limitans interna Mesenchyme Spinal cord
skins
Membrana
limitans externa
d e
Neuroepithelial cells
Ventricular Marginal zone
zone
Intermediate
(shell) zone

Fig. 11.12 Development of the spinal cord from the caudal portion of the neural tube. a 23 days. b 6 weeks. c 9 weeks. d, e The wall of the
neural tube becomes thick (d) and can be divided into three zones (e). [E347-09]

Clinical remarks
cally and ultimately degenerates. The brainstem is, however,
Particularly impressive are the (closure) defective malforma- often functional, so ‘meroanencephaly’ would be the more
tions in the area of the Neuroporus anterior or Neuroporus correct term. The frequency is 1:1,000 with a familial aggre-
posterior in the lumbar region L5/S1, which can have different gation, so a genetic component is also to be taken into ac-
longitudinal expansion: count.
The dysraphia exhibit different grades or values and, in addi-
tion to the layers of neural tissue, can also affect the tissue
layers lying over the top (lack of closure of the vertebral
arches, of the vertebral arches and meninges with and without
respective involvement of the nerve tissue). Typically, the
Proc. spinosus of the vertebral arches is split, from which the
clinical description of the disorder spina bifida is derived. A
distinction is made between:
• Spina bifida occulta: 10% of the population, if applicable
only proven radiographically or through abnormal hair
growth (› Fig. 11.13a)
• Spina bifida cystica: 0.1%, the most frequent defect in neo-
nates; involvement of the meninges (meningocele) or by me-
ninges and nerve tissue (meningomyelocele, › Fig.
11.13b); the cause is, among other things, folic acid defi-
ciency during pregnancy
• Spina bifida aperta: uncovered defect of the myelon (myelo-
schisis)
Closure defects in the area of the Neuroporus anterior are the
most common congenital malformations of the brain. Cranial
meningoencephalocele and anencephaly are included in
these. Here, too, the covering tissues, i.e. meninges and the
calvaria, are affected:
• In the Cranium bifidum these closure defects are in the me-
dian plane. Depending on the tissue, one speaks of cranial
meningocele, meningoencephalocele or meningohydroen-
cephalocele (with sections of the ventricle in the hernia
sac). a b
• In the case of a particularly early impaired closure of the
Neuroporus anterior, the development of the skull bones Fig. 11.13 Spinal dysraphia with different degrees of severity. a Spi-
and the prosencephalon system is disrupted. It leads to ex- na bifida occulta with hairy skin area. b Meningomyelocele in the
encephaly, exposing the brain, which is changed pathologi- lumbar region. [E347-09]

592
 11.2 Structure of the nervous system

11.1.4 Development of the peripheral nervous traumatic brain trauma, neurological hereditary disorders in
s­ ystem the family, risk factors and autonomic body functions. Special
examination techniques relating to the functional systems
As already described, neural crest cells exit during the neurulation and the cranial nerve functions complement the targeted,
symptom-focused history and will be discussed separately in
of the epithelial complex and finally come to rest on the side of the
the relevant chapters. In general, for every patient, the overall
neural tube below the surface of the ectoderm (formation of neural function of the CNS should be evaluated through a preliminary
crest cells). They exhibit a mesenchymal migration behaviour, sim- assessment of consciousness, orientation to time, space and
ilar to that of free connective tissue cells. The migration of neural people, as well as with regard to their memory, concentration
crest cells is closely related to the disappearance of the N-CAM ability and basic mood. In the clinic, impairments of con-
(cell adhesion molecules) formed by the neural tube and the cad- sciousness, for example, are divided into:
herins, as well as to the appearance of membrane-like integrins. • Somnolence: abnormal sleepiness, easily awakened, de-
layed reaction to verbal communication, prompt response to
The neural crest cells give rise to various cell types that are located
pain stimuli
in particular in the peripheral nervous system (neurons and glia, • Stupor: abnormally heavy sleepiness, difficult to awaken,
formation of the different types of ganglia, adrenal medulla) or as delayed but targeted defence regarding pain stimuli
melanocytes in the skin. A loose connective tissue structure, such • Coma: Can no longer be awakened by external stimuli
as the face cartilage or the Pia mater, is also formed. In addition, the clinical neurological examination assesses
the severity of impaired consciousness but also does so quan-
titatively, by means of the spontaneous behaviour of the pa-
tient, reaction to verbal prompts or pain stimuli points
11.2 Structure of the nervous system (Glasgow Coma Scale). This quantification allows an estima-
Anja Böckers tion of the extent to which consciousness is impaired over the
course.
Content-related impairment to consciousness can be disorien-
Skills tation, confusion or perception disorders, such as alcohol or
drug-related delirium.
After working through this chapter, you should be able to:
• explain and demonstrate the macroscopic structure of the
CNS in its sections on a model of the brain, pointing out the
surface structures named here
• explain and demonstrate the core areas and fibre systems 11.2.2 Structure of the CNS
named here on a horizontal section of the internal structure
of the telencephalon Sections
The CNS can be divided into the Medulla spinalis (spinal cord)
and encephalon (brain). The brain is comprised of 5 sections as
per embryological development (› Chap. 11.1.1):
11.2.1 Overview • Medulla oblongata or myelencephalon (‘extended marrow’)
• Pons (bridge)
The nervous system is basically divided into a peripheral nervous • Mesencephalon (midbrain)
system (PNS) and a central nervous system (CNS). While the • Diencephalon (interbrain)
central nervous system is well protected in the vertebral canal and • Telencephalon or cerebrum (endbrain)
in the bony cranial cavity (› Fig. 11.14a), the structures of the The medulla, pons and mesencephalon together form the brain-
PNS exit the protective spine at the Foramina intervertebralia. In stem (Truncus encephali). The pons attaches dorsally to the cere-
addition to this macroscopic border, this subdivision can also be bellum.
understood microscopically, since the nerve cell fibres are sur- Other important designations derived from the development of
rounded by different insulating glial cells: in the CNS these are the brain vesicles, are the bringing together of the telencephalon and
oligodendrocytes; in the PNS the SCHWANN cells form the my- the diencephalon to form the prosencephalon (forebrain) as well
elin sheath. In the same way, the meningeal envelope of the CNS, as of the pons and the cerebellum to form the metencephalon. The
the Dura mater, transitions into the epineurium of the peripheral metencephalon and myelencephalon in turn form the rhomben-
nerve in the above-mentioned border area. cephalon.
In functional terms you can differentiate between an autonomous
and a somatic nervous system, which serve subconscious or con- Topographical relationships
scious control and sensory perception. Both systems either provide The description of relational positions in the CNS (› Fig. 11.15) is
the CNS with information (afferents) or relay information from the differentiated from the torso or extremities:
CNS to the peripheral areas (efferents). This functional organisa- • Structures of the Truncus encephali are described by their posi-
tion of the nervous system (› Fig. 11.14b) is not identical in all tion relative to a vertical axis passing through the brainstem, the
sections to the morphological structure of the CNS. MEYNERT's axis.
• Structures of the telencephalon or diencephalon are described in
relation to a longitudinal axis through the earlier forebrain
Clinical remarks (FOREL's axis).
The clinical neurological examination consists of a medical The Medulla spinalis extends cranially into the adjacent part of the
history and physical examination. The medical history will fol- brain, the Medulla oblongata. This passes through the Foramen
low the usual procedure, but questions should also be asked magnum of the Os occipitale into the interior of the skull. Inside
in particular about existing neurological disorders, previous the skull, the front surface of the pons attaches to the clivus, while
the cerebellum fits into the posterior fossa and is covered superior-
ly by the Tentorium cerebelli, a duplication of the Dura mater. The

593
11 General neuroanatomy

Encephalon

CNS Nn. craniales

Medulla spinalis
Plexus cervicalis

Plexus brachialis

R. ventralis
N. spinalis

Cauda equina

Plexus
lumbosacralis

Conscious or subconscious control or information processing CNS

Efferents Afferents

Somatic Autonomous Somatic Autonomous

system system system system PNS

Somato- Viscero- Somato- Viscero-

efferents efferents afferents afferents

Effectors Receptors

Smooth Exteroception Smooth Fig. 11.14 Structure of the ner-

Skeletal muscles, (eye, ear, skin) muscles,
muscles viscera, Proprioception viscera,
vous system, Systema nervo-
glands (joints, glands sum; a Morphological structure,
b muscles, tendons) ventral view and dorsal; b Func-
tional organisation. b [L126]

position of the Tentorium cerebelli – and thus the border between 11.2.3 Morphology of the CNS
the cerebrum and cerebellum – is marked on the outside of the
skull by the Protuberantia occipitalis externa. Above this point is A description of the outer shape of the CNS is given here. The Me-
the occipital lobe of the telencephalon, while the temporal lobes dulla spinalis and cerebellum are described in › Chap. 12.6 or in
attach to the middle cranial fossa and the frontal lobes attach to the › Chap. 12.4 .
anterior cranial fossa, and the convex surface of the telencephalons
reaches the calotte. Surface morphology
The external appearance of the brain does not normally lead to
conclusions about its general or even individual function. The

594
 11.2 Structure of the nervous system

Superior, parietal, top

Mesencephalon

FOREL axis

Rostral,
anterior,
front

Occipital,
posterior, rear
Inferior, basal, bottom
Cerebellum
Telencephalon (= metencephalon)
Prosencephalon Pons Rhomb-
Diencephalon
Medulla oblongata encephalon
(= myelencephalon)
Medulla spinalis
Dorsal,
posterior, rear
Ventral, anterior, front

MEYNERT's axis
Caudal, bottom
Fig. 11.15 Alignment and posi-
Telencephalon Mesencephalon Medulla oblongata
tional terms of the CNS and spi-
Diencephalon Mesencephalon and pons Medulla spinalis nal cord; structure of the central
nervous system.

brain of an adult weighs an average of 1.4 kg with a gender-specific • the Sulcus parieto-occipitalis, which according to its name is
dimorphism that is comparable to differences in height and weight between the Lobus parietalis and the Lobus occipitalis, al-
in men and women. The consistency of the brain in a fixed state is though it is only clearly definable on the medial hemisphere side
often described as ‘tofu-like’ and its surface colour as greyish. Un- (› Fig. 11.16d)
fixed, the brain exhibits a lighter, almost rosy colour and has a con- The previously mentioned 4 lobes are clearly visible on the Facies
sistency which is most closely compared to that of unfixed liver tis- superolateralis. In total, the cerebrum has 6 lobes:
sue. The brain surface presents with regular grooves and shows in- • The insular lobes (Lobus insularis) lie in the depths of the Sul-
ter-individual differences. cus lateralis in the Fossa lateralis cerebri and, because it is over-
grown during the development of the Lobi frontalis, parietalis
Telencephalon and temporalis, it is only visible when you push these to the side
The telencephalon is the largest section of the CNS and is the most (› Fig. 11.17).
highly developed part where conscious perception of information • The Lobus limbicus only becomes visible through a midline sec-
takes place. In principle, it is divided into 2 cerebral hemispheres tion through the Corpus callosum on the Facies medialis of the
(Hemispheria cerebri), which are connected above the Corpus cerebrum. It includes the Gyrus cinguli on the Facies medialis
callosum and enclose a cerebrospinal fluid-filled cavity system as well as its continuation on the Facies inferior, the Gyrus para-
within them. The hemispheres are divided from each other by the hippocampalis, through which the Sulcus collateralis is sepa-
Fissura longitudinalis cerebri. An outer convex surface, the Fa- rated from the Lobus temporalis (› Fig. 11.16c).
cies superolateralis, reaches cranially to the Margo superior
(hemispheral rim) in the Facies medialis or caudally to the Mar- NOTE
go inferolateralis to merge with the Facies inferior. These Facies The telencephalon is divided into 6 lobes: the Lobus frontalis, Lo-
inferior, in turn, border the Facies medialis of the brain in the bus parietalis, Lobus occipitalis, Lobus temporalis, Lobus insularis
frontal section via the Margo inferomedialis, eventually reaching and the Lobus limbicus.
the Corpus callosum. The ventrally or dorsally reaching endpoints
of the convex are described as frontal poles (Polus frontalis), tem-
poral poles (Polus temporalis) and occipital poles (Polus occipi- Lobus frontalis
talis) (› Fig. 11.16). In the Lobus frontalis, one can distinguish 3 main ridges on the Fa-
The mature brain is characterised by the ridges (Gyri cerebri) and cies superolateralis: Gyri frontales superior, medius and inferior
grooves (Sulci cerebri) on its surface. In doing so, the primary (› Fig. 11.18). At its point of contact with the lateral sulcus, the
grooves, which are common to all humans and which are already inferior gyrus can be divided from anterior to posterior into the
fully established in the 8th embryonic month, can be distinguished Partes orbitalis, triangularis and opercularis. The motor lan-
from the secondary and tertiary grooves, which exhibit individual guage centre (BROCA's centre) is located in the two posterior
variability. The sulci bordering the lobes include: parts. Just in front of the Sulcus centralis, the only sulcus which
• the Sulcus centralis between the frontal lobe (Lobus frontalis) cuts into the Margo superior, is the Gyrus precentralis, in which
and parietal lobes (Lobus parietalis) the primary motor function centre is located. The Facies inferior of
• the Sulcus lateralis (syn.: Fissura lateralis) between the Lobus the Lobus frontalis is characterised by irregular Gyri and Sulci or-
frontalis and the temporal lobes (Lobus temporalis) bitales. As a rule, the Gyrus rectus is parallel to the Margo infero-

595
11 General neuroanatomy

Sulcus centralis
Polus frontalis
Sulcus lateralis
Fissura longitudinalis
cerebri Sulcus parieto-
occipitalis

Margo superior
Polus
frontalis Polus
Sulcus centralis
occipitalis
Gyrus precentralis
Fossa lateralis
Gyrus postcentralis cerebri Incisura
Polus preoccipitalis
Sulcus parieto- b temporalis
occipitalis

a Polus occipitalis Sulcus cinguli Sulcus centralis

Gyrus cinguli Lobulus paracentralis
Lobus limbicus
Corpus
Precuneus
Polus frontalis Gyrus rectus callosum
3
Sulcus parieto-
Septum 2
Fissura longi- Sulci 1
occipitalis
pellucidum
tudinalis cerebri orbitales 4 Cuneus
Fornix
Polus temporalis Sulcus
Fossa lateralis cerebri calcarinus
Fossa lateralis cerebri
Polus temporalis
Incisura
Gyrus parahippo-
Gyrus hippo- preoccipitalis
campalis, Uncus Sulcus
campalis, Uncus
Diencephalon collateralis
d Sulcus hippocampalis
Lobus limbicus,
Gyrus parahippocampalis

Sulcus collateralis
Gyrus occipito- Corpus callosum
Sulcus hippocampalis
temporalis medialis 1 Rostrum 3 Truncus
Incisura preoccipitalis 2 Genu 4 Splenium
Gyrus cinguli

c Polus occipitalis Sulcus calcarinus

Lobus frontalis Lobus temporalis Lobus occipitalis

Lobus parietalis Lobus limbicus

Fig. 11.16 Lobes of the cerebrum, Lobi cerebri. a View from above. b Lateral view with substructure of the cerebrum hemisphere in the Lobus
frontalis, Lobus parietalis, Lobus temporalis and Lobus occipitalis. c View from below. d Medial view.

Sulcus circularis insulae medialis. It runs through the Sulcus olfactorius, in the Bulbus and
Sulcus centralis
insulae Pedunculus olfactorius, bounded laterally (› Fig. 11.16c).

Gyrus longus Lobus parietalis

insulae In the Lobus parietalis on the Facies superolateralis close to the Gyrus
postcentralis, in which the primary somatosensory functional centre
is located, 2 lobes can be distinguished: Lobulus parietalis superior
Limen and inferior. At the borderline to the Lobus temporalis, 2 smaller
insulae gyri can be described: the Gyrus supramarginalis, which lies dome-
shaped over the end of the Sulcus lateralis, and the Gyrus angularis
Gyri breves Incisura preoccipitalis at the end of the Sulcus temporalis superior. A third lobulus, the Lob-
insulae Polus temporalis ulus paracentralis, runs in an arch on the Facies medialis around the
Sulcus centralis and, because it can be assigned to both the Lobus pa-
Fig. 11.17 Ridges (gyri) and grooves (sulci) of the cerebral hemi-
spheres. Lateral view of the left-hand Lobus insularis after removal of rietalis and the Lobus frontalis correspondingly, it is divided further
the opercula of the forehead, parietal and temporal lobes that cover into a Pars frontalis and a Pars parietalis. The nearly rectangular corti-
the island region. The Lobus insularis is used for the processing of cal area between the Lobulus paracentralis and Sulcus parieto-occipi-
olfactory, gustatory and visceral information. talis is ultimately called the precuneus (› Fig. 11.16, › Fig. 11.18).

596
 11.2 Structure of the nervous system

Pars opercularis Sulcus centralis

Sulcus intraparietalis
r l is Lo b u
r io us t ra

lis
lus
pa

G y r u s p r e c en t r a
ri e

n
Lo bu l u

pe

i
ed

G y r u s p o s t ce
s pa

su

m
ri e

ta
is
alis

lis
tal
sup

ta

sup
t ang

li
f ron
G y r u s f r on

rama

s in
s
ru
Gy

ularis

erio
Sulcus parieto-

rus
gi

ferior
Gy r u s

f r o ntali s
i n f erior
na
occipitalis

Gy
lis

r
r
p erio
s su
Pars triangularis
s po rali s
ru di u Fig. 11.18 Ridges (gyri) and
Gy s tem lis me
les ru po r a grooves (sulci) of the cerebral
y
G y ri o r bita G tem hemispheres. Lateral view of the
rus infer
ior
Gy
Pars orbitalis
or al is cerebrum from the left. The
te mp
Sulcus and Fossa lateralis cerebri rus Incisura preoccipitalis Gyrus frontalis inferior is divided
Gy into the Pars orbitalis, Pars tri-
angularis and Pars opercularis.

Lobus temporalis campalis bends slightly medially, so that a small hook, the Uncus
In the Lobus temporalis one can distinguish 3 principal ridges on gyri hippocampalis, forms (› Fig. 11.16c).
the Facies superolateralis and frontal lobes: Gyri temporales supe-
rior, medius and inferior. The Gyrus inferior forms the Margo in- Diencephalon
ferolateralis and continues smoothly to the Facies inferior. Of par-
ticular note are the characteristics of the Gyrus temporalis superi- NOTE
or: in the Sulcus lateralis are the Gyri temporales transversi The diencephalon extends from the roof of the third ventricle to the
(HESCHL's gyri or convolutions), which comprise the primary exit of the Aqueductus mesencephali (SYLVII). It is divided into a
acoustic function centre. In the posterior lateral portion of the Gy- simplified order from cranial to caudal in 4 sections:
• Epithalamus
rus temporalis superior, in the dominant hemisphere (right side of
• Thalamus with metathalamus (metathalamus = Corpus genicula-
the left hemisphere), the sensory language centre is located (WER- tum laterale and mediale)
NICKE's area). The inferior view of the Lobus temporalis is rela- • Hypothalamus with hypophysis
tively unspecific in that the Gyri occipitotemporales lateralis and • Subthalamus
medialis continue from the Gyrus temporalis inferior, separated by
the Sulcus occipitotemporales. (› Fig. 11.16c, › Fig. 11.18). The diencephalon is both a hub between the brainstem and cere-
bral hemispheres and an important point of coordination between
Lobus occipitalis the neuronal and endocrine systems. It is hardly visible from the
In the Lobus occipitalis the Facies superolateralis exhibits no spe- outside, as it is almost completely covered by the extensive growth
cific features, so that Gyri occipitales are spoken of in only general of the hemispheres during embryonic development of the telen-
terms. On the Facies medialis, on the other hand, an area can be cephalon. Visible only in the basal view are small sections (› Fig.
seen extending from the Sulcus parieto-occipitalis to the Sulcus 11.19): these include the N. opticus [II], of which the intersection
calcarinus, which due to its triangular form is known as the cuneus of fibres in the Chiasma opticum and the Tractus opticus evert
(‘wedge’). The Sulcus calcarinus extends from the Polus occipitalis together with the eye structure from the diencephalon during de-
to the Sulcus parieto-occipitalis in the depths of the lobes. The pri- velopment. Viewed laterally, the optic tract marks the transition
mary optical functional centre is located in the immediately adja- from the diencephalon to the mesencephalon. The tractus becomes
cent cortical areas of the Sulcus calcarinus. The Gyrus lingualis thicker along its further posterior pathway to the lateral geniculate
joins directly below the Sulcus calcarinus. If the gyri are further body (Corpus geniculatum laterale), which together with the me-
traced to the basal side, the Facies inferior of the Lobus occipitalis dial geniculate body (Corpus geniculatum mediale) is to be at-
are thrown up by the Gyri occipitotemporales medialis and latera- tributed to the diencephalic thalamus. Both can be seen by pushing
lis, which exhibit no sharp border with the Lobus temporalis the temporal lobes slightly off the brainstem laterally. In front of
(› Fig. 11.16, › Fig. 11.18). the Tractus opticus, the Substantia perforata anterior can be
found on both sides, riddled with a large number of smaller vessels
Lobus insularis that penetrate here into the depth of the brain. The Tuberculum ol-
The Lobus insularis is characterised by 5–9 fan-shaped ridges, factorium lies underneath it, representing part of the olfactory sen-
which can be divided into the anterior-lying Gyri breves and the sory processing function. Directly behind the Chiasma opticum, in
rather more posteriorly located Gyri longi, each ending at the Sul- the angle formed by the diverging Tractus optici, the infundibu-
cus circularis insulae (› Fig. 11.17). lum or the infundibular stalk can be situated in an anterior to pos-
terior arrangement. The hypophysis, the Tuber cinereum and the
Lobus limbicus Corpora mamillaria are differentiated.
The Lobus limbicus with its main section, the Gyrus cinguli, If the Lobus occipitalis and the cerebellum are forced apart, the pi-
arches across the Facies medialis via the Corpus callosum and is neal gland (Glandula pinealis) can be recognised occipitally in
bordered above by the Sulcus cinguli and below by the Sulcus cor- the depth of the subarachnoid space as part of the diencephalic
poris callosi. Further on, the Gyrus cinguli narrows and joins with ­epithalamus.
the Gyrus lingualis as the Gyrus parahippocampalis and contin- The level structure of the diencephalon is only visible after a cut in
ues to the Facies inferior. At the rostral end, the Gyrus parahippo- the median plane through the Corpus callosum. With this incision,

597
11 General neuroanatomy

Chiasma opticum N. opticus [II]

Infundibulum Trigonum olfactorium

Tuber cinereum
Substantia perforata anterior
Corpus mamillare

Substantia perforata Tractus opticus

posterior
Crus cerebri
Pedunculus
Tegmentum cerebri
Substantia nigra mesencephali

Corpus
geniculatum
laterale Meta-
Corpus thalamus
Nucleus ruber geniculatum
mediale
Aqueductus mesencephali Fig. 11.19 Diencephalon from
below. The brainstem has been
separated at the level of the
Mesencephalon Diencephalon mesencephalon (dotted incision
in › Fig. 11.20).

the IIIrd ventricle is opened so that its roof and the outlet of the The cerebrum is also connected with the brainstem via strong con-
­aqueduct are clearly visible. The lateral wall of the IIIrd ventricle is necting branches (Pedunculi cerebri or Crura cerebri), that run
formed by the diencephalon (› Fig. 11.20). The term ‘subthala- on the ventral side of the mesencephalon (› Fig. 11.21c). Between
mus’ includes several accumulations of nerve cell bodies that origi- these lies the Fossa interpeduncularis. The openings of numerous
nally came from the ventral portion of the thalamus, but which smaller vessels here give this pit a sieve-like form and its name,
have been forced out of the way in further development of the IIIrd Substantia perforata posterior. On the dorsal side, the mesen-
ventricle. The subthalamus is therefore not delineated on a median cephalon extends caudally from the rostrally located pineal gland
section of the cerebrum. (Glandula pinealis) to the upper small cerebellar peduncle (Pedun-
culi cerebellaris superior). What is striking here is the typical sur-
Truncus encephali face relief, characterised by the quadrigeminal plate (Lamina tecti
The function of the brainstem comes on the one hand from the or quadrigemina). In doing so, 2 upper and 2 lower hills (Colli­culi
cranial nerve cores located in it and on the other hand, functionally, superiores and inferiores) can be differentiated, each one connect-
through controlling motor, visual or acoustic reflex activity and the ed via a brachium of the same name with the Corpora geniculata
localisation of important life-sustaining centres, such as the respirato- laterale and mediale of the diencephalon (› Fig. 11.21a). The tri-
ry centre. The Truncus encephali is a stalk-shaped structure, with the angular area between the lower ‘hills’ and the Pedunculi cerebel-
telencephalon spreading over it like the top of a tree. Dorsally, this lares superiores are also known as Trigonum lemnisci lateralis.
‘tree top’ has another small ‘tree top’ in the form of the cerebellum. The swelling at the pons or its transverse running fibres clearly
The surface morphology of the brainstem needs to be studied on the marks the boundary between the mesencephalon and pons. The
dissection, ventrally and laterally but on the dorsal side the brainstem pons in the Sulcus bulbopontinus is just as clearly delineated cau-
is largely covered by the cerebellum so that it can only be seen dorsal- dally to the Medulla oblongata. The pons is connected via the mid-
ly if the cerebellum is detached from its connecting branches, the dle cerebellar peduncles (Pedunculi cerebellares medii) with the cere­
small cerebellar peduncles (Pedunculi cerebellares) (› Fig. 11.21). bellum. The removal of the cerebellum to expose the dorsal brain-
stem implicitly implies the removal of the roof of the tent-shaped
NOTE IVth ventricle. This procedure also means that the floor of the cavi-
The Truncus encephali has rostral contact with the diencephalon and ty which is filled with cerebrospinal fluid, the rhomboid fossa
extends caudally to the Decussatio pyramidum before continuing in- (Fossa rhomboidea), is visible. The pathway of the Striae medul-
to the spinal cord. It is composed in a craniocaudal arrangement of: lares marks the transverse border area of the pons from caudal to
• Mesencephalon
the Medulla oblongata. Finally, the edges of the ventricle roof (Ve-
• Pons
• Medulla oblongata
lum medullare inferius) taper down to a point lying in the Sulcus
Characteristic of the three sections are the exit points of the 12 cra- medianus, the obex, limiting the rhomboid fossa caudally. The Sul-
nial nerves (see also › Chap. 12.5). cus medianus continues into the spinal cord and is accompanied by

598
 11.2 Structure of the nervous system

Thalamus
Fornix, Corpus Plexus
Sulcus choroideus
hypothalamicus ventriculi tertii
Gyrus paraterminalis
Stria medullaris
Commissura thalami
anterior
Commissura
Area subcallosa habenularum
Epitha-
Lamina terminalis
Glandula lamus
Hypothalamus pinealis
Chiasma opticum Commissura Fig. 11.20 Median section
Corpus mamillare posterior through the IIIrd ventricle (Ven-
triculus tertius) and level struc-
Adenohypo- ture of the interbrain (dienceph-
Mesencephalon alon) in the epithalamus,
physis
Hypophyse
Neurohypo- Cerebellum thalamus, hypothalamus and
physis subthalamus. Portions of the
diencephalon are brown, while
Pons those of the mesencephalon are
green.

furrows running parallel to it, the Sulcus intermedius posterior and small accumulations of grey matter in the form of cranial nerve
Sulcus posterolateralis. At the level of the obex, there are incon- nuclei on the one hand, but also, as macroscopically conspicuous
spicuous elevations in the posterior strands, which are described as and well-demarcated structures on the other:
Tubercula gracile and cuneatum (› Fig. 11.21a). Ventrally you • in the Mesencephalon, the Substantia nigra and the Nucleus ru-
can see the onion-like bulge of the Medulla oblongata, the bulbus, ber (› Fig. 11.22b)
which is also characterised by longitudinal grooves, the Fissura • in the Pons, the Nuclei pontis (› Fig. 11.22c)
mediana anterior and the Sulcus anterolateralis. Next to the Fissura • in the Medulla oblongata, the Nucleus olivaris inferior (› Fig.
mediana anterior, the pyramis and further laterally, the olive, bulg- 11.22d)
es. In the Sulcus anterolateralis, before the olive, and in the Sulcus In the Truncus encephali, white and grey matter are more or less
retro-olivaris, behind the olive, several cranial nerves leave the arranged in a clearly defined order in 3 longitudinal zones. Starting
brainstem. In the Decussatio pyramidum there are transverse ventrally, in the first layer are accumulated fibres (e.g. the Crura
running pyramidal fibres that ultimately limit the Medulla oblon- cerebri), in a middle layer, the cranial nerve cores, and in the dorsal
gata caudally. section, the parent reflex centres (tectum, cerebellum). In the mes-
encephalon, these three layers are also referred to by the terms ba-
sis, tegmentum and tectum.
11.2.4 Distribution of grey matter in the CNS
Spinal cord
Telencephalon The mix of grey and white matter is reversed in the spinal cord so
A frontal section through the telencephalon makes it clear that that the Medulla spinalis, in contrast to the cerebrum, is character-
along the gyri and sulci of the telencephalon there is an approx. ised by a centrally located Substantia grisea which is surrounded by
0.5 cm broad layer of grey matter (Substantia grisea), which is the white matter. In the cross-section, this grey matter of the spinal
Cortex cerebri. Neuronal perikarya and glial cells are typically ar- cord is in a butterfly shape (› Fig. 11.22e).
ranged in 6 layers so that one speaks of the isocortex, in contrast to
the allocortex, which only consists of 3–4 layers, and in terms of
developmental history consists of an older section, the paleocortex 11.2.5 Distribution of white matter in the CNS
(e.g. olfactory outer layer) and archicortex (e.g. hippocampus). The
Substantia grisea accumulates in the white matter of the telenceph- While the grey matter includes the nerve cell bodies, the white sub­
alon, the Substantia alba. In addition to the Cortex cerebri, grey stance (Substantia alba) is composed of nerve cell fibres, i.e. mye­
matter is also incorporated in the depths of the white matter of the linated or non-myelinated axons of neurons. The axons connect
cerebrum. nerve cells of the central nervous system over different distances.
The core areas of the Nucleus caudatus, the claustrum, the Fibres between cortex areas of the same telencephalic hemisphere
putamen, the Globus pallidus, the amygdala, and the thalamus, are association fibers (Fibrae associationes). Adjacent gyri con-
which is already attributed to the diencephalon, can here be clearly nect these cortex area fibres, thus known as Fibrae arcuatae cere-
distinguished macroscopically (› Fig. 11.22a). bri. So-called fascicles finally connect different lobi of the telen-
cephalon with each other. However, these pathways cannot be de-
Truncus encephali lineated on simple horizontal or frontal sections through the
In cross-sections through the Truncus encephali, no superficial cerebrum. Only special preparation techniques, such as the fibrilla-
cortex layer can be detected. Embedded in the white matter are tion of a fixed brain, set these fibres free (› Fig. 11.23a).

599
11 General neuroanatomy

Brachium colliculi inferioris

Velum medullare superius
Colliculus inferior
Corpus geniculatum Brachium colliculi
Brachium colliculi mediale superioris
Lamina tecti
inferioris
Corpus geniculatum
laterale Glandula
pinealis
N. trochlearis [IV]
Tractus opticus
Colliculus superior
Pedunculus cerebri
Colliculus Pedunculus Colliculus inferior
Pedunculus cere- facialis cerebri
bellaris superior
N. trochlearis [IV]
Fovea superior
Pedunculus
cerebellaris
medius Sulcus N. trige-
medianus minus [V] Pedunculus cere-
Pedunculus bellaris superior
cerebellaris Sulcus limitans Pedunculus cere-
N. facialis [VII]
inferior bellaris medius
Apertura lateralis N. vestibulocochlearis [VIII] Pedunculus cere-
Stria medullaris
ventriculi quarti ventriculi quarti bellaris inferior
N. glossopharyngeus [IX]
Fossa rhomboidea,
Velum medullare inferius Sulcus medianus
N. hypoglossus [XII]
Trigonum nervi hypoglossi Tuberculum
N. vagus [X] Tuberculum cuneatum
cuneatum
Trigonum nervi vagi
Tuberculum gracile
Area postrema Tuberculum gracile N. accessorius [XI]
Obex

Sulcus posterolateralis Fasciculus cuneatus N. cervicalis [C1]

Sulcus intermedius posterior Fasciculus gracilis

Sulcus medianus
a b

N. oculomotorius [III]

Tractus opticus
Fossa inter-
peduncularis
Pedunculus
cerebri
Radix motoria
N. trigeminus [V]
Radix sensoria
Pedunculus cere-
bellaris medius
N. abducens [VI]

Sulcus basilaris
N. facialis [VII]

N. vestibulo-
Sulcus bulbo-
cochlearis [VIII]
pontinus
Oliva

Pyramis Fissura mediana

ventralis

Decussatio pyramidum

Fig. 11.21 Truncus encephali. a Dorsal view. b Lateral view. c Ventral view. [L238]

600
 11.2 Structure of the nervous system

Fissura longitudinalis cerebri

Gyrus cinguli Corpus callosum, Truncus

Nucleus caudatus, Corpus

Putamen
Capsula extrema

Gyri insulae
Capsula externa
Claustrum
Globus pallidus lateralis Capsula interna

Globus pallidus medialis

Tractus opticus
Nucleus caudatus, Cauda
Corpus amygdaloideum Corpus mamillare

Hippocampus

a Thalamus Hypothalamus Pons

Colliculus Aqueductus Nucleus Fossa Sulcus

superior mesencephali ruber rhomboidea medianus

Substantia
nigra
Nuclei
pontis

Fossa inter- Pedunculus c

peduncularis cerebri

Sulcus Pedunculus Sulcus medianus Substantia grisea,

medianus cerebellaris inferior posterior Cornu posterius

d
e
Fissura mediana Pyramis Nuclei olivaris
anterior inferior Canalis Fissura Substantia grisea,
centralis mediana Cornu anterius
anterior

Fig. 11.22 Distribution of Substantiae grisea and alba in the CNS. a In the telencephalon, displayed as a frontal section at the level of the Cor-
pora mamillaria. b In the mesencephalon. c In the pons. d In the Medulla oblongata. e In the Medulla spinalis. b–e [R247]

Commissural fibers (Fibrae commissurales) are fibre systems and smaller bundles of commissural fibres such as the Commissura
that connect the two hemispheres. Fibres between corresponding anterior, the Commissura posterior or the Commissura fornicis
brain areas will be referred to as homotopic, whereas those be- (› Fig. 11.23b).
tween non-corresponding areas are heterotopic fibres. Commissur- Furthermore, fibre systems are also contained in the white matter
al pathways can frequently be macroscopically clearly identified on connecting brain sections of different altitudes; that is, from the
median cuts. These include the strongly formed Corpus callosum cortex into caudal sections or in the opposite direction from caudal

601
11 General neuroanatomy

Fibrae arcuatae cerebri

Cingulum

Fasciculus
longitudinalis
superior

Fasciculus uncinatus

a Fasciculus longitudinalis inferior

Corpus callosum

Rostrum Genu Truncus Splenium

Radiatio corporis callosi

Forceps major

Forceps minor

Pars anterior
Commissura anterior
Pars posterior

Commissura posterior
Tapetum
b Commissura habenularum

Corpus callosum, Truncus Capsula interna, Genu

Fig. 11.23 Fibre systems of the
Sulcus corporis callosi Gyrus precentralis brain. a Association fibres (Neu-
rofibrae associationes) and
Corona radiata short association fibres (Fibrae
Corpus callosum, Genu
arcuatae cerebri), which connect
Sulcus parieto-occipitalis
U-shaped adjacent gyri with one
Capsula interna,
Crus anterius
another; diagram, view of the
Corpus callosum, brain from the left side. b Com-
Splenium
missural fibres (Neurofibrae
Capsula interna, commissurales). The Corpus cal-
Crus posterius Corpus geniculatum
laterale losum was, in addition to the
median plane, largely divided,
Tractus opticus and individual Corpus callosum
Sulcus calcarinus
fibres are presented. c Projec-
Pedunculus cerebri Pons tion fibres (Neurofibrae projec-
Tractus pyramidalis, tiones). The Capsula interna and
c Pyramis Fibrae corticospinales pyramidal tract have been
exposed.

sections, e.g. from the spinal cord to the cortex, in ascending order. Clinical remarks
Such fibre systems are called projection fibres. Macroscopically
speaking, the most definable bundling of such projection fibres is The absence (agenesis) of the Corpus callosum is one of the
the Capsula interna in the telencephalon or the Crura cerebri of most commonly observed malformations in humans (3–7 cas-
es/1,000 births). Various reasons lead to non-systemic or in-
the mesencephalon (› Fig. 11.23c).
complete formation of the Corpus callosum between the 5th
and 16th week of pregnancy, so that the connections between
NOTE the left and right cerebral hemispheres may be absent or se-
The most important fibre systems of the CNS are summarised in verely underdeveloped. The changes in the brain do not nec-
› Table 11.1. essarily lead to a change in behaviour. The symptoms depend

602
 11.3 Meninges

to a certain extent on the underlying cause of the dysfunction. 11.3.1 Overview

Frequently exhibited, in addition to neuropsychiatric deficits,
are difficulties in solving multimodal tasks such as prob- The brain and spinal cord are surrounded by a fibrous envelope
lem-solving, the understanding of language and grammar, or system, the meninges (brain and spinal membrane), › Fig. 11.24).
the description of emotions with words (alexithymia).
Here, a distinction is made between hard (Pachymeninx) and soft
Only rarely is a callosotomy, the neurosurgical transection of
the Corpus callosum, performed today for the treatment of re- membrane tissue (Leptomeninx). The pachymeninx forms the
fractory epilepsy. Patients with a separated Corpus callosum, outer membrane and essentially consists of the stiff Dura mater.
split-brain patients, are conspicuous in that information pro- The Leptomeninx is located underneath and consists of the Arach-
cessed in the right hemisphere is not made available to the noidea mater, which lies against the dura from the inside, and the
linguistic centre located in the left (dominant) hemisphere, Pia mater, lying directly on the nervous tissue. There is a physio-
and subsequently, although the information is for example logical gap between the Arachnoidea and the Pia mater, the sub-
seen and described, it cannot be named.
arachnoid space (Spatium subarachnoideum). It is the outer sub-
arachnoid space and completely surrounds the brain and spinal
cord (also › Chap. 11.4.4).
Table 11.1 Fibre systems of the Substantia alba.

Fibre system Connection Clinical remarks

Association fibres In the case of a traumatic brain injury, the Dura mater and the
Fasciculus longitudinalis Lobus frontalis with Lobus parietalis and Lobus Arachnoidea mater can tear. The outer subarachnoid space is
superior occipitalis then opened up and there might be a connection to the out-
side (subarachnoid fistula), so that cerebrospinal fluid runs
Fasciculus longitudinalis Lobus occipitalis with Lobus temporalis
out of the nose (Rhinoliquorrhoea) or the ear (Otoliquor-
inferior
rhoea). In order to determine whether the excretory secretions
Fasciculus arcuatus Lobus frontalis with Lobus temporalis (BROCA actually are cerebrospinal fluid, you can today determine
­centre with WERNICKE’S area) β2-transferrin, a glycoprotein, which only appears in the
Fasciculus uncinatus Lobus frontalis with basal Lobus temporalis β2-isoform in CSF.
Cingulum Lower sections of the Lobus frontalis with lower
­sections of the Lobus parietalis and the Lobus
­parahippocampalis

Commissural fibres Sinus durae matris

Dura mater
Corpus callosum Frontal, parietal and occipital lobes in both hemi- Granulationes
1
spheres Arachnoidea arachnoideae
mater
Commissura anterior Tractus olfactorii; front parts of the Lobi temporales
(amygdala; Gyrus parahippocampalis) of both hemi-
Plexus
spheres
Pia choroideus
Commissura posterior Nuclei commissurae posteriores of both hemi- mater
spheres
Commissura fornicis Hippocampus of both hemispheres

Projection fibres
Tentorium
Tractus corticospinalis Cortex (especially Gyrus precentralis) with spinal cord
cerebelli
Spatium sub-
Tractus corticopontini Cortex with core areas of the pons (with Sinus
arachnoideum
durae
Tractus corticonuclearis Cortex with core areas of the cranial nerves in the matris)
Foramen
mesencephalon, pons and Medulla oblongata
interventriculare Cisterna
Fornix Hippocampus and parts of the limbic system and cerebello-
Ventriculus tertius medullaris
the diencephalon
Fasciculi thalamocorticales Thalamus with cortex Cisternae Apertura
2
subarachnoideae mediana

Canalis centralis

11.3 Meninges
Michael J. Schmeißer
Sinus durae matris

Skills Dura mater

Arachnoidea
After working through this chapter, you should be able to: mater
• name the 3 meninges and describe their topographical loca-
1 2
tion to the brain and spinal cord Spatium
• describe the blood supply to the meninges, also explaining Granulationes subarachnoideum
the reasons and consequences of meningeal bleeding arachnoideae
• describe the innervation of the meninges and the two clini- Pia mater
cal test methods to check for a meningism
Fig. 11.24 Positions of the meninges within the bony skull as sagit-
tal section. [L126]

603
11 General neuroanatomy

11.3.2 Embryology which faces the brain. In some places within the bony skull, these
two layers split from each other. This thereby creates oblong cavi-
The membrane of the brain and spinal cord develop from the Me- ties (Sinus durae matris), which are lined with endothelium and
ninx primitiva. This is mesenchymal connective tissue that origi- in which the venous blood from the brain and meninges is collect-
nates from the neural crest and the paraxial mesoderm and sur- ed and is directed towards the V. jugularis interna (› Chap. 11.3.5,
rounds the neural tube. With the formation of the dura subchon- › Chap. 11.5.8). In addition, the Lamina interna forms plate-like
dral plate, the Meninx primitiva is separated into the pachymeninx duplicatures, which form the structure of the interior of the skull,
and leptomeninx. separate certain portions of the brain from each other and equally
stabilise the position of the brain in the event of mechanical dam-
age to the skull. These include the following structures (› Fig.
11.3.3 Pachymeninx – Dura mater 11.26, › Fig. 11.24, › Fig. 11.27):
• Falx cerebri (cerebral falx): This relatively large dural septum is
The Dura mater mainly consists of dense, collagenous, fibrous con- aligned medially sagittally in the Fissura longitudinalis cerebri
nective tissue and is therefore a kind of ‘organ capsule’ for the cen- and separates the two cerebral hemispheres above the Corpus
tral nervous system. The Dura mater of the brain (Dura mater cra- callosum. Its upper margin contains the Sinus sagittalis superior,
nialis) fuses directly with the periosteum of the bony skull so that, which fixes it cranially to the calvaria. The falx is positioned ros-
intracranially, you cannot differentiate a physiological gap between trocaudally at the Crista galli and the Crista frontalis, occipitally
the dura and bony skull. The Dura mater of the spinal cord (Dura attached to the Protuberantia occipitalis interna. The Sinus sagit-
mater spinalis), on the other hand, forms a tubular sac, which sur- talis inferior is situated in its lower free margin, afterwards mov-
rounds the spinal cord, and except for its bony attachment points ing occipitally into the Sinus rectus, which in turn is enclosed by
on the Foramen magnum and Os sacrum, is not fused with the the root of the falx. From here, the Falx cerebri exits on both
bony vertebral canal. Therefore spinally, the majority is present as sides via the Tentorium cerebelli.
epidural space (Spatium epidurale; syn.: peridural cavity or Spati- • Tentorium cerebelli (cerebellar tentorium): This tent-shaped dural
um peridurale) which surrounds the dural sac and is filled with septum extends in a horizontal orientation within the Fossa cranii
­adipose tissue and a dense venous plexus (Plexus venosus vertebra- posterior, between the bottom of the Lobi occipitales of the cere-
lis internus) (› Fig. 11.25). brum and the Facies superior of the cerebellum. Its root is fixed oc-
cipitally, together with the Falx cerebri, at the Protuberantia occipi-
talis interna at the level of the Confluens sinuum; lateral to the
Clinical remarks margins of the Sinus transversus along the Os occipitale and fur-
Injecting a local anaesthetic in the epidural or peridural space ther forward laterally on the margin of the Sinus petrosus superior
surrounding the spinal dural sac, is described as peridural an- at the upper edge of the petrous pyramid. In the medial direction,
aesthesia (PDA for short) (› Fig. 11.34). The needle is intro- the root of the Tentorium cerebelli runs up to the Dorsum sellae
duced in the median sagittal alignment between 2 Procc. spi- and is attached to the Procc. clinoidei posteriores and anteriores.
nosi through the ligament structures of the vertebral column
Between both sides of the tentorium a slit-shaped gap (tentorium
in the epidural space, without penetrating the Dura mater spi-
nalis. The local anaesthetic therefore exerts its effects on the slot, Incisura tentorii) remains for the passage of the brainstem (at
spinal roots and dorsal root ganglia from outside the dura. The the level of the mesencephalon), vessels and cranial nerves.
PDA is used in various operations and in obstetrics for periop- • Falx cerebelli (cerebelli falx): The Falx cerebelli is a short, cres-
erative elimination of pain (analgesia). cent-shaped dural septum, that is attached occipitally to the
Crista occipitalis interna and protrudes dorsocaudally into the
Incisura cerebelli posterior in a median sagittal alignment.
The Dura mater cranialis consists of 2 superimposed layers: the • Diaphragma sellae: This horizontally oriented dural septum is
Lamina externa adhering to the bone and the Lamina interna, attached to the Procc. clinoidei anteriores and posteriores and
spans the Fossa hypophysialis in the Fossa cranii media. It con-
Arcus vertebrae tains a hole in its centre for the passage of the infundibular stalk.
Trabeculum arachnoideum

Vein Clinical remarks

Spatium epidurale With increased intracranial pressure, which can be the result
Spatium
subarachnoideum Periost of a cerebral haemorrhage or a brain tumour, sections of the
Lobi temporales can be pressed into the Incisura tentorii (ten-
Dura mater torial notch). This allows the Nn. oculomotorii or the entire
Pia mater
mesencephalon to be trapped. It thereby creates a mid-brain
syndrome, which manifests itself with increasing disorienta-
Arachnoidea mater
tion, fixed pupils in response to light, and increased and
Radix posterior pathological reflexes of the extremities.
Connective tissue
septum
(Lig. denticulatum) Ganglion sensorium
nervi spinalis

Corpus vertebrae
Truncus n. spinalis 11.3.4 Leptomeninx
Radix anterior
Arachnoidea mater
Fig. 11.25 Topography of the meninges within the vertebral canal; The Arachnoidea mater lies flat in the skull and in the vertebral ca-
at the level of the IVth cervical vertebra in cross-section. [L126] nal of the inner layer of the Dura mater, the so-called neurotheli-

604
 11.3 Meninges

Tentorium cerebelli
Falx cerebri
Sinus petrosus inferior
Sinus sagittalis superior
Falx cerebri
Sinus sagittalis inferior
Sinus sphenoparietalis

A. carotis interna Vv. superiores cerebri

N. opticus [II]
V. magna cerebri
Sinus cavernosus
Incisura tentorii
Hypophysis
Sinus transversus
Crista galli Sinus sigmoideus
Sinus intercavernosi Sinus rectus
Plexus basilaris Confluens sinuum
Tentorium cerebelli
Sinus occipitalis
Sinus marginalis
Foramen magnum
Tentorium cerebelli
Sinus petrosus superior

Fig. 11.26 Dura mater cranialis and duplicatures. Lateral view.

Sinus sagittalis superior Sutura sagittalis

Granulationes arachnoideae
V. emissaria parietalis
Epidermis
Cutis
Dermis [Corium]
Lacunae laterales
Galea aponeurotica
Os parietale
Lamina externa
Vv. diploicae Diploë Calvaria
Dura mater cranialis Lamina interna
Spatium subarachnoideum
Arachnoidea mater
cranialis
Cortex cerebri, Gyri cerebri
Pia mater cranialis
Spatium
subarachnoideum Falx cerebri

Substantia alba
Fig. 11.27 Roof of the skull,
meninges and Sinus durae
matris. Frontal section.

um. There is therefore no physiological gap between the dura and Clinical remarks
arachnoid, but there is between the arachnoid and Pia mater. This
Spatium subarachnoideum (outer subarachnoid space) is filled Meningiomas are slow-growing tumours which are almost al-
ways benign, mostly derived from mesothelial cells. They
with cerebrospinal fluid and, in particular in the area of the brain, mostly appear in the inter-hemispheric gap, especially in the
is threaded through with numerous spidery tissue-like connective area of the Sinus sagittalis superior (parasagittal meningio-
tissue trabeculae (Trabeculae arachnoidae). In some cases, it is ma). Often they remain unnoticed for a long time, because the
expanded to cisterns, in which, among other things, greater cere- surrounding tissue adapts and they can thus achieve a signifi-
bral arteries and some cranial nerve roots run (also › Chap. cant size before you experience, for example, a sudden sei-
11.3.2). Furthermore, in the direction of the dura, you can find vil- zure. If they can be operated on, meningiomas have a good
lous protuberances of the arachnoid. These mushroom-shaped prognosis if a radically large amount of the tumour tissue can
be removed.
arachnoidal granulations (Granulationes arachnoideae) can
pene­trate into the lumen of the Sinus durae matris and some even
up to the cranial bones and the diploic veins. They are important
drainage routes for CSF into the venous system and are particularly Pia mater
numerous and strongly pronounced at the Sinus sagittalis superior The Pia mater cranialis and Pia mater spinalis are directly next to
(PACCHIONIAN granulations, › Fig. 11.27). In the spinal cord, the brain and spinal cord. The Pia mater cranialis therefore fol-
dorsally in the area of the spinal nerve roots, are arachnoid granu- lows perivascularly – in contrast to the Dura and Arachnoidea ma-
lations. These come in contact with the epidural venous plexus and ter cranialis – all gyri and sulci down into the deep and large blood
ensure the spinal fluid flow. vessels and into the brain tissue. These sections are called VIR-

605
11 General neuroanatomy

CHOW-ROBIN spaces. A special feature of the Pia mater spinalis subdural haematoma is usually also a result of a traumatic
is the Lig. denticulatum. This plate, which is aligned in the frontal event, but the bridging veins are torn and it may take much
plane and consists of tight connective tissue, extends from the Fo- longer for the first symptoms to appear. In terms of computer
ramen magnum to above the first lumbar nerve on both sides be- tomography, subdural haematomas are hyperdense and uni-
convex. Treatment is by surgery and the insertion of waste
tween the spinal cord and Dura mater spinalis and respectively
drainage.
breaks through the arachnoid (› Fig. 11.25). A subarachnoid haematoma usually occurs when an enlarge-
ment (aneurysm) in an artery in the subarachnoid space rup-
NOTE tures. Such a haemorrhage is also hyperdensed by computed
Within the bony skull, the Dura and Arachnoidea mater pull togeth- tomography, whereby the accumulation of blood over large
er across the surface and thus across the gyri and sulci of the parts of the subarachnoid space, depending on how far it ex-
brain. On the other hand, the Pia mater lies directly on the brain tends, can be seen, especially in the cisterns. Again, in terms
tissue and therefore follows the gyri and sulci into the depths with- of prognostics, surgery as early as possible is necessary with
out exception (› Fig. 11.27). closure of the source of bleeding playing an important role.

11.3.5 Neurovascular pathways of the meninges Innervation

Sensorily, the meninges of the brain are predominantly supplied by
Arteries and veins branches of the N. trigeminus [V]. However, they also involve the
In the vessels of the Dura mater cranialis, a distinction is made be- N. glossopharyngeus [IX] and the N. vagus [X] as well as the cer-
tween Vasa privata (meningeal vessels, Aa. or Vv. meningeae) and vical spinal nerves and their sensory innervation.
Vasa publica (Sinus durae matris). Vasa privata are responsible for A topographical distinction is made between:
the arterial and venous blood supply of the dura, and Vasa publica • N. trigeminus [V]
carry the venous blood of the brain to the V. jugularis interna. In- – R. meningeus anterior of the N. ethmoidalis posterior
terestingly, the Arachnoidea mater does not have its own blood (branch of the N. nasociliaris; this in turn is the branch of the
supply, but the Pia mater does, the vessels of which in turn are in N. ophthalmicus [V/1]) for the meninges of the Fossa cranii
direct contact with the blood vessels of the brain. anterior
A distinction is made between the following arteries: – R. meningeus recurrens (R. tentorius) of the N. ophthalmic-
• R. meningeus anterior of the A. ethmoidalis anterior: supplies us [V/1] for the Tentorium cerebelli
the Dura mater cranialis of the Fossa cranii anterior – Rr. meningei of the N. maxillaris [V/2] or N. mandibularis
• A. meningea media of the A. maxillaris: supplies the largest part [V/3] for the meninges of the Fossa cranii media
of the Dura mater cranialis overall, primarily the Fossa cranii • N. glossopharyngeus [IX] and N. vagus [X]
media, and also partly the Fossa cranii anterior – Rr. meningei of the N. vagus [X] and N. glossopharyngeus
• A. meningea centralis of the A. carotis interna: supplies in par- [IX] for the dura of the Fossa cranii posterior with the excep-
ticular the Tentorium cerebelli tion of the clivus
• A. meningea posterior of the A. pharyngea ascendens: supplies • cervical spinal nerves
the largest part of the Dura mater cranialis of the Fossa cranii – sensory branches of C1–C3 supply the meninges of the clivus
posterior after passing through the Foramen magnum
• Rr. meningei of the A. vertebralis or A. occipitalis: also supply The cerebral meninges are autonomically innervated, parasympa-
part of the Dura mater cranialis of the Fossa cranii posterior thetically through fibres of the head ganglia, sympathetically
• Aa. radiculares and Aa. medullares from the Rr. spinales: sup- through fibres of the Ganglion cervicale superius.
ply the Dura mater spinalis In the spinal cord, the Rr. meningei of each spinal nerve exit seg-
Usually, paired Vv. meningeae accompany the above arteries or mentally from the sensory and autonomic innervation of the me-
branches. ninges.

NOTE
Bridging veins is how the venous sections are defined, connecting
Clinical remarks
the superficial cerebral veins with the Sinus durae matris. They ex- The meninges are extremely sensitive to pain, in contrast to
tend from the brain surface through the subarachnoid space, the brain and spinal cord itself. This sensitivity to pain is par-
arachnoid and Dura mater cranialis into the respective sinuses. ticularly evident in inflammatory processes such as meningi-
tis. The affected patients have severe headaches and concom-
itant painful neck stiffness. The latter is caused by an irritation
Clinical remarks of the membrane that covers the brain and is also known as
meningism. In a clinical neurological examination, a menin-
An intracranial epidural haematoma describes a collection of gism is determined through the following 2-test procedure:
blood between the cranial bone and Dura mater cranialis. The • BRUDZINSKI’s sign: In doing this, the patient relaxes lying
cause is often a skull trauma, in which a main vessel supply- on their backs with their heads lying passively forward. If the
ing the brain, such as the A. meningea media, ruptures. In ce- patient’s legs act reflexively (to relieve the irritated menin-
rebral computed tomography, an epidural haematoma is hy- ges), the sign is considered positive.
perdense (denser than the environment) and has a biconvex • KERNIG’s sign: In this case, the stretched leg is raised pas-
shape due to the defined attachment sites of the Dura mater sively by the patient when lying down. If there is an active
to the sutures of the cranial bones. The most important step is flexion in the knee joint due to irritated meninges, the sign
early surgery with ligation of the bleeding vessel. is positive.
In the event of an intracranial subdural haematoma, the blood
collects between the Dura mater and the Arachnoidea mater. A

606
 11.4 Ventricular system and adjacent structures

11.4 Ventricular system and adjacent structures spaces are in the depths of the cerebral brain and are lined by
Anja Böckers ependymal cells; they can be referred to as the ventricular system
in the narrower sense. They include 4 ventricles and the Canalis
centralis (› Fig. 11.28):
Skills • Ventriculi laterales primus (Ist ventricle, left) and secundus
(IInd ventricle, right) in the telencephalon
After working through this chapter, you should be able to: • Ventriculus tertius (IIIrd ventricle) in the diencephalon
• describe and demonstrate the flow of CSF on the specimen • Ventriculus quartus (IVth ventricle) in the rhombencephalon
or on a model of the ventricular system from the site of its
• Aqueductus mesencephali as a connection between IIIrd and
formation through the respective sections of the ventricular
system to its resorption sites IVth ventricle
• explain at least 2 key functions of CSF • Canalis centralis in the spinal cord
• correctly describe sections of the ventricular system on the The outer subarachnoid space is essentially formed by the sub-
horizontal and frontal sections of the brain arachnoid space surrounding the brain and spinal cord (› Chap.
• list the wall-forming structures of Ist–IIIrd ventricles 11.4.4). Amongst its extensions are the cisterns, including the Cis-
terna interpeduncularis, Cisterna ambiens and the Cisterna ponto-
cerebellaris.
The cerebrospinal fluid (› Chap. 11.4.5) is produced in the Plexus
11.4.1 Overview and structure choroidei of the ventricles and is spread over the Apertura medi-
ana (Foramen MAGENDII) and the paired Aperturae laterales
The brain is surrounded for protection by the cerebrospinal fluid. It (Foraminae LUSCHKAE) of the IVth ventricle in the outer sub-
is located in the outer (› Chap. 11.4.4) and the inner cerebrospi- arachnoid space, where it is absorbed. Inner and outer cerebrospi-
nal fluid spaces (› Chap. 11.4.3). The inner cerebrospinal fluid nal ­fluid spaces consist of a volume of approx. 140 ml CSF. The cere-

Foramen interventriculare Ventriculus lateralis, Pars centralis

Ventriculus tertius

Ventriculus lateralis, Recessus suprapinealis

Cornu frontale
Recessus pinealis

Ventriculus lateralis,
Recessus
Cornu occipitale
supraopticus

Aqueductus
mesencephali
Recessus infindibuli
Apertura mediana

Ventriculus lateralis, Ventriculus quartus

Cornu temporale
Apertura lateralis

a Canalis centralis

Cornu frontale

Pars centralis
Foramen interventriculare
Ventriculus tertius

Aqueductus
mesencephali

Pons Cornu temporale

Ventriculus
quartus

Apertura lateralis
Cerebellum

b Medulla oblongata Canalis centralis

Fig. 11.28 Ventricles of the brain, Ventriculi encephali; a View from the left side. b Front view.

607
11 General neuroanatomy

brospinal fluid system has a mechanical protection function and Table 11.2 Topography of the lateral ventricles.
transports nutrients and degradation products. It has also been dis-
Ventricle, Wall Adjacent structures Plexus
cussed whether the cerebrospinal fluid composition affects circu- section choroideus
lating substances in the CSF and neurotransmitter hormonal and
Roof Corpus callosum (truncus) No
homeostatic signalling pathways. Ventriculi
laterales, Front wall Corpus callosum (genu)
Cornu
Medial wall Septum pellucidum
­frontale
11.4.2 Embryology Lateral wall Caput nuclei caudati

Ventriculi Roof Corpus callosum Yes

Ventricular system
laterales, Floor Thalamus
With the development of the brain vesicles from the neural tube,
Pars
there is also simultaneously development of the ventricular system ­centralis
Medial wall Septum pellucidum, fornix
along with the inner cavities of the brain system (› Chap. 11.1.1). Lateral wall Corpus nuclei caudati
The two telencephalic vesicles enclose the paired lateral ventricle, Roof Medulla of the Lobus occipitalis No
Ventriculi
and the second of the secondary brain vesicles encloses the IIIrd laterales, Floor Medulla of the Lobus occipitalis
ventricle of the later diencephalon. After hemispheric rotation, Cornu
only small-lumen openings remain between the two, the Foramina ­occipitale
Medial wall Calcar avis
interventricularia (Foramina MONROI). In the area of the sec- Lateral wall Radiatio optica
ondary cerebral vesicle located in the mesencephalic part of the Ventriculi Roof Cauda nuclei caudati Yes
brain, the neural tube lumen narrows due to strong growth of the laterales, Floor Hippocampus
neural tube wall, so that only a narrow passageway between the Cornu
Medial wall Fimbria hippocampi
IIIrd and IVth ventricle, the Aqueductus mesencephali, remains. ­temporale
The neural tube lumen of the rhombencephalon becomes the IVth Lateral wall Cauda nuclei caudati
ventricle and the Canalis centralis of the Medulla oblongata or the Anterior wall Amygdala
spinal cord. Roof Tela choroidea ventriculi tertii Yes
Ventriculus
tertius Floor Hypothalamus
Development of the Plexus choroideus
Anterior wall Lamina terminalis ventriculi
The Plexus choroideus arises from the neuroepithelial of the brain
­tertii
vesicles by blood vessels growing into the ependyme. At these
points, the ventricular wall consists of the epithelial plexus (Lami- Lateral wall Thalamus, epithalamus

na epithelialis) and the connective tissue Tela choroidea (Lamina Ventriculus Roof Velum medullare superius Yes
propria), which differentiates the Pia mater. The vessels grow into quartus c­ erebelli and Velum medullare
inferius cerebelli
the ependymal roof of the IVth ventricle, in the medial wall of the
lateral ventricles and in the roof of the IIIrd ventricle. Both of the Floor Fossa rhomboidea
aforementioned systems develop together in the 7th embryonic Lateral wall Pedunculi cerebelli
week and are then distributed due to the strong outgrowth of the
telencephalon on the lateral ventricles and the IIIrd ventricle. But
they remain connected throughout life through the Foramina in- sections. (› Table 11.2). The border between the diencephalon
terventricularia (› Fig. 11.29). The choroid plexus is initially cre- with its thalamic nuclei and the telencephal Nucleus caudatus is
ated only in the central portion of the lateral ventricles, but ex- marked in the lateral ventricles by the pathway of the V. thalamo­
pands over the course of hemispheric rotation into the adjacent striata superior.

Fissura longitudinalis
Fornix

Ventriculus lateralis,
Corpus callosum
Pars centralis

Nucleus caudatus

V. thalamostriata
V. interna cerebri
superior

Tela choroidea
ventriculi tertii Plexus choroideus

Taenia thalami Thalamus

Fig. 11.29 Plexus choroideus in

Ventriculus tertius Telencephalon
the lateral ventricles, Ventriculi
laterales, and the IIIrd ventricle,
Adhesio
interthalamica Diencephalon Ventriculus tertius; diagram of
frontal section.

608
 11.4 Ventricular system and adjacent structures

Ventriculus lateralis, Corpus callosum, Truncus

Pars centralis

Nucleus caudatus, V. thalamostriata

Corpus superior

Capsula interna
Fornix, Crus

Insula [Lobus insularis]

Calcar avis
Fossa lateralis

Polus temporalis Ventriculus lateralis,

Cornu occipitale
Ventriculus lateralis, Fig. 11.30 Lateral ventricles,
Cornu temporale
Hippocampus,
Ventriculi laterales. View from
Alveus hippocampi the left at the top rear; after
Trigonum collaterale removal of the upper parts of
the cerebral hemispheres.

11.4.3 Inner cerebrospinal fluid space Aqueductus mesencephali

The IIIrd ventricle communicates through the Aqueductus mesen-
Ventriculi laterales primus and secundus cephali (SYLVII) with the IVth ventricle. The aqueduct begins in
The Ventriculi laterales (› Fig. 11.30) each form, viewed laterally, the posterior part of the ventricular floor and runs between the
a tube which is bent in a C-shape, whereby the opening of the ‘C’ Lamina tecti and Tegmentum mesencephali through the mesen-
points rostrally and has a spur-like bulge posteriorly. The upper cephalon to the roof of the IVth ventricle. It is the narrowest point
arm of the ‘C’ is the Cornu frontale [anterius] in the frontal lobe, of the inner cerebrospinal fluid spaces. If it narrows or even closes,
continues as the Pars centralis in the parietal lobes and with the the Ist–IIIrd ventricles can expand through the CSF congestion
Cornu occipitale [posterius] reaches the occipital lobes of the tel- (solid) (› Fig. 11.31).
encephalon. Via a triangular expansion of the tube, the Trigonum
collaterale, there is also a wide-lumen connection in the lower leg Ventriculus quartus
of the ‘C’, which in turn penetrates into the temporal lobes (Cornu The IVth ventricle has similarities with a tent, with its tip directed to
temporale [inferius]). the cerebellum, while the basis points ventrally and is bordered by
The lateral ventricles are an important anatomical landmark on the rhombus pit (rhomboid fossa). The Fossa rhomboidea is bor-
sectional images (CT, MRI) through the telencephalon. The core dered by the cerebellar peduncles (Pedunculi cerebelli) from the
areas of the basal ganglia and clinically important projection fibres pons, and – characterised by the horizontally running Stria medul-
which, in their entirety, form the Capsula interna, are located in laris ventriculi quarti – by the Medulla oblongata (› Fig. 11.21;
the immediate vicinity. Knowledge of the ventricle limits is there- › Chap. 11.1.2). The IVth ventricle has arm-shaped protuberances
fore of high clinical relevance. For a basic understanding, it should on both sides, the Recessus laterales. At the ends, the IVth ventricle
be remembered that even the Nucleus caudatus of the basal ganglia is connected with the outer subarachnoid spaces via the Aperturae
also reaches its final extent by – like the lateral ventricles – follow- laterales ventriculi quarti (Foraminae LUSCHKAE) and via the Ap-
ing the hemispherical rotation so that it abuts the lateral wall of the ertura mediana ventriculi quarti (Foramen MAGENDII), located in
lateral ventricles both in the Crus frontale as well as in the Crus the median plane. However, it also continues caudally into the Ca-
temporale. The thalamus remains as an integral part of the non-ro- nalis centralis of the Medulla oblongata or spinalis.
tating diencephalon mediobasal of the lateral ventricle, but lateral
to the IIIrd ventricle.

NOTE
The structures that have accumulated in the walls of the lateral
ventricles are listed in › Table 11.2.

Ventriculus tertius
The ventriculi laterales (Ist and IInd ventricle) stand on both sides
over the Foramina interventricularia (MONROI) with the un-
paired IIIrd ventricle. The IIIrd ventricle is located between both
parts of the thalami which connect over the Adhesio interthalam- a b
ica, and has characteristic protuberances (› Fig. 11.28): in front of
Fig. 11.31 Liquorrhea in the CT. a CT of a patient with liquorrhea
the rostrally oriented Recessus supraopticus, it binds the Chiasma
through narrowing of the Aqueductus mesencephali. The brain ventri-
opticum to the ventricle, including lowering the floor of the IIIrd cles have been significantly enlarged at the expense of the cerebral
ventricle in the Recessus infundibularis in the infundibular stalk. parenchyma (hydrocephalus). The patient presented with massive
Closely aligned with the Glandula pinealis (pineal gland) are the intellectual impairment and significant gait disturbance. b CT of a
Recessus suprapinealis and the Recessus pinealis. healthy person for comparison. [R317]

609
11 General neuroanatomy

Clinical remarks Table 11.3 Arterial blood supply of the Plexus choroidei.

If too much cerebrospinal fluid is produced or it does not cir- Ventricle Artery
culate or cannot be absorbed, the result is hydrocephalus. A
Ventriculi A. choroidea anterior (from the A. carotis interna)
common cause is an obstruction, allowing the CSF to back up laterales A. choroidea posterior lateralis (from the A. cerebri posterior)
before the constriction (› Fig. 11.31). If such an obstruction
forms before the cranial sutures are occluded, the intracranial Ventriculus A. choroidea posterior medialis
pressure increase can lead to an increase in the circumference tertius (from the A. cerebri posterior)
of the head. Later, the increase in pressure leads to head- Ventriculus A. inferior posterior cerebelli (from the A. vertebralis)
aches, nausea and vomiting, loss of consciousness and visual quartus A. inferior anterior cerebelli (from the A. basilaris)
disturbances, the latter due to congested Papillae nervi optici.
bloodstream and the cerebrospinal fluid: a fenestrated capillary en-
dothelium, the basal membranes of the endothelium or Plexus epi-
thelium, and the choroid plexus epithelial cells connected together
11.4.4 External subarachnoid fluid spaces – via tight junctions. The vessels involved in the formation of the re-
S
­ patium subarachnoideum spective vascular bundles of the choroid plexus are shown sum-
marised in › Table 11.3.
The subarachnoid space is located between the Arachnoidea mater The Plexus choroideus of the lateral ventricles and the IIIrd ventri-
and Pia mater and surrounds the brain and spinal cord. The arach- cle is ‘T’-shaped or ‘↑’-shaped, with the lateral, almost horizontal
noidea straddle the irregularities of the brain surface or base so limbs of the ‘T’ or the lateral extensions of the arrowhead extend-
that it results in enhancements of the subarachnoid space. The larg- ing from the medial side into the Pars centralis and the Cornu tem-
est of these cisterns is the Cisterna cerebellomedullaris, which porale of the lateral ventricles, while the long, vertical leg of the ‘T’
spans the cerebellum and Medulla oblongata. It can be penetrated or the arrow shaft is found in the roof of the IIIrd ventricle (› Fig.
through the Membrana atlantooccipitalis (suboccipital puncture). 11.33). The Plexus choroideus of the IVth ventricle partially pro-
Above the cerebellum, the Cisterna quadrigeminalis expands to trudes from the Aperturae laterales into the subarachnoid space
the quadrigeminal plate, continuing lateral to the pons in the Cis- and is clinically described as BOCHDALEK’s flower basket.
terna ambiens, where it connects rostrally to the Cisterna interpe-
duncularis, located between the Crura cerebri. A multi-chambered Cerebrospinal fluid formation and absorption
system, the Cisterna basalis, consists of smaller expansions of the From its place of formation, the Plexus choroidei and the ependymal
subarachnoid space, especially at the base of the frontal lobe, which layer of all the ventricles, the cerebrospinal fluid circulates through
also includes the Cisterna chiasmatica (› Fig. 11.32). the Foramina interventricularia in the IIIrd ventricle through the
Aqueductus mesencephali (SYLVII) in the IVth ventricle and finally
through the Foraminae laterales and mediana into the subarachnoid
11.4.5 Cerebrospinal fluid space and, thereafter into the outer subarachnoid space (› Fig.
11.32). A small portion is directed into the Canalis centralis of the
The Plexus choroideus and the ependymic cells of the ventricle to- Medulla spinalis, while the main flow passes through the Cisterna
gether form approximately 500 ml CSF a day, i.e., the consistent basalis and the convexity of the telencephalon hemispheres to the
amount of cerebrospinal fluid (approx. 140 ml) is exchanged ap- cerebellum and into the spinal canal. The interaction of different
proximately three times a day. transport mechanisms is thereby described: in addition to an orient-
ed cilia impact of the ependymal cells of the ventricular wall, respira-
Plexus choroideus tory-dependent pressure fluctuations and a pulsatile flow are also
The choroid plexus arches out into the ventricular lumen with its designated by systolic volume changes of the brain. The cerebrospi-
numerous vascular fissures, but is in each case attached to the Pia nal fluid circulates to a small extent through the ependyma into the
mater via the Taeniae choroideae. Like the ependyma, the Plexus extracellular space of the brain or back into the ventricular system. It
epithelium is organised in a one-layered cubic pattern and its sur- is mainly rebsorbed via arachnoid villi, especially via the PACCHIO-
face is covered in microvilli, enlarging it. To protect the brain from NIAN’s granulations at the Sinus sagittalis superior, into the venous
possible harmful effects, there is a blood–CSF barrier between the blood system of the Sinus durae matris. Further drainage paths can

Granulationes arachnoideae Plexus choroideus ventriculi lateralis

Cisterna pericallosa Sinus sagittalis superior

Spatium subarachnoideum Plexus choroideus

ventriculi tertii
Foramen interventriculare*
Cisterna quadrigemina
Ventriculus tertius
Sinus rectus
Cisterna chiasmatica

Cisterna interpeduncularis Confluens sinuum

Aqueductus mesencephali** Plexus choroideus

ventriculi quarti
Ventriculus quartus
Fig. 11.32 Diagram of cerebro-
Apertura mediana ventriculi quarti
Cisterna pontocerebellaris spinal fluid circulation.
∗
Apertura lateralis Cisterna cerebellomedullaris posterior clinically: Foramen MONROI
∗∗
clinically: SYLVIUS canal

610
 11.4 Ventricular system and adjacent structures

Fissura longitudinalis cerebri

Ventriculus lateralis,
Cornu frontale
Corpus callosum, Genu
Cavum septi pellucidi
Fornix, Columna
Septum pellucidum
Foramen interventriculare
Nucleus caudatus, Caput
V. thalamostriata superior
Ventriculus lateralis,
Pars centralis Lamina affixa

Nucleus caudatus, Corpus Taenia fornicis

Capsula interna Plexus choroideus

ventriculi tertii
Nucleus caudatus, Cauda
Tela choroidea
Fornix, Crus ventriculi tertii

Hippocampus V. interna cerebri

Trigonum collaterale V. magna cerebri
Calcar avis Fig. 11.33 Lateral ventricles,
Ventriculi laterales. Top view;
Ventriculus lateralis,
Cornu occipitale after removal of the central part
of the Corpus callosum and the
leg of the fornix.

be found along the blood and lymph canal of the cranial nerves and and Vth lumbar vertebrae, i.e. much lower than the lower end
spinal nerve roots in the spinal canal (› Fig. 11.32). of the spinal cord (Conus medullaris at the level of the Ist or
IInd lumbar vertebra, › Fig. 11.34).
Cerebrospinal fluid composition
The formation of the clear CSF is an active process in which an os-
motic gradient is built up via Na+-K+-ATPases, in which water can
flow through aquaporine canal into the ventricular system. Forma- 11.4.6 Circumventricular organs
tion of cerebrospinal fluid can be reduced by inhibition of the en-
zyme carbonic anhydrase. Usually, CSF contains 99% water with Location
osmolarity comparable to blood, but significantly fewer proteins In addition to the ependymal cells, other individual brain cells lim-
(0.2%) and only a few cells (less than 4 cells/ml). it the subarachnoid space. In some locations of the ventricular sys-
tem, in particular in the IIIrd and IVth ventricles, these types of
cells are so numerous and locally concentrated that they are de-
Clinical remarks scribed as the circumventricular organs (CVO) (› Fig. 11.35).
The composition of the CSF is typically altered in various dis- They are mostly unpaired and are primarily located in the median
eases. In order to be able to explore the cerebrospinal fluid, plane of the brain. Special characteristics of these organs are spe-
the subarachnoid space is punctured with a hollow needle cialised ependymal cells (tanycytes) and fenestrated capillary en-
(lumbar puncture). In most cases, the puncture site is be- dothelium that raise the blood–brain barrier at these points. Tany-
tween the spinous processes of the IIIrd and IVth, or the IVth
cytes have cilia on their apical cell membrane that can make con-
tact with the cerebrospinal fluid.

Spatium epidurale

Spatium subarachnoideum

Dura mater spinalis

Epidural (peridural) anaesthesia

Lumbar puncture

Vertebra lumbalis III

Vertebra lumbalis IV

N. lumbalis [L5], R. anterior

N. lumbalis [L4], R. anterior

Intervertebral disc between

Vertebra lumbalis V and Os sacrum
Fig. 11.34 Puncture locations
for the lumbar puncture and
peridural anaesthesia.

611
11 General neuroanatomy

Plexus choroideus ventriculi tertii

Organum subfornicale
11.5 Cerebral vessels
Organum Thomas Deller
subcommissurale

Glandula pinealis

Organum vasculosum Skills

laminae terminalis
After working through this chapter, you should be able to:
Eminentia mediana
• identify and name the large cerebral arteries on a dissection
Neurohypophysis (brain with meninges)
• divide the large vessels into sections, to explain their path-
Plexus choroideus ventriculi quarti ways outside and inside the skull, and to identify and name
Area postrema their exiting and end branches
• explain the Circulus arteriosus at the base of the brain, to
Fig. 11.35 Circumventricular organs. Mid-sagittal section. draw it from memory and to name its variations
• name the supply areas of the vessels supplying the brain as
The CVOs are divided into: well as the functional areas of the cerebral cortex (after read-
ing the chapter on the Cortex cerebri) and drawing them on a
• sensory CVOs in the narrower sense:
depiction of the brain (superposition of vascular supply and
– Organum subfornicale in the anterior wall of the IIIrd ventricle brain anatomy)
– Organum vasculosum laminae terminalis in the Lamina ter- • name the vessels that supply the different sections of the
minalis immediately dorsal to the Chiasma opticum Capsula interna (central vascular supply) on a horizontal
– Area postrema at the bottom of the rhombus pit section of the brain
• secretory CVOs • recognise the large Sinus durae matris on an opened skull
– Eminentia mediana of the pituitary infundibulum and draw the bridging veins and venous anastomoses on a
depiction of the facial veins
– Glandula pinealis
– posterior pituitary
Organum subcommissurale is formed in humans only in the foe-
tal and newborn phase.
11.5.1 Overview
Function
CVOs are a communication interface between the blood flow with Clinical significance of the vessel anatomy of the brain
its signal substances – such as neuropeptides (including leptin, Every doctor will repeatedly come into contact over the course of
ghrelin), cytokines, glucose or hormones – and the brain or the ce- their professional career with the issues of ‘blood supply to the
rebrospinal fluid. Through their connections to the brainstem and brain’, ‘stroke’ or ‘vascular dementia’. It is therefore of great practical
hypothalamus they are involved in the endocrine and autonomic importance to know the anatomical pathway of the vessels and
regulation of food intake, energy and fluid balance, body tempera- their respective supply area: if it should come to the closure of a ce-
ture and sleep. Accordingly, afferents are found in the subfornical rebral artery and thus to a reduced perfusion (ischemia) of the sup-
organ from the hypothalamus and efferent fibres which stimulate plied brain area, they can no longer fulfil their function. Accord-
vasopressin neurons of the Nuclei paraventricularis and supraopti- ingly, the patient suffers from neurological symptoms which are
cus, thus influencing the regulation of blood volume and blood typical for this brain area. It is therefore also possible to see, for ex-
pressure. The Organum vasculosum laminae terminalis is also ample, along with a motor weakness in the face and arm area as
assigned a special role in the change of body temperature or the well as motor speech disturbances, an infarction of the A. cerebri
development of fever via temperature-sensitive neurons. The Area media if one knows that the A. cerebri media supplies the appro-
postrema in turn, along with the Nucleus tractus solitarii and the priate brain areas.
Nucleus dorsalis nervi vagi are also described as a vagal complex. It In addition, however, progress in medicine and especially in the
picks up signals in the blood or cerebrospinal fluid via chemore- ‘neuro-subjects’ of neurology, neurosurgery, neuroradiology and
ceptors and can cause vomiting via this complex. psychiatry has led to new imaging techniques (e.g. angio-MRI), in-
vasive treatments (e.g. lysis in the event of a stroke) and innovative
neurosurgical techniques that require significantly more knowl-
Clinical remarks edge of the vascular anatomy of the brain than a few years ago. The
The unique nature of the CVOs opens up a wide variety of vessel anatomy of the brain is therefore no longer ‘specialist knowl-
pharmacological treatment approaches. Examples are: edge’, but is required as basic knowledge for many clinical disci-
• Salicylic acid, which acts as a cyclo-oxygenase inhibitor via plines.
a reduced fever-reducing prostaglandin formation: with fe-
vers, the sensitivity of temperature-sensitive neurons of the
Overview of the arterial and venous structures
Organum vasculosum laminae terminalis is reduced, e.g. by
the body’s own prostaglandins. These neurons normally ini- The brain is supplied with blood via 4 arteries with a strong calibre:
tiate physiological cooling mechanisms, which in the case of two Aa. carotis internae (from the A. carotis communis) and two
fever only functions to a delayed extent or not at all. Acetyl- Aa. vertebrales (from the A. subclavia; › Fig. 11.36). The two
salicylic acid reduces prostaglandin formation, increasing Aa. vertebrales join at the level of the brainstem and form the un-
the sensitivity of neurons, readjusts the fever-related set- paired A. basilaris (A. vertebralis/basilaris system; › Fig. 11.37,
point adjustment, and clinically reduces fever. › Fig. 11.38, › Fig. 11.39). From the two Aa. carotes internae and
• Neuroleptics for treatment of central vomiting (emesis), e.g.
the A. basilaris, on the basal side of the brain, the polygonal arterial
due to administration of opioids: neuroleptic drugs bind to
dopamine receptors in the Area postrema and thus have an arches, the Circulus arteriosus cerebri (WILLISII, circle of ­WILLIS)
antiemetic effect. are created; › Fig. 11.37, › Fig. 11.38, › Fig. 11.39). The brain
vessels for the two hemispheres exit from these. The supply areas of

612
 11.5 Cerebral vessels

A. callosomarginalis A. cerebri media

A. carotis interna,
A. cerebri anterior Pars cerebralis

A. communicans posterior
A. carotis interna,
Pars cerebralis A. cerebri posterior

A. inferior anterior cerebelli

A. ophthalmica A. basilaris

A. inferior posterior cerebelli

Siphon caroticum

A. carotis interna,
A. vertebralis
Pars cavernosa
A. carotis interna, Pars cervicalis
A. carotis interna,
Pars petrosa Fig. 11.36 Internal arteries of
A. carotis externa
the head. The brain is supplied
A. carotis communis by 2 Aa. carotes internae and 2
Aa. vertebrales.

A. cerebri anterior (ACA)

A. communicans
anterior (ACom)
A. striata medialis distalis
Aa. centrales (A. centralis longa [HEUBNER])
anteromediales
(from ACA) A. ophthalmica
Aa. centrales A. carotis
anteromediales interna (ICA)
(from ACom)
A. hypophysialis
superior A. cerebri
media (MCA)

Aa. centrales
posteromediales
(from PCom)
Aa. centrales Aa. centrales antero-
A. choroidea
posteromediales laterales (from MCA)
anterior
(from PCA)
A. communicans
A. cerebri posterior posterior (PCom)
(PCA)
Aa. choroideae
posteriores

A. superior
Aa. centrales
cerebelli (SCA)
postero-
laterales
(from PCA)

Aa. pontis
A. basilaris (BA)

A. labyrinthii

A. inferior anterior
cerebelli (AICA)

A. vertebralis (VA)

A. inferior posterior
cerebelli (PICA)
Fig. 11.37 Circulus arteriosus
A. spinalis anterior A. spinalis posterior cerebri (WILLISII, circle of
W
­ ILLIS); Diagram.

613
11 General neuroanatomy

A. communicans anterior Bulbus olfactorius

A. frontobasalis lateralis A. frontobasalis medialis

A. cerebri anterior, Tractus olfactorius

Pars precommunicalis
[II]
Area subcallosa
A. carotis interna
A. cerebri media,
Pars sphenoidalis A. communicans posterior

Insula [Lobus insularis] [III]

A. cerebri media, A. cerebri posterior,

Pars insularis Pars postcommunicalis

A. choroidea anterior A. superior cerebelli

Substantia perforata [V]

posterior
A. labyrinthi
A. cerebri posterior,
Pars precommunicalis [VII]

A. superior [VIII]
cerebelli
[IX]
A. basilaris
A. inferior anterior cerebelli
[VI]
[X]
[XII]
[XI]
A. vertebralis
A. inferior posterior cerebelli
A. spinalis anterior

Fig. 11.38 Arteries of the brain on the Facies inferior of the brain. The vessels supplying the brain are shown in their typical topographic con-
texts. For a better illustration of the pathway of the A. cerebri media, a section of the temporal lobe has been separated on the right. For better
visibility of the A. cerebri posterior, the right half of the cerebellum was removed.

the cerebral arteries (see below, topography and supply areas of the Clinical remarks
arteries) are not dependent on the anatomical lobe boundaries. The ischemic tolerance of the brain amounts to a maximum of
Therefore, for example, the A. cerebri media supplies parts of the 7–10 min. This is of great relevance to the resuscitation of pa-
Lobus frontalis, Lobus parietalis and the Lobus temporalis. tients in the event of a cardiac arrest.
The supply of the brain depends on the arterial blood flow through Even if the blood flow to the brain only temporarily decreases
the large arteries supplying the brain. In healthy patients with a typi- (e.g. when suddenly getting up or standing up straight), there
cal Circulus arteriosus (› Fig. 11.37, › Fig. 11.38, › Fig. 11.39), may be a temporary decreased blood flow to the brain that
could result in a lack of function. The patient drops to the
angiographic examinations allow 3 flow sectors to be identified: the
ground (syncope or fainting). Due to the horizontal position of
A. carotis interna therefore supplies the equilateral hemisphere on the body, the cerebral blood flow improves rapidly and the pa-
one side as a rule, with the exception of the Lobus occipitalis and tient wakes up after a short time.
parts of the Lobus temporalis (Carotis-interna flow area). The
A. vertebralis/basilaris system on the other hand supplies the brain-
stem, the cerebellum and the remaining hemispherical sections on The global blood flow through the brain is kept constant within
both sides (vertebralis/basilaris flow area). However, the flow areas of certain blood pressure limits (about 80–120 mmHg) by the dilata-
the vessels may differ from this ‘normal situation’ in individual pa- tion and contraction of the resistance vessels. This also increases/
tients due to congenital vascular variations and/or vascular disease. decreases the blood pressure in the brain. The regional blood flow
The venous drainage of the blood from the brain is carried out in- is controlled – regardless of the global blood pressure – by local
dependently of the arteries via the venous canal of the Dura mater, metabolic factors. These are very closely linked to the local activity
the Sinus durae matris (› Fig. 11.40, › Fig. 11.59). These receive of the nerve tissue. Nerve cells are very active, they increase the K+,
the blood via a superficial and a deep venous system: the veins on the CO2 and the H+ concentration (acidosis) in their environment.
the brain surface flow directly through bridging veins, i.e. through This leads to localised vessel dilatation.
the meninges and on to a sinus, whereas the veins collect blood
from the depths of the brain in the unpaired V. magna cerebri (vein
of GALEN), which is connected to the network of the S­ inus durae
Clinical remarks
matris via the Sinus rectus. The relationship between nerve cell activity and circulation is
used in functional imaging (functional MRI; fMRT). The BOLD
Blood flow to the brain contrast (BOLD = blood oxygenation level-dependent) de-
The brain is traversed by approx. 15% of the cardiac output, which scribes the change of the image signal depending on the oxy-
gen content of erythrocytes: the stronger the nerve cell activity
gives it a continuous supply of oxygen and glucose. Without this
in an area, the more oxygen is consumed there and the more
blood supply, brain function will fail within minutes as the brain
does not have its own oxygen or glucose reserves.

614
 11.5 Cerebral vessels

A. cerebri media [II] A. carotis interna, Pars cerebralis

A. ophthalmica Pars postcommunicalis
A. cerebri anterior
Pars precommunicalis
[IV] [VI] A. communicans anterior
Canalis opticus
Hypophysis
[V/1]
Proc. clinoideus anterior
[III]
Proc. clinoideus posterior
A. carotis interna, Pars cavernosa
A. cerebri posterior
[V/2]
A. communicans posterior Sulcus caroticus

Plexus caroticus internus Foramen lacerum

[V/3] Foramen ovale
Apex partis petrosae
A. cerebri Pars precommunicalis Canalis caroticus
posterior Pars postcommunicalis
Foramen spinosum
A. meningea media
A. superior cerebelli
A. basilaris
A. labyrinthi A. inferior anterior cerebelli
[VII]
Porus acusticus internus
[VIII]
Foramen jugulare
[XI]
A. vertebralis
[X]
[IX] Sulcus sinus sigmoidei
Sinus sigmoideus A. spinalis anterior
[XII] A. inferior posterior cerebelli
Medulla oblongata
Pia mater cranialis
Spatium subarachnoideum Foramen magnum
Arachnoidea mater cranialis Sinus occipitalis
Dura mater cranialis

Fig. 11.39 Arteries of the brain in topographical connection with the cranial base. On the right side, a part of the A. carotis interna is
removed. In vivo, the underlying Foramen lacerum is closed by a fibrous cartilage plate.

Anastomotic vein of TROLARD V. thalamostriata superior

V. emissaria parietalis
Vv. superiores cerebri
Sinus sagittalis inferior
Foramen interventriculare
V. interna cerebri
(V. emissaria frontalis)
Sinus sagittalis superior

Vein of LABBÉ V. magna cerebri*

Sinus sphenoparietalis V. basalis**

V. ophthalmica superior Sinus rectus

V. angularis
V. emissaria occipitalis

Sinus cavernosus Confluens sinuum

V. occipitalis
V. ophthalmica inferior
V. emissaria mastoidea
Plexus venosus foraminis ovalis
Sinus sigmoideus

Bulbus superior venae jugularis

Plexus pterygoideus

V. facialis
V. jugularis interna
V. retromandibularis

Fig. 11.40 Inner and outer veins of the brain. The cerebral veins collect the blood in a superficial and deep venous system. From there, it flows
into the Sinus durae matris and the V. jugularis interna. ∗ Vein of GALEN, ∗∗ Basal vein of ROSENTHAL

615
11 General neuroanatomy

the regional blood flow increases (see above), the more oxy- Clinical remarks
genated haemoglobin is supplied to this area. This manifests
itself in a measurable increase in signal in the area of activat- A continuous and complete Circulus arteriosus reduces the
ed adjacent brain tissue. With an fMRT, you can thus identify risk of stroke in patients with an imminent closure of the A.
regions of the brain, e.g. it is activated when learning. carotis interna.

Nomenclature Connections to the A. carotis externa

Naming the cerebral arteries is – as is so often the case in anatomy The A. ophthalmica is the first major intracranial branch of the
– done according to tradition. The names were usually chosen on A. carotis interna (› Fig. 11.36, › Fig. 11.39). Its terminal branch,
the basis of topographical relationships and describe only the ap- the A. dorsalis nasi, forms an anastomosis with the A. angularis, a
proximate area of the CNS that is supplied by the artery. The terminal branch of the A. facialis (from the A. carotis externa).
A. cerebri anterior therefore originates, e.g. in the front (anterior), Thus, the flow areas of the internal carotid artery and the external
from the Circulus arteriosus cerebri, but then runs with its main carotid artery are connected with each other, with the blood nor-
branches dorsally and supplies large areas of the frontal and pari- mally flowing from the A. dorsalis nasi into the A. angularis.
etal cortex in the area of the hemispherical rim. Although the
A. superior cerebelli runs above the cerebellum, it also supplies
functionally important sections of the brainstem with its branches
Clinical remarks
– which is why a combined occlusion of the cerebellum and brain- If the A. carotis interna is closed on one side, the blood flow in
stem occurs when the artery is occluded. the A. angularis can reverse direction, i.e., the blood then
In addition to the international anatomical nomenclature, abbrevi- flows from the A. angularis via the A. dorsalis nasi and the A.
ations derived from the English names of the vessels are often ophthalmica into the Circulus arteriosus. This flow reversal
can be diagnosed with a doppler ultrasound (› Chap. 11.5.9).
used in clinical practice (e.g. PICAS = posterior inferior cerebellar
artery; also › Table 11.6).

Individual differences in the blood supply Connections of the superficial arteries of the hemispheres
The brain shows – as with many other organs – variations in its The terminal branches of the superficial arteries supplying the
blood supply. These can either be congenital or acquired. A con- brain form leptomeningeal anastomoses in the area of the hemi-
genital variant is, for example, the duplication of the A. cerebri an- spheres of the cerebellum – even over the Corpus callosum (anas-
terior dextra (the person in question would therefore have 3 Aa. tomoses between terminal branches of both Aa. cerebri anteriores,
cerebri anteriores). It is also possible that not all the vessels are often between the Aa. callosomarginales and Aa. pericallosae of
formed. In the case of acquired changes of vessels, the diameter of both sides). However, these anastomoses are not sufficient to com-
an existing vessel is normally changed, e.g. if the A. communicans pletely take over the blood supply in the event of acute under-per-
posterior is expanded in the event of an occlusion of the A. carotis fusion of a brain-supplying vessel. It leads to ischemic cerebral in-
interna, and the A. cerebri media is supplied via the vertebral ar- farction. These vessels supplying the brain are therefore referred to
tery/basilaris flow area. as ‘functional end arteries’. Nevertheless, the leptomeningeal collat-
erals are not unimportant, because the collateral supply means the
area of the infarct is not as large as it would be in the case of a cere-
Clinical remarks bral infarct without this collateral supply. Furthermore, the collat-
The variability of vessels supplying the brain also leads to a erals supply the surroundings of the infarct (penumbra), so that
variability of the supply areas. Accordingly, it may be the case this tissue, in the event of a re-opening of the closed vessel (e.g. by
with occlusion of an atypical vessel that clinical stroke symp- dissolution of a blood clot, ‘thrombolysis’), can survive. However,
toms may occur, which cannot be explained initially by ‘text- this has to be done quickly: ‘Time is brain’.
book anatomy’.

NOTE
Functional terminal arteries and end arteries
Anastomoses and terminal arteries A vessel without anastomoses with other vessels is regarded as an
It is of great practical importance to determine in the case of the end artery (terminal artery). Its occlusion leads to an infarct of the
under-perfusion of a vessel, how well the blood flow in the capil- supplied areas. In the case of an existing but largely insufficient
lary bed can be maintained by vascular connections (collaterals) to supply by anastomoses with other vessels, one speaks of function-
other vessels. The brain has a whole series of collateral connections, al end arteries. The brain contains both forms of end arteries.
the most important of which are listed below.

Circulus arteriosus cerebri (WILLISII, circle of WILLIS) Central blood supply

The Circulus arteriosus (› Fig. 11.37, › Fig. 11.39) is only seen After their departure from the main vessel, the central vessels (e.g.
in its ideal form – with all around, end-to-end and communicating Aa. centrales anteromediales) do not form any other significant
vessels – in about half (approx. 45%) of all autopsy studies. In the collateral. They are considered to be terminal arteries in the tradi-
other cases, variations were observed, with the most frequent tional sense. Their occlusion leads to ischemia and tissue loss in
changes (about 20–30%) involving the A. communicans posterior their supply area.
and the A. cerebri posterior.

616
 11.5 Cerebral vessels

Clinical remarks dorsolaterally of the A. carotis externa in approx. 50% of the cases.
However, because of this variability in the output, it cannot be said
The word ‘stroke’ describes clearly that a patient is ‘struck
with certainty which of the two carotids is ‘inside’ and which is
down’ if they, for example, fall due to a sudden motor paraly-
sis. The most common causes of a stroke are acute circulatory ‘outside’ and, in ultrasound examinations, the anatomical fact that
disorder (ischemia, 80–90% of the cases), acute bleeding in the A. carotis interna – in contrast to the A. carotis externa – has
the brain (intra-cerebral haemorrhage, approx. 10%) or a sub- no branches in the neck area (› Fig. 11.41) is used to identify it.
arachnoid haemorrhage (approximately 3%). The Pars petrosa starts where it enters the petrous bone. The
The first and most important diagnostic measure is a CT of the A. carotis interna runs in the Canalis caroticus and drains over the
brain, in order to find out whether bleeding or ischemia is re- Foramen lacerum, which is sealed with fibrous cartilage. Along its
sponsible for the neurological symptoms. The advantage of CT
pathway, there are smaller branches to the tympanic cavity
compared to the MRI is the short time it takes and the associ-
ated time profit (see below). (Aa. caroticotympanicae; › Fig. 11.41).
In the case of ischemia, which is created by a thrombus, you After leaving the petrous bone, the A. carotis interna runs through
can try to dissolve the thrombus within the first few hours by the venous chamber system of the cavernous sinus (Pars caverno-
pharmacological means (thrombolysis). The success of this sa, › Fig. 11.42). It lies first on the lateral surface of the Corpus
treatment depends on the duration of the disruption to the ossis sphenoidale and then runs upwards in the Sulcus caroticus.
blood supply (‘time is brain’), which is why in many hospitals Below the Proc. clinoideus posterior it turns forward and runs hori­
specialist stroke stations (stroke units) have been set up.
zontally to the Proc. clinoideus anterior. This lies directly under-
How­ever, in the case of bleeding, a thrombolysis is obviously
contraindicated. Therefore, a quick review of the cause of a neath the N. opticus. Along its pathway, the A. carotis interna pro-
stroke (either bleeding or ischemia) is of paramount impor- vides smaller branches to the meninges, to the Ganglion trigemi-
tance for the fate of the patient. nale and to the pituitary gland (A. hypophysialis inferior) (› Fig.
11.41).
The Pars cerebralis begins where the A. carotis interna leaves the
dura and enters an extension (cistern) of the subarachnoid space,
which is named after it (Cisterna carotica). It moves back again oc-
11.5.2 A. carotis interna and its branches cipitally and laterally for a short distance and comes to lie under
the Substantia perforata anterior. There, it divides into 2 terminal
Large parts of the anterior telencephalon and diencephalon are branches. Along its pathway there are 4 vessels (› Fig. 11.41):
supplied by the A. carotis interna. The anatomy of this vessel is of • A. ophthalmica (below the N. opticus; › Fig. 11.39)
great clinical importance (duplex ultrasound of the neck vessels; • A. hypophysialis superior
angiography). Anatomically, a distinction is made between 4 sec- • A. choroidea anterior
tions (› Fig. 11.41): • A. communicans posterior
• Pars cervicalis – ‘throat’: from the Bifurcatio carotidis to the The loop-shaped (‘S-shaped’) pathway of the Pars cavernosa and
skull entry Pars cerebralis near the Proc. clinoideus anterior resembles a cork-
• Pars petrosa – ‘rock’: in the Bifurcatio carotidis of the temporal screw or a siphon. Therefore, this section is described as a carotid
bone siphon. Approximately at the level of the knee of the siphon or
• Pars cavernosa – ‘cavity’: in the Sinus cavernosus shortly after, the A. ophthalmica exits the A. carotis interna
• Pars cerebralis – ‘brain’: in the subarachnoid space it is divided (› Fig. 11.41).
into 2 terminal branches, A. cerebri anterior and A. cerebri me-
dia NOTE
The internal carotid artery
Topography • is formed at the level of the IVth cervical vertebra
The cervical part begins with the carotid fork, which is usually at • leaves dorsolaterally from the A. carotis communis in 50% of cas-

the level of the IVth cervical vertebra. The A. carotis interna lies es
• has no vascular outflow in the throat area
• is divided into 4 anatomically defined sections: Pars cervicalis,
Pars petrosa, Pars cavernosa, Pars cerebralis
A. cerebri anterior A. cerebri media • forms an S-shaped loop system (carotid syphon)
Pars cerebralis A. choroidea anterior • has the A. ophthalmica as the first larger vascular branch
• branches into the A. cerebri anterior and the A. cerebri media
A. ophthalmica A. communicans posterior
• supplies the pituitary gland, the trigeminal ganglion, the eye, and
R. meningeus
** the anterior parts of the telencephalon and the diencephalon
A. hypophysialis superior Rr. basales tentorii

* Pars cavernosa
Rr. ganglionares trigeminales Aa. caroticotympanicae Branches of the A. carotis interna
R. meningeus The branches (direct vessel outflow) of the A. carotis interna are:
A. hypophysialis inferior
Pars petrosa • Aa. hypophysiales: The A. hypophysialis inferior originates
Apertura externa from the Pars cavernosa and essentially supplies the neurohy-
Apertura interna canalis carotici canalis carotici
pophysis. The Aa. hypophysiales superiores from the Pars cere-
A. canalis pterygoidei Pars cervicalis
bralis (› Fig. 11.41) supply the infundibulum. The portal veins
of the pituitary gland (Vv. portales hypophysiales) develop from
Fig. 11.41 Sections of the A. carotis interna. No branches exit from
the Pars cervicalis, which is why the artery can be safely distin- their capillary system, leading to the adenohypophysis (› Chap.
guished from the A. carotis externa during an ultrasound examination 11.2.2) and form a second capillary network around their endo-
of the neck organs. [E402] ∗ Carotid passage, ∗∗ through the Dura crine cells (vascular transport system for hypothalamic control
mater cranialis in the area of the Diaphragma sellae. hormones to the adenohypophysis).

617
11 General neuroanatomy

Diaphragma sellae Infundibulum

Chiasma opticum
Sinus intercavernosi
[II]
Sinus cavernosus
A. ophthalmica
[III]
A. carotis interna, Pars cerebralis
A. carotis interna, Pars cavernosa

[IV]
Hypophysis
[Glandula pituitaria]
[VI]

[V/1]
Sella turcica, Fossa hypophysialis
Dura mater cranialis

[V/2] Sinus sphenoidalis

Fig. 11.42 Pars cavernosa of the A. carotis interna. In the chamber system of the Sinus cavernous are the A. carotis interna and N. abducens
[VI]. In the wall of the sinus are the N. oculomotorius [III], N. trochlearis [IV], N. ophthalmicus [V/1] and N. maxillaris [V/2]. There are topograph-
ical relationships to the pituitary gland and the Sinus sphenoidalis.

• A. ophthalmica: The eye and parts of the viscerocranium are Bifurcation of the A. carotis interna into its terminal branches
supplied via the A. ophthalmica. It is the first major arterial The A. carotis interna crosses the Area perforata anterior and di-
branch of the A. carotis interna. It runs through the Canalis ner- vides into its two main branches at the medial end of the Sulcus
vi optici together with the N. opticus (› Fig. 11.39). One of its lateralis. The midbrain artery, the A. cerebri media, thereby follows
terminal branches penetrates into the N. opticus as the A. cen- the original pathway of the A. carotis interna, while the front brain
tralis retinae and reaches the retina of the eye. Another terminal arteries, A. cerebri anterior, bend almost at a right angle from the
branch (A. dorsalis nasi) forms an anastomosis with the A. facia- A. carotis interna and pull anteromedially towards the Fissura lon-
lis. gitudinalis cerebri (› Fig. 11.38, › Fig. 11.39).
• A. communicans posterior (› Fig. 11.37, › Fig. 11.38, › Fig.
11.41): It sends branches into the brain and supplies parts of the A. cerebri anterior
thalamus and third ventricle (Aa. centrales posteromediales; A. The A. cerebri anterior (› Fig. 11.38, › Fig. 11.43) provides the
thalamotuberalis). It extends to the occipital via the Tractus op- front part of the medial hemisphere area and a cortical strip paral-
ticus and reaches the A. cerebri posterior anteriorly to the N. oc- lel to the hemispheral rim. It sends branches inside the brain to
ulomotorius [III]. supply the Capsula interna (parts of the Crus anterius) and the bas-
• A. choroidea anterior (› Fig. 11.37, › Fig. 11.38, › Fig. al ganglia. From its distribution site, it runs anteromedially to the
11.41): It supplies important parts of the inside of the brain (in- Fissura longitudinalis cerebri (› Fig. 11.38). It connects there with
cluding the Crus posterius of the Capsula interna) as well as the A. cerebri anterior of the opposite side via the A. communi-
parts of the visual system (Tractus opticus, Corpus geniculatum cans anterior. As it continues, it winds around the Corpus callo-
laterale), the Plexus choroideus, amygdala and hippocampus. sum and finally splits into two main branches (› Fig. 11.43), the
There are also branches into the mesencephalon. The A. cho- A. pericallosa (between the Corpus callosum and Gyrus cinguli)
roidea anterior runs along the Tractus opticus, winds around the and the A. callosomarginalis (via the Sulcus cinguli). Branches of
uncus of the temporal lobe and reaches the lateral ventricle. the A. cerebri anterior are:
• Aa. centrales anteromediales: They branch off early in the ini-
tial section of the A. cerebri anterior and pass through the Subs­
Clinical remarks tantia perforata anterior into the interior of the brain to the hy-
From atherosclerotic changes of the internal carotid artery, pothalamus, fornix and the Lamina terminalis.
small thrombi can occur. If a thrombus is flushed into the • Backwards-running A. striata medialis distalis (recurrent ar-
A. ophthalmica and from there into the A. centralis retinae, it tery of HEUBNER, A. centralis longa): It also originates from
can most commonly lead to a sudden, painless unilateral the initial section of the A. cerebri anterior (› Fig. 11.47) – as a
blindness. If this thrombus is dissolved, then this blindness
rule, it emerges at the level of the A. communicans anterior or
(amaurosis) is only fleeting (fugax). But it is an important sign
of a cerebral circulatory disorder and can be a warning of a from the immediately adjacent vascular segment of the A. cere-
major stroke. bri anterior. It forms a backward loop, runs antiparallel to the
During the foetal period, all 3 (!) cerebral vessels are supplied A. cerebri anterior back to the Substantia perforata anterior and
with blood by the A. carotis interna. After the A. cerebri poste- supplies the anterior horn of the Capsula interna as well as parts
rior connects with the vertebralis/basilaris flow area, how­ of the basal ganglia (› Fig. 11.47).
ever, the original vascular trunk of the A. cerebri posterior is • A. polaris frontalis: It flows to the anterior brain sections.
stunted and continues as a remnant of a mostly thin A. com-
The A. communicans anterior (› Fig. 11.37, › Fig. 11.38) con-
municans posterior. In 20% of cases, however, the foetal ves-
sel situation is also detectable in adults (‘foetal form of the nects the two Aa. cerebri anteriores with each another. It can be
A. cerebri posterior’). In these cases, the A. cerebri posterior is fenestrated dually and is only about 5 mm long. This vessel also
part of the A. carotis interna flow area. supplies the Chiasma opticum with superficial branches and sends
central branches into the depths of the brain, e.g., to the Gyrus
­cinguli, the hypothalamus and the septum region.

618
 11.5 Cerebral vessels

Adhesio interthalamica Fornix, Corpus

Corpus callosum
Plexus choroideus ventriculi tertii
Foramen interventriculare
Sulcus centralis
Septum pellucidum
Tela choroidea ventriculi tertii
Corpus callosum, Genu

A. callosomarginalis Thalamus

A. pericallosa
Glandula pinealis

Commissura anterior Sulcus parieto-occipitalis

Lamina terminalis V. magna cerebri

Hypothalamus
A. parieto-occipitalis
A. cerebri anterior,
Pars precommunicalis
Sulcus calcarinus
A. communicans anterior
A. calcarina
Chiasma opticum

A. carotis interna A. cerebri posterior,

A. occipitalis medialis
Hypophysis

A. basilaris Aqueductus mesencephali

Pons Tectum mesencephali

A. vertebralis

Fig. 11.43 A. cerebri anterior. The A. cerebri anterior initially provides the A. communicans anterior to the opposite side and then passes
­dorsally around the Corpus callosum. The Lobus occipitalis is supplied by the A. cerebri posterior.

Clinical remarks laterally and delivers the Aa. centrales anterolaterales in its open-
ing section to supply the inner brain (› Fig. 11.37, › Fig. 11.47).
Vascular bulges (aneurysms) are not uncommon in the area of Via the medial end of the Sulcus lateralis, it enters the Fossa latera-
the Circulus arteriosus. The most common are aneurysms of
the A. communicans anterior (up to 40 %). When performing
lis and separates into several terminal branches over the island, the
surgery on an aneurysm in this area, care should be taken that insula (› Fig. 11.38, › Fig. 11.44, › Fig. 11.45). These vessels are
the artery of HEUBNER is not damaged. The central branches named after their respective supply area (e.g. the A. sulci centralis
of the A. communicans anterior must also be looked after runs in the Sulcus centralis).
during the operation, as otherwise – fortunately temporary for
the most part – a postoperative memory disturbance (A. com-
municans anterior syndrome) may occur. 11.5.3 Aa. vertebrales/A. basilaris and their branches

A. vertebralis
A. cerebri media The posterior sections of the cortex, the cerebellum and the brain-
The A. cerebri media (› Fig. 11.44) supplies the largest part of the stem are mainly supplied by blood vessels from the vertebrobasilar
lateral brain surface, the insula and – with central branches – the flow area (› Fig. 11.37, › Fig. 11.38, › Fig. 11.39, › Fig. 11.46).
Capsula interna (parts of the Crus anterius, genu) and the basal Similar to the A. carotis interna, you can differentiate 4 sections in
ganglia. At first it continues the pathway of the A. carotis interna the A. vertebralis:

A. sulci precentralis A. sulci centralis

A. sulci postcentralis
A. prefrontalis
A. parietalis posterior

Main stem of the

R. gyri angularis
Rr. terminales
superiores
R. temporalis
posterior
A. frontobasalis

R. temporalis Fig. 11.44 A. cerebri media on

Insula medius the Facies lateralis cerebri. The
A. cerebri
Main stem of the temporal lobes have been
anterior
Rr. terminales inferiores pulled down into the Sulcus lat-
A. carotis eralis with a hook, which gives
R. temporalis
interna A. cerebri anterior
you a view into the Fossa latera-
media lis with the A. cerebri media and
its branches. [L127]

619
11 General neuroanatomy

A. frontobasalis medialis

Ventriculus lateralis,
Cornu frontale
A. cerebri anterior

V. anterior septi pellucidi

A. cerebri media

Lamina affixa
Capsula interna
V. thalamostriata Fig. 11.45 A. cerebri media,
A. choroidea anterior
superior choroidal arteries and internal
veins of the brain. By removing
V. interna large areas of the brain, the Fos-
Plexus choroideus cerebri sa lateralis (left) and the lateral
ventricles open up. In the Fossa
lateralis, the A. cerebri media
Tela choroidea
R. choroideus
ventriculi tertii
branches off. In the lateral ven-
posterior
tricles, the A. choroidea anterior
(coming from the front below;
A. cerebri posterior
V. magna cerebri from the A. cerebri interna) and
Aa. choroideae posteriores late-
Sinus sagittalis inferior
rales (coming from dorsal; from
Glomus choroideum the A. cerebri posterior) form a
plexus of vessels. The inner
Falx cerebri venous system is shown on the
Tentorium cerebelli right side in the vicinity of the
Sinus sagittalis superior
Tela choroidea of the third ven-
tricle.

• Pars prevertebralis: from the A. subclavia (passing at the level NOTE

of BWK I) to the Foramen transversarium HWK VI The A. vertebralis
• arises as a branch of the A. subclavia at the level of the first tho-
• Pars transversaria: within the Foramina transversaria of HWK
racic vertebral body
VI–II • is divided into 4 anatomical sections: Pars prevertebralis, Pars
• Pars atlantica: from the transition to the atlas and arch of the vertebralis, Pars atlantica, Pars intracranialis
atlas to the passage through the Foramen magnum • merges at the level of the pontomedullary junction with the verte-
• Pars intracranialis: intracranially up to where it joins the bral artery of the opposite side to the unpaired, central A. basilaris
A. basilaris • supplies the brainstem, the cerebellum and the occipitotemporal
sections of the brain
• can be examined by ultrasound in the Trigonum arteriae vertebralis
Topography
The Partes prevertebralis and transversaria are described in
› Chap. 3.3.2. The Pars atlantica starts with the outlet of the ver-
tebral artery from the Foramen transversarium of the IInd cervical Branches of the A. vertebralis
vertebra. The artery initially forms an arc (‘vertebral siphon’, re- Along its pathway, the A. vertebralis provides numerous branches
serve length for movements in the atlantoaxial joint), passes to the neck muscles, to the meninges and to the spinal cord (Rr. spi-
through the Foramen transversarium of the first cervical vertebra, nales; › Fig. 11.37). Critical vessels of the intracranial section are:
then turns dorsally and finally medially via the Sulcus arteriae ver- • A. inferior posterior cerebelli (› Fig. 11.38, › Fig. 11.46):
tebralis of the posterior atlas. It breaks through the Membrana at- This artery is considered to be the most variable cerebral vessel,
lantooccipitalis posterior and reaches the Foramen magnum as the origin and extent of the supply area are very different on
(› Fig. 11.46). This is the start of the Pars intracranialis. The an individual basis. They can even be missing. As a rule, it
A. vertebralis runs dorsally to anteromedially around the Medulla emerges from the A. vertebralis at the level of the olive, travels
oblongata and joins approximately at the level of the pontomedul- along the brainstem and forms a radiologically very characteris-
lary transition to the unpaired A. basilaris. Along its pathway it tic loop (caudal loop) in the vicinity of the cerebellar tonsils, be-
provides the A. spinalis anterior and the A. inferior posterior fore passing through the vallecula of the cerebellum (Vallecula
cerebelli (› Fig. 11.38, › Fig. 11.39, › Fig. 11.46). cerebelli) vermis and hemispheres of the lower cerebellum
(› Fig. 11.46). Along its course it supplies parts of the Medulla
oblongata and of the posterior and lower cerebellum (posteroin-
Clinical remarks ferior parts). There is often also an A. spinalis posterior for the
A doppler examination of the A. vertebralis is quite possible supply of the spinal cord. However, this can also originate direct-
on the atlas (Pars atlantica). It lies there in the depth of a trian- ly from the A. vertebralis (about 25%).
gle, spanned by three short neck muscles (M. rectus capitis • A. spinalis anterior: It originates just before the confluence of
posterior major; M. obliquus capitis superior; M. obliquus ca- the Aa. vertebrales (› Fig. 11.37, › Fig. 11.48), moves caudally
pitis inferior). With the head leaning forward, the direction of
and merges approximately at the level of the Foramen magnum
blood flow through the A. vertebralis can be easily determined.
with the A. spinalis anterior of the opposite side. It supplies the
ventral parts of the spinal cord (see also, vascular supply of the
spinal cord).

620
 11.5 Cerebral vessels

Plexus choroidei ventriculorum lateralium Corpus geniculatum mediale

Corpus geniculatum laterale A. choroidea posterior lateralis

Columna fornicis A. choroidea posterior medialis

A. choroidea anterior Tectum mesencephali

Corpus callosum A. cerebri posterior (PCA)

A. cerebri media (MCA) R. parieto-occipitalis

A. communicans posterior (PCom) R. calcarinus

A. cerebri anterior (ACA) Rr. temporales

a. cerebri posterioris
[II]
A. superior cerebelli
A. ophthalmica
[IV]
Siphon caroticum
[V]
A. cerebri posterior (PCA)
[VIII]
A. carotis interna (ICA)
[VII]
[III]
[IX]
A. basilaris (BA) A. inferior posterior
cerebelli
Aa. pontis
A. spinalis posterior
[VI]
A. vertebralis (VA)
A. inferior anterior cerebelli
[XI]
A. labyrinthi
[X]
A. spinalis anterior

Fig. 11.46 Arteries of the posterior cranial fossa. The A. vertebralis, A. basilaris and their branches supply the upper spinal cord, the brain-
stem and the cerebellum. [L127]

A. basilaris posterior run parallel laterally and dorsally, while the A. superior
Topography cerebelli goes below the tentorium and the A. cerebri posterior
The A. basilaris originates from the Aa. vertebrales approximately above the tentorium. The A. superior cerebelli supplies the up-
at the level of the gap between the pons and the Medulla oblongata. per parts of the cerebellum and, with branches to the brainstem,
It runs along the middle of the pons and its branches supply large the dorsal pons.
parts of the brainstem and the cerebellum. At about the level of the
mesencephalon (Cisterna interpeduncularis), it splits back into 2 NOTE
vessels, the posterior cerebral arteries, Aa. cerebri posteriores The A. labyrinthi runs through the Meatus acusticus internus and
(› Fig. 11.38, › Fig. 11.39). supplies the inner ear. As a rule it is a branch of the A. inferior an-
terior cerebelli, but it can also originate from the other cerebellar
Branches of the A. basilaris arteries or the A. basilaris.
The branches of the A. basilaris are:
• A. inferior anterior cerebelli (› Fig. 11.38, › Fig. 11.46): It
originates in the lower portion of the A. basilaris and moves pos-
Clinical remarks
teriorly and externally (posterolateral pathway). In doing so, it Circulatory disorders of the Aa. pontis can cause the motor fi-
usually lies ventrally of the cranial nerves VI, VII and VIII and bre tracts in the ventral pons to fail and lead to acute paraple-
runs with the N. facialis [VII] and the N. vestibulocochlearis gia. Since the dorsal portions of the pons are supplied by
[VIII] to the Meatus acusticus internus. Here it often forms a branches of the A. superior cerebelli, these sections in which
there are important regions for consciousness (e.g. Formatio
sling for the outflow of the A. labyrinthi (› Fig. 11.39). It then
reticularis) and for eye movements, remain functional.
moves on to the cerebellum, supplying it underneath and, with Locked-in-patients are therefore typically fully aware and not
branches, the lateral sections of the pons as well. The area of sup- cognitively restricted. They are however completely paralysed
ply of the A. inferior anterior cerebelli depends on the size of the and can communicate with their environment only by blinking
area of supply of the A. inferior posterior cerebelli. or eye movements.
• Aa. pontis (› Fig. 11.38, › Fig. 11.46): These vessels arise di- The idea of being trapped in one's own body with full mental
rectly from the A. basilaris and supply the ventral portions of the clarity has led to numerous literary debates on the subject. A
famous case is that of the French journalist Jean-Dominique
pons as short Rr. mediales or as longer Rr. laterales.
Bauby, who at the age of 43 years suffered a stroke with
• A. superior cerebelli (› Fig. 11.38, › Fig. 11.46): This vessel is locked-in syndrome. While in a paralysed state, he wrote the
the least variable small artery. It usually develops shortly before book Le scaphandre and le papillon (English: The Butterfly and
the splitting of the A. basilaris into the Aa. cerebri posteriores. It the Diving Bell) by blinking at letters of the alphabet. He died
is first separated from the posterior cerebral artery by the N. oc- shortly after the publication of the book.
ulomotorius [III]. The A. superior cerebelli and the A. cerebri

621
11 General neuroanatomy

A. cerebri posterior central arteries (› Fig. 11.37, › Fig. 11.47). Because of their path-
The Aa. cerebri posteriores are the terminal branches of the A. bas- way into the depth of the brain, these vessels are known as ‘pene-
ilaris and arise approximately at the level of the Cisterna interpe- trating’ vessels. They occur in vascular groups at the base of the
duncularis (› Fig. 11.37, › Fig. 11.38, › Fig. 11.39, › Fig. brain. If the vessels are removed at this point, numerous small
11.46). It supplies large parts of the mesencephalon and occipito- ‘holes’ remain in the brain tissue, which is why these entry points
temporal parts of the hemispheres with its branches. The Aa. cere- are referred to as a perforated area (Substantia perforata). A dis-
bri posteriores run parallel to the Aa. superiores cerebelli laterally tinction is made between:
and dorsally. They run above the tentorium to the Lobus occipitalis • Substantia perforata anterior: is located on the Facies inferior
and release several groups of vessels along their pathway. Finally, of the brain, confined forwards and laterally by the Trigonum
they branch into their cortical terminal branches, which supply the olfactorium and to the rear by the Tractus opticus (› Fig.
Lobus occipitalis and parts of the Lobus temporalis and Lobus pa- 11.19).
rietalis (› Fig. 11.43, › Fig. 11.46). Branches of the A. cerebri • Substantia perforata posterior: is located in the depths of the
posterior are: Fossa interpeduncularis of the mesencephalon (› Fig. 11.19).
• Aa. centrales posteromediales (› Fig. 11.37): These vessels In addition, penetrating vessels also enter the brain tissue in the
emerge from the initial part of the A. cerebri posterior, i.e. before area of the basal diencephalon. The penetrating vessels are com-
the exit point of the A. communicans posterior. They penetrate bined in groups to facilitate understanding (› Table 11.4):
– along with the central vascular branches of the A. communi-
cans posterior – through the Substantia perforata posterior and
supply large portions of the diencephalon (thalamus, subthala- Table 11.4 Central vessels.
mus, Globus pallidus and the wall of the IIIrd ventricle).
• Aa. centrales posterolaterales (› Fig. 11.37): These vessels Vessel/vascular Entry Origins Supply area
group ­(including)
emerge after the exit of the A. communicans posterior from the
A. cerebri posterior and supply parts of the diencephalon Aa. centrales Substantia • A. cerebri • Caput nuclei caudati
(epiphysis, thalamus, geniculate body) and mesencephalon. anteromediales perforata anterior • Globus pallidus
anterior • A. communi- • Commissura anterior
• Aa. choroideae posteriores (› Fig. 11.45, › Fig. 11.46): The
cans anterior • Capsula interna
posterior choroidal arteries are variable in number. They arise
after the inflow of the A. communicans posterior and run ap- Aa. centrales Substantia A. cerebri media • Nucleus caudatus
anterolaterales perforata • Putamen
proximately at the level of the Corpus geniculatum laterale
(Aa. lenticulo­ anterior • Globus pallidus
around the diencephalon. Through the Fissura choroidea it striatae) • Capsula interna
reaches the Plexus choroideus of the lateral ventricle, where (medial vessels)
there are connections to the A. choroidea anterior. Branches of Aa. centrales Substantia • A. cerebri • Thalamus
these vessels also supply the Corpus geniculatum laterale, other p
­ osteromediales perforata ­posterior • Hypothalamus
parts of the thalamus, and the Plexus choroideus of the IIIrd posterior • A. communi- • Globus pallidus
ventricle. cans posterior
Aa. centrales Substantia A. cerebri poste- • Thalamus
p
­ osterolaterales perforata rior (Pars post- • Corpus geniculatum
11.5.4 Central blood supply posterior communicalis) mediale
• Colliculi
• Glandula pinealis
The inside of the front brain, i.e. the subcortical cores, the medulla
with the Capsula interna and the mesencephalon are supplied by

Falx cerebri

Capsula interna
Aa. callosomarginales

Aa. pericallosae

Nucleus caudatus
Putamen
Septum pellucidum

A. cerebri anterior,
Pars postcommunicalis
Insula
A. communicans
anterior Fig. 11.47 Central vessels.
From the proximal sections of
A. cerebri anterior,
Pars precommunicalis the Aa. cerebrales and the
Aa. communicantes, the arteries
A. carotis interna (ICA) move into the inner brain. These
penetrating vessels are end
Aa. centrales anteromediales arteries, which explains why the
A. cerebri media occlusion of one of these ves-
A. striata medialis distalis,
Aa. centrales anterolaterales (A. centralis longa [HEUBNER]) sels can lead to a cerebral
infarction. [L127]

622
 11.5 Cerebral vessels

NOTE
The central vessels penetrate basally into the brain and run rela-
tively straight to the dorsal. Accordingly, you can derive the approx- A. spinalis posterior
imate coverage areas of these central vessels from the entry point A. spinalis anterior
of the vessels and from the location of the core areas to these entry
locations: A. medullaris segmentalis
• anteromedial vessels – anteromedial structures such as the Nu-
A. vertebralis
cleus caudatus
• anterolateral vessels – anterolateral-lying structures such as the A. cervicalis ascendens
Globus pallidus, Putamen A. cervicalis profunda
• posterior vessels – posterior structures such as the Thalamus and Truncus thyrocervicalis
Hypothalamus A. subclavia
Nn. spinales

In addition, portions of the brain's interior are supplied by choroi-

dal vessels. The choroid blood vessels of the lateral ventricles are A. medullaris segmentalis
connected via the Plexus choroideus and form a thin vascular co-
rona or plexus, which connects the tributaries of the A. carotis in- A. intercostalis posterior
terna and of the A. vertebralis/basilaris to each other (› Fig.
11.45, › Table 11.5).
A. radicularis magna

Clinical remarks
Circulatory disturbances in the area of the A. choroidea anteri-
or lead to a triad of motor, sensory and visual deficits (Arteria
choroidea anterior syndrome):
• hemiplegia (due to failure of the motor tracts in the Crura
A. sacralis lateralis
cerebri)
• hemisensory disorders (due to failure of the Crus posterius
of the Capsula interna)
• hemianopsia (due to failure of the Tractus opticus and parts
of the Radiatio optica)
Fig. 11.48 Arteries of the spinal cord. The cervical sections of the
spinal cord are supplied by branches of the Aa. vertebrales and in its
thoracolumbar sections by branches of the segmental arteries. [E402]

11.5.5 Vascular supply of the spinal cord posterior horns and parts of the anterior branch. The Aa. verte-
brales can also go into the paired Aa. spinales posteriores (25%).
The spinal cord is supplied by the following vessels (› Fig. 11.48, However, these vessels originate far more often from the A. infe-
› Fig. 11.49): rior posterior cerebelli (normal case). The A. spinalis posterior
• A. spinalis anterior (longitudinal pathway in the Fissura medi- supplies the posterior threads and posterior horns of the spinal
ana anterior) cord. The vasocorona mainly forms between these and predom-
• Aa. spinales posteriores (paired; longitudinal pathway shortly inantly supplies the marginal zone on the anterior lateral
after the entry point of the Radix posterior) strands.
• Vasocorona (transverse connections between spinal arteries on • The thoracolumbar can, in principle, lead blood to the spinal
the surface of the spinal cord) cord at the level of each spinal nerve (› Fig. 11.49). The seg-
Due to the length of the spinal cord, vessels feed blood at different mentally created arteries, especially the Aa. intercostales posteri-
segment heights into this system (› Fig. 11.48). ores and the Aa. lumbales, form as branches of their Rr. dorsales,
• Cervically, these are the Aa. vertebrales and their branches. The (› Chap. 3.3.2) the Rr. spinales that enter the spinal canal
Aa. vertebrales give off a branch ventrally, which becomes the through the Foramina intervertebralia. There they divide into a
A. spinalis anterior. This runs caudally in front of the Fissura R. anterior and a R. posterior, respectively, which lead to the ver-
spinalis anterior and supplies the anterior horns, the base of the tebrae and ligaments. A third branch, the A. medullaris seg-
mentalis, runs to the structures of the spinal cord. During devel-
opment and maturation of the spinal cord, approximately 75% of
Table 11.5 Choroidal vessels.
the Aa. medullares segmentales regress and form the thin root
Vessel Origins Flow area arteries, the Aa. radiculares anteriores and posteriores, for the
supply of the spinal ganglions and the roots. The remaining ar-
A. choroidea A. carotis interna • Tractus opticus
anterior • Capsula interna (Crus posterius)
teries persist as the Aa. medullares segmentales, providing the
• Anterior hippocampus Aa. radiculares and reaching the spinal cord with their main
• Crura cerebri, Tegmentum mesencephali branch, which they supply together with the other medullary ar-
• Plexus choroideus teries. The diameter of the Aa. medullares segmentales and their
Aa. cho- A. cerebri posterior • Corpus geniculatum laterale branches can vary. However, at the level of the Intumescentia
roideae pos- • Hippocampus and fornix lumbosacralis, a relatively large root artery is often found, which
teriores • Thalamus (posterior sections) is often described due to its calibre as the A. radicularis magna
• Dorsal mesencephalon and usually reaches the spinal cord over the 10th or 11th Foramen
• Glandula pinealis
interventriculare.

623
11 General neuroanatomy

R. radicularis posterior
Aa. spinales posteriores
R. radicularis anterior
R. radicularis posterior

R. radicularis anterior

A. medullaris
segmentalis
A. medullaris
segmentalis R. spinalis

A. spinalis Fig. 11.49 Segmental supply of

A. intercostalis
anterior the spinal cord. The spinal cord
posterior sinistra
is supplied by the A. spinalis
A. intercostalis
anterior (unpaired, middle of
posterior dextra
the spinal cord), 2 Aa. spinales
posteriores (medially of dorsal
roots) as well as a vessel circle
(vasocorona) between these
Aorta
vessels. At the level of the tho-
racolumbar, segmental arteries
feed blood into this system.
[E402]

11.5.6 Topography and supply areas of the arteries (ischemia), a combination of neurological symptoms develop that
allows conclusions to be drawn about the affected vessel. Know­
The vasculature supplying the brain is not bound to the lobe ledge of the supply areas of the arteries is therefore the basis of clin­
boundaries or anatomical structures of the brain. Their names are ical work. The focus is on the vessels that supply the surface anato-
therefore only an ‘approximate’ reflection of their situation and my of the telencephalon, the Capsula interna and the brainstem.
their supply areas. In addition, there are significant interindividual
differences in the anatomy of the cerebral vessels; in individual cas- Surface of the telencephalon
es, the anatomy deviates considerably from the ‘standard pathway’ The A. cerebri anterior, A. cerebri media and A. cerebri posterior
of the vessels and their ‘standard supply areas’ shown here, which supply the margin of the telencephalon. Their respective supply ar-
explains the variety of neurological deficits in circulatory disorders. eas stretch over the Facies superolateralis, Facies medialis and Fa-
cies inferior (› Fig. 11.50, › Fig. 11.51):
Topography • Direct branches of the A. carotis interna supply the pituitary
The anatomical pathway of the individual vessels was described in gland, as well as the middle area of the Chiasma opticum. The
the previous sections. The most important points are summarised A. choroidea anterior exiting from it (see below) supplies larger
in › Table 11.6. In addition to the descriptions in the Terminolo- sections within the brain.
gia Anatomica, the arteries are also referred to by the internation- • The A. cerebri anterior enters the Fissura longitudinalis cerebri
ally accepted abbreviations based on English-language anatomical anteromedially and runs above the Corpus callosum to approxi-
terminology, which are used in clinical practice. mately the Sulcus parieto-occipitalis. With its branches, it sup-
plies most of the medial surface of the Lobus frontalis and Lobus
Supply areas of the cerebral arteries parietalis, as well as the Corpus callosum (› Fig. 11.51). At the
The large cerebral vessels supply – with interindividual variations! Facies superolateralis, it reaches, with its branches, a 2–3 cm
– characteristic areas of the brain. If there is a reduced blood flow wide strip laterally of the hemispheral rim (› Fig. 11.50).

Sulcus centralis
Supply area of the
A. cerebri anterior (ACA)

Supply area of the

A. cerebri media (MCA)

Supply area of the

A. cerebri posterior (PCA)

Supply area of the

A. basilaris/Aa. vertebrales
(BA/VA)

Sulcus lateralis

Cerebellum Truncus encephali

Fig. 11.50 Supply areas of the
cerebral arteries (endbrain).
Lateral view. [L126]

624
 11.5 Cerebral vessels

Table 11.6 Topography of the arteries supplying the brain.

Artery Topography and special features

A. carotis interna (ICA, ‘internal carotid • Four topographic anatomically defined sections: Pars cervicalis, Pars petrosa, Pars cavernosa, Pars cerebralis
artery’) • Exit from Sinus cavernosus lateral of the Chiasma opticum
A. ophthalmica • First major vessel of the A. carotis interna
• Emergence below the N. opticus
• Passes through the Canalis nervi optici into the eye socket
• Anastomosis (A. dorsalis nasi) with A. facialis (A. angularis)
A. choroidea anterior • Vessel branch of the A. carotis interna
• Moves along the Tractus opticus to the inferior horn of the lateral ventricle
A. cerebri anterior (ACA, ‘anterior • Runs laterally to the Chiasma opticum, to the rostral
­cerebral artery’) • Passes to the Fissura longitudinalis cerebri
• Runs above the Corpus callosum to the occipital
A. communicans anterior (ACom, • Between the Aa. cerebri anteriores
­‘anterior communicating artery’) • Location before the Chiasma opticum
A. cerebri media (MCA, ‘middle cerebral • Passes around the Polus temporalis to the Fossa lateralis cerebri
artery’) • Branching above the insula, leaving the Sulcus lateralis and the pathway of the branches on the lateral surface anatomy of
the cerebrum
A. vertebralis (VA, ‘vertebral artery’) • Four topographic anatomically defined sections: Pars prevertebralis, Pars transversaria, Pars atlantis, Pars intracranialis
• Runs ventrally and forms the A. basilaris (such as the lower rim of the pons)
A. inferior posterior cerebelli (PICA, • Exit from A. vertebralis at the level of the olive (but can be missing)
­‘posterior inferior cerebellar artery’) • Loop at the level of the cerebellar tonsils (radiological feature)
• Entry to the cerebellar valley (Vallecula cerebelli) above the vermis
A. basilaris (BA, ‘basilary artery’) • Pathway in the Sulcus basilaris of the pons
• Divided into the Aa. cerebri posteriores (approximately at the level of the mesencephalon)
A. inferior anterior cerebelli (AICA, • Exit from the lower section of the A. basilaris, ventral of the cranial nerves VI, VII, VIII
­‘anterior inferior cerebellar artery’) • Runs to the Meatus acusticus internus with emission of the A. labyrinthi (usually) and from there to the underside of the
cerebellum
A. superior cerebelli (SCA, ‘superior • Emerges caudally of the N. oculomotorius [III] from the A. basilaris
­cerebellar artery’) • Runs below the Tentorium cerebelli
• Moves posterior to the cerebellum surface
A. cerebri posterior (PCA, ‘posterior • Emerges cranially of the N. oculomotorius [III]
­cerebral artery’) • Runs above the Tentorium cerebelli
• Moves posterior to the occipitobasal surface of the cerebrum
A. communicans posterior (PCom, • Connection of the A. carotis interna and A. cerebri posterior
­‘posterior communicating artery’) • Runs laterally from the hypophysis and Corpora mamillaria

• The A. cerebri media enters through the Fossa lateralis and reach • The A. cerebri posterior runs to the Lobus occipitalis and sup-
the lateral cerebral surface (› Fig. 11.50). There it supplies por- plies on its way large portions of the Facies inferior and Facies
tions of the Lobus frontalis, Lobus parietalis and Lobus tempo- medialis of the brain (› Fig. 11.51), including the inferior por-
ralis. Their supply area also captures the tip of the Lobus tempo- tions of the Lobus temporalis.
ralis (Polus temporalis).

Sulcus centralis
Supply area of the
A. cerebri anterior (ACA)

Supply area of the

Sulcus parieto- A. cerebri media (MCA)
occipitalis
Supply area of the
A. cerebri posterior (PCA)

Supply area of the

A. basilaris/Aa. vertebrales
(BA/VA)
Sulcus
calcarinus Supply area of the
A. carotis interna (ICA)
Corpus callosum
Cerebellum
Chiasma opticum

Truncus encephali Fig. 11.51 Supply areas of the

cerebral arteries (endbrain).
Medial view. [L126]

625
11 General neuroanatomy

NOTE Table 11.7 Vascular supply to the Capsula interna.

From the surface anatomy of the telencephalon the A. cerebri ante-
rior supplies the anterior two-thirds of the medial surface of the Capsula inter- Arteries Origins
cortex, the A. cerebri media two-thirds of the lateral surface, and na
the A. cerebri posterior the inferior and occipital surfaces.
Crus anterius Aa. centrales anteromediales A. cerebri anterior
A. striata medialis distalis (A. centralis A. cerebri anterior
Capsula interna and central sections of the telencephalon and longa; A. recurrens HEUBNER)

diencephalon Aa. centrales anterolaterales A. cerebri media

The supply of the central telencephalon areas is of particular clini- Genu Aa. centrales anterolaterales A. cerebri media
cal significance. The fibre tracts from the cortex are bundled and Crus posterius Aa. centrales anterolaterales A. cerebri media
pass between the basal core areas (Nucleus caudatus, thalamus,
A. choroidea anterior A. carotis interna
Globus pallidus, putamen) through the Capsula interna. It is clear
that a lack of blood flow in this ‘bottleneck’ causes severe neurolog-
ical deficits. Due to the considerable expansion of the Capsula in- media and the A. carotis interna (› Table 11.7; › Fig. 11.52,
terna in the longitudinal direction of the brain, but also in the dor- › Fig. 11.53). The anterior limb (Crus anterius) is supplied by
sobasal direction, several central groups of vessels contribute to branches of the A. cerebri anterior and the A. cerebri media and
their supply. These arise from the A. cerebri anterior, the A. cerebri the knee (genu) and anterior portions of the posterior limb (Crus

Caput nuclei caudati Capsula interna,

Crus anterius
Fissura longi-
tudinalis cerebri

Commissura
anterior

Putamen

Capsula interna,
Insula Genu

Globus pallidus

Columna fornicis

Capsula interna,
Crus posterius

Supply area of the

A. cerebri anterior (ACA)

Thalamus Supply area of the

A. cerebri media (MCA)
Glandula
Supply area of the
pinealis
A. cerebri posterior (PCA)

Supply area of the

A. choroidea anterior

Supply area of the Fig. 11.52 Supply areas of the

Cerebellum cerebral arteries (endbrain).
A. basilaris/Aa. vertebrales
(BA/VA) Horizontal section. [L126]

Fissura longitudinalis
cerebri
Supply area of the
Corpus callosum A. cerebri anterior (ACA)
Corpus striatum
Ventriculus (Nucleus caudatus Supply area of the
lateralis and putamen) A. cerebri media (MCA)

Supply area of the

A. cerebri posterior (PCA)

Supply area of the

A. choroidea anterior

Sulcus Supply area of the

lateralis A. carotis interna (ICA)

Insula

Commissura A. carotis Chiasma Globus pallidus

Fig. 11.53 Supply areas of the
anterior interna opticum cerebral arteries (endbrain).
Frontal section. [L126]

626
 11.5 Cerebral vessels

posterius) by branches of the A. cerebri media. Further occipitally Table 11.9 Arterial blood supply of the cerebellum.
located sections of the hind branch reach the A. choroidea anteri-
Artery Cortical area Central area
or, an important central branch of the A. carotis interna. They
move into the inner brain and supply central areas of the brain: A. superior cerebelli Upper part of the Nucleus dentatus
(SCA; constant) ­cerebellum
Crus posterius of the Capsula interna, hippocampus, amygdala and
deep cores of the telencephalon and diencephalon (› Fig. 11.52, A. inferior anterior Rear lower part of the
› Fig. 11.53). Their supply area varies greatly. ­cerebelli (AICA; variable) ­cerebellum
A. inferior posterior Front lower part of the The rest of the cores
­cerebelli (PICA; variable) ­cerebellum
Clinical remarks
In the case of a stroke or bleeding in the area of the Capsula Table 11.10 Arterial blood supply of the spinal cord.
interna, two vessels are very frequently involved:
• A branch of the A. cerebri anterior (part of the Aa. centrales Artery Cortical area
anteromediales): A. striata medialis distalis (syn.: A. centra-
A. spinalis anterior Front horn, base of the dorsal horn, parts of the
lis longa, A. recurrens, HEUBNER-arteries) anterior strand
• A branch of the A. cerebri media (part of the Aa. centrales
anterolaterales): A. lenticulostriata Aa. spinales posteriores Rear lower part of the cerebellum
Vasocorona Border areas of the anterior strand

Brainstem and cerebellum Cerebellum

The brainstem and cerebellum are supplied by branches of the ver- The cerebellum is supplied by three arteries. The A. superior cere-
tebrobasilar system. It is important to understand that the Aa. cere- belli is formed consistently and supplies the upper part of the cere-
bellares are not only important for cerebellar care, but also play a bellum and the Nucleus dentatus. The 2 other small cerebral arter-
crucial role in the supply of the brainstem. ies, the A. inferior anterior cerebelli and the A. inferior posterior
cerebelli, supply the rest of the cerebellum, where they are interde-
Brainstem pendent in size (i.e., they ‘compete’ for the rest of the area, hence an
A medial and a lateral supply area can be differentiated on the increase in, for example, the A. inferior anterior cerebelli leads to a
brainstem. The medial supply area is reached by direct branches of reduction in the A. inferior posterior cerebelli). Unlike the telen-
the A. vertebralis, A. basilaris or the A. cerebri posterior, while the cephalon, there are anastomoses in the cerebellum between the su-
lateral supply area is fed by branches of the cerebellar arteries perficial and central arteries; this reduces the risk of isolated cen-
(which, in turn, originate from the vertebrobasilar system). In the tral infarction. The anatomical contexts in the cerebellum (as a
Medulla oblongata a posterior supply area can still be delineated; rule) are summarised in › Table 11.9 and › Fig. 11.54.
here, the A. spinalis posterior supplies portions of the dorsal me-
dulla. The vessels supplying the brainstem are listed in › Table Spinal cord
11.8and › Fig. 11.54. The supply of the spinal cord can be subdivided into the areas of the
A. spinalis anterior, Aa. spinales posteriores and vasocorona. The
Table 11.8 Arterial supply of the brainstem. supply areas are summarised in › Table 11.10 and › Fig. 11.55.
Brainstem section Medial supply area Lateral supply area
Mesencephalon A. cerebri posterior • A. superior cerebelli
Clinical remarks
• A. cerebri posterior
An ischemia in the area of the A. spinalis anterior leads to a
Pons A. basilaris (Aa. pontis) • A. superior cerebelli classic neurological syndrome (anterior spinal artery syn-
• A. inferior anterior cere- drome) with:
belli (very variable) • cross-sectional symptoms below the lesion (spinal shock in
Medulla oblongata • Aa. vertebrales A. inferior posterior cere-
the early phases/spastic paralysis in later stages; disorders
• A. spinalis anterior belli
• Aa. spinales posteriores

Hemispherium Vermis Supply area of the

cerebelli cerebelli A. superior cerebelli (SCA)
Mesen-
cephalon Supply area of the
A. inferior posterior cerebelli
(PICA)

Supply area of the

A. inferior anterior cerebelli
(AICA)

N. oculo- Supply area of the

motorius [III] A. spinalis anterior
Pons Supply area of the
A. basilaris (BA) Fig. 11.54 Supply areas of the
Plexus choroideus Ventriculus
ventriculi quarti quartus
cerebral arteries (brainstem and
Medulla Supply area of the
oblongata A. cerebri posterior (PCA)
cerebellum). Sagittal section.
[L126]

627
11 General neuroanatomy

of the bladder and rectum function) due to the failure of the 11.5.7 Clinical description of the vascular sections
anterior horns and the anterior lateral strands
• Disorders of pain and temperature perception (lateral In clinical medicine (especially in the Sciences of neurology, psychi-
strand) in the event of preserved touch and vibration per- atry, neurosurgery and neuroradiology), an alphanumeric nomen-
ception (posterior strand); so-called dissociated sensory
clature of the vascular sections of the large cerebral vessels has been
disturbance. Reason: failure of the anterior lateral strand in
the event of an intact posterior strand adopted in addition to the anatomical designation of the vessels.
Due to their clinical relevance, these designations are summarised
in › Table 11.11 and juxtaposed with the anatomical terms. For the
subdivision of the A. carotis interna, this textbook uses the updated
segment name of Bouthillier et al. (1996), which follows the flow of
Aa. spinales blood of the A. carotis interna and has found its way into the clini-
posteriores
cal nomenclature of neuroradiology in recent years.
R. radicularis
posterior

11.5.8 Venous sinuses of the brain

Overview
The venous system of the brain (› Fig. 11.40, › Fig. 11.59) takes
A. medullaris a back seat in clinical importance compared to the arteries. There
segmentalis are however some important conditions that mainly affect the ve-
nous blood vessels of the brain. The pathways of the veins are also
A. spinalis R. radicularis important for neurosurgery.
anterior anterior The venous blood vessels can be divided into 2 groups:
Supply area of the Supply area • Sinus durae matris (› Fig. 11.59)
Aa. spinales posteriores of the vasocorona • Veins
Supply area of the
– surface of the brain
A. spinalis anterior – internal areas of the brain
Both have characteristic features compared to the veins of the rest
Fig. 11.55 Supply areas of the spinal cord. Cross-section. [L126] of the body:

Table 11.11 Clinical (radiological) names of the vessel sections of the major blood vessels supplying the brain.

Artery Segment Topography/anatomical structures

A. carotis interna, C1 – ‘Cervical’ Cervical part
ICA = internal carotid
C2 – ‘Petrosal’ Pars petrosa until the end of the Canalis caroticus
artery
C3 – ‘Lacerum’ Up to a ligament between Lingula sphenoidalis and the apex of the Os petrosus (‘Lig. petrolingualis’)
C4 – ‘Cavernosus’ In the Sinus cavernosus up to the exit point of the dura below the Proc. clinoideus
C5 – ‘Clinoidal’ Between the Proc. clinoideus anterior and the base of the Os sphenoidale
C6 – ‘Ophthalmica’ Up to the outlet of the A. communicans posterior; outlet of the A. ophthalmica
C7 – ‘Communicans’ Up to the bifurcation of the ACI in the Aa. cerebri anterior and media
A. cerebri anterior, A1 Pars precommunicalis; from its starting point up to the outlet of the A. communicans anterior
ACA = anterior cerebral
A2 Pars postcommunicalis; from the A. communicans anterior up to the outlet of the A. callosomarginalis; also: Pars in­­
artery
fracallosa
A3 Pars postcommunicalis; distal from the outlet of the A. callosomarginalis (A. pericallosa); some authors differentiate
even more segments (A4 and A5)
A. cerebri media, M1 Pars sphenoidalis; from its outlet up to where it branches into 2 or 3 main branches
MCA = middle cerebral
M2 Pars insularis; in the Fossa lateralis, above the insula
artery
M3 Pars opercularis; in the Fossa lateralis to lateral routed branches on the cortical surface
M4 Pars terminalis; after the vessels leave the Sulcus lateralis
A. cerebri posterior P1 Pars precommunicalis; from its outlet up to the A. communicans posterior; passes through the Cisterna interpeduncularis
(PCA, posterior cerebral
P2 Pars ambiens; from the A. communicans posterior up to the outlet of the Rr. temporales anteriores (upper Cisterna
artery)
ambiens)
P3 Pars quadrigeminalis; from the anterior temporal branches up to where it splits into the Aa. occipitales medialis and
lateralis (upper Cisterna quadrigeminalis)
P4 Pars calcarinus; terminal branches: Aa. occipitales medialis and A. occipitalis lateralis
A. vertebralis, V1 Pars prevertebralis
VA = ­vertebral artery
V2 Pars transversaria
V3 Pars atlantis
V4 Pars intracranialis

628
 11.5 Cerebral vessels

• no venous valves Table 11.12 Venous inflows to the V. magna cerebri.

• often run independently of the arteries
Vein Most important Areas of the brain
• no typical Tunica media (isolated muscle cells), thereby have inflows
thin walls (veins)
V. interna cerebri V. choroidea superior Plexus choroideus, Hippocam-
• rigid walls of the Sinus durae matris, thus protected against a
pus
collapse
V. septi pellucidi Septum pellucidum

Drainage of the blood from the brain V. thalamostriata Nucleus caudatus

Exit points V. basalis V. anterior cerebri Corpus callosum and adjacent
Venous blood vessels (› Fig. 11.40, › Fig. 11.59) are connected gyri
to each other and also with extracranial veins. To put it simply, the V. profunda cerebri Putamen, Globus pallidus
blood flows from the veins on the surface and inside the brain into
the Sinus durae matris. From there, it leaves the inside of the skull
in various ways. Important exit points are: • Vv. superiores cerebri: direct inflows to the Sinus sagittalis su-
• Sinus sigmoideus to the V. jugularis interna (Foramen jugulare) perior (› Fig. 11.59, › Fig. 11.60).
→ the most important! • V. media cerebri: collects blood from veins in the vicinity of the
• Sinus cavernosus via the Foramen ovale to the Plexus pterygoideus Sulcus lateralis; outflow into the Sinus sphenoparietalis and from
• Vv. emissariae to the V. occipitalis (Foramina emissaria) there into the Sinus cavernosus
In addition, there are smaller intracranial veins that drain into ex- • Vv. inferiores cerebri: direct inflows to the Sinus transversus
tracranial veins via openings at the base of the skull (including ve- Superficial veins that flow directly into the Sinus durae matris must
nous outflows via the Foramen magnum, the Foramen ovale, and cross the surface of the brain via the subarachnoid space and pierce
the Canalis caroticus). the arachnoid and dura to join the Sinus durae matris. They are
therefore referred to as ‘bridging veins’ (› Fig. 11.60). This ve-
Emissary veins nous bleeding can lead to a subdural haematoma (› Chap. 11.3.5).
The Vv. emissariae connect the Sinus durae matris with the diploic
veins (= larger venous blood conductors within the diploë of the Deep veins
skull bones) and with the extracranial veins. Because they have Vv. profundae cerebri collect the blood of the central areas and fi-
no venous valves, they allow for rapid pressure equalisation be- nally lead via the unpaired V. magna cerebri into the Sinus rectus
tween internal and external fluctuations in intracranial pressure. (› Fig. 11.61). From each side, the V. magna cerebri receives 2
Emissary veins can be found in several Sinus durae matris (› Fig. main inflows each: the V. interna cerebri leads blood dorsally from
11.40). the medullary body and the central cores; the V. basalis leads
blood basally from the areas at the base of the brain and its central
Venous anastomosis to the V. facialis regions:
The Sinus cavernosus receives inflows from the Vv. ophthalmicae. • V. interna cerebri: originates at the level of the Foramen inter-
These are connected with the V. angularis of the V. facialis via the ventriculare due to the confluence of several veins (› Ta-
Fissura orbitalis superior and the Fissura orbitalis inferior. Under ble 11.12). In the roof of the IIIrd ventricle it runs to the occipital
certain conditions, the venous blood from the inside of the skull and joins below the splenium of the Corpus callosum with the
can flow away via these veins to the V. facialis and then to the V. interna cerebri of the opposite side to the unpaired V. magna
V. jugularis interna (› Fig. 11.40). cerebri (› Fig. 11.61).
• V. basalis: originates in the area of the Substantia perforata ante-
rior from several venous tributaries (› Table 11.12), including
Clinical remarks from the basal cortical areas, the insula and dorsally neighbour-
Because the veins and Sinus durae matris have no venous ing central regions. It flows around the Crus cerebri and into the
valves, the blood can also flow into the brain (reverse flow of V. magna cerebri or the V. interna cerebri (› Fig. 11.61).
blood). As a result, infections from the soft tissue of the head • V. magna cerebri (vein of GALEN): originates from the conflu-
are dragged into the Sinus durae matris, e.g. an infection of ence of the Vv. internae cerebri and Vv. basales below the spleni-
the upper lip can lead to a bacterial cavernous Sinus thrombo-
um of the Corpus callosum (› Fig. 11.61). If the veins flow to-
sis via the V. angularis.
gether into one place, this is called the Confluens venosus poste-
rior. The great cerebral vein, V. magna cerebri, is only about 1 cm
long and leads blood to the Sinus rectus. At its junction with the
Veins sinus, it is attached to the dura.
Endbrain and diencephalon
A distinction is made between superficial veins, Vv. superficiales
cerebri, which collect the blood from the surface of the brain, and
Clinical remarks
deep veins, Vv. profundae cerebri, via which the blood flows off The outflow of blood through the venous system is responsi-
from the central brain areas: ble for the occurrence of ‘altitude sickness’. This occurs in up
to 25% of people who go without acclimatisation within a
Superficial veins short space of time to a height of 2,500 m. Patients complain
especially about headache, dizziness and nausea. Pathophys-
Vv. superficiales cerebri drain the blood from the surfaces of the
iologically, it is assumed that the arterial blood flow to the
endbrain and diencephalon in the Sinus durae matris (› Fig. brain is increased to maintain the oxygenation of the brain at
11.59, › Fig. 11.60). A distinction is made between three groups a lower partial pressure of oxygen. The larger amount of blood
that are connected to each other via strong venous anastomoses: must drain off through the veins, thereby being significantly

629
11 General neuroanatomy

widened, causing a headache. The more difficult it is for the Sinus durae matris
blood to drain due to the individual anatomy of the venous The venous blood from the cerebral veins flows into the Sinus du-
system, the more the cerebral veins clog up and the more like- rae matris (› Fig. 11.59, › Table 11.13). These blood vessels lie
ly headaches are at high altitude. between the two layers of the Dura mater (› Fig. 11.27). They are
therefore rigid walls and do not collapse. On the inside, they are
lined with endothelium. The Sinus durae matris are directly adja-
Brainstem and cerebellum cent to the cranial bones and form shallow pits on their surface.
The venous drainage of the brainstem and cerebellum form numer- In idealised graphical representations, the Sinus durae matris are
ous anastomoses on the brain surface. As an overview, you can note: often depicted as large, smooth tube systems (› Fig. 11.59). They
• rostral parts (mesencephalon, upper pons, rostral cerebellum): actually arise from intradural venous networks that have joined to-
drain rostrally into the V. basalis, V. magna cerebri, Sinus rectus gether. Therefore, there are Corpus callosum structures within the
• middle parts (pons, lower cerebellum sections): drain laterally tubes as well as larger lateral lacunae and venous plexuses (› Fig.
into the Sinus durae matris 11.60, › Fig. 11.27). The internal structure of the Sinus durae ma-
• caudal parts (Medulla oblongata): drain laterally and caudally to tris is therefore uneven and there are considerable inter-individual
the Sinus durae matris as well as to the spinal venous plexuses differences.
The venous blood predominantly takes 2 pathways:
Spinal cord • either dorsally to the Confluens sinuum and from there via the
The veins of the spinal cord form numerous anastomoses at its sur- Sinus rectus and Sinus sigmoideus to the V. jugularis
face. They connect via the Vv. radiculares with the venous plexus • or forward basally to the Sinus cavernosus and via the Sinus
of the epidural gap, the Plexus venosus vertebralis internus. This petrosi superior and inferior to the V. jugularis (and the Plexus
venous plexus drains its blood via the Plexus venosus vertebralis pterygoideus)
externus into the Vv. intervertebrales and from there into the
V. cava inferior. NOTE
The Vv. radiculares are closely related to the arachnoidea in the • running through the Sinus cavernous: A. carotis interna, N. abdu-
root pouches. The cerebrospinal fluid can be reabsorbed via the cens [VI]
arachnoid villi, as well as in the Granulationes arachnoideae of the • running in the lateral wall of the sinus: N. oculomotorius [III], N.

Sinus durae matris. Thus, the spinal cord veins play an important trochlearis [IV] and N. ophthalmicus [I]
role in CSF circulation.
Clinical remarks
Thrombosis of the Sinus durae matris (Sinus thrombosis) is a
Table 11.13 Pathway of the Sinus durae matris. rare and serious disease of the brain. This can occur through
Sinus durae matris Pathway and characteristics purulent infections of the face (septic Sinus thrombosis), but
also spontaneously when there is an increased tendency for
Sinus sagittalis • Attachment to Falx cerebri up to Protuberantia occipi- blood to clot (e.g. polycythaemia, but also through the nega-
­superior talis interna tive impact of contraceptives). The patients suffer from head-
• Pathway is anterior–posterior in the Sulcus sinus sag- aches, seizures, paralysis and clouding of consciousness. The
ittalis of the skull bones diagnosis is made with imaging (MRI, CT).
• Bridging veins drain into it or its lateral lacunae
• Flows into the Confluens sinuum
Sinus sagittalis inferior Pathway on bottom edge of the falx to the Sinus rectus
Sinus rectus Formation at the connection point where the falx and
tentorium meet the Sinus sagittalis superior and V. mag- 11.5.9 Presentation of the vasculature
na cerebri
Confluens sinuum Confluence of Sinus transversi, Sinus rectus, Sinus sag- The pathway of the cerebral vessels and the formation of the collat-
ittalis superior and Sinus occipitalis eral supply in the area of the Circulus arteriosus are individually
Sinus occipitalis • Lies in the midline of the Os occipitale different. In the event of an operation it is therefore important to
• Flows toward the Confluens sinuum know the individual blood flow situation of a patient before the
Sinus marginalis • Surrounds the Foramen magnum
time, both for the benefit–risk decision and for the surgical plan-
• Connected to Sinus occipitalis and Plexus venosus ning. Examples are operations on vessels leading to the brain (e.g.
vertebralis internus operation of a carotid) or intracranial vascular surgery (e.g. aneu-
Sinus transversus From the Confluens sinuum which emerges from the Os rysm, angioma).
occipitale laterally to the Sinus sigmoideus
Sinus sigmoideus S-shaped pathway via Pars mastoidea of the Os tempo-
Angiography, angio-CT and angio-MRI
rale to the Foramen jugulare and to the V. jugularis For the presentation of the vessels, there are various methods. The
Sinus cavernosus • Chambered venous space on both sides of the Sella
classic method is the angiography (or the digital subtraction angio­
turcica graphy). To this end, a catheter is inserted into the A. carotis inter-
• Connected via the Plexus basilaris on the clivus with na or the A. vertebralis, and an iodine, water-soluble contrast
the Sinus cavernosus on the opposite side agent is injected as a bolus. Several successive recordings show the
• Topographically very important region (see ‘Note’ box) blood flow in the arteries, capillaries and veins. A second method
Sinus petrosi superior • Pathway at the top or bottom edge of the Pars petrosa is the angio-CT, in which an iodine-containing contrast agent is
and inferior ossis temporalis injected into the vein in order to be able to differentiate the vessels
• Connection of the Sinus cavernous with the Sinus more clearly from the tissue. In neuroradiology, this procedure
sigmoideus
currently plays a rather subordinate role. In contrast, the an-

630
 11.5 Cerebral vessels

A. cerebri anterior A. communicans

(ACA, A1 segment) anterior (ACOM)
A. carotis interna A. cerebri anterior
(ICA, Pars cerebralis) (ACA, A2 segment)
A. cerebri media
(MCA, M1 segment)
A. carotis interna
(ICA, Pars cavernosa); A. cerebri media
Siphon caroticum (MCA, M2 segment)
A. communicans
posterior (PCOM)

A. carotis interna A. basilaris (BA)

(ICA, Pars petrosa) A. vertebralis
(VA, V4 segment)

A. carotis interna A. vertebralis

(ICA, Pars cervicalis) (VA, V3 segment)

A. carotis externa
A. vertebralis
Sinus caroticus (VA, V2 segment)

A. carotis
A. carotis
communis dextra
communis sinistra
A. vertebralis
A. vertebralis sinistra
dextra
(VA, V1 segment)

A. subclavia
A. subclavia sinistra
dextra

Fig. 11.56 Magnetic resonance

angiography of the arteries
supplying the brain. Overview.
[T786]

A. cerebri anterior A. communicans

(ACA, A2 segment) anterior (ACOM)

A. ophthalmica A. cerebri anterior

(ACA, A1 segment)
A. carotis interna
(ICA, Pars cavernosa) A. carotis interna
(ICA, Pars cerebralis)
A. communicans
posterior (PCOM) A. cerebri media
(MCA, M2 segment)
A. carotis interna
(ICA, Pars petrosa) A. cerebri media
(MCA, M1 segment)
A. superior
cerebelli (SCA)
A. cerebri posterior
(PCA, P1 segment)
A. basilaris (BA)
A. cerebri posterior
A. inferior anterior
(PCA, P2 segment)
cerebelli (AICA)

A. vertebralis A. inferior posterior

(VA, V4 segment) cerebelli (PICA)
Fig. 11.57 Magnetic resonance
angiography of the arteries
supplying the brain. Caudal
view. [T786]

631
11 General neuroanatomy

A. communicans A. cerebri media (MCA)

anterior (ACOM) A. communicans
posterior (PCOM)
A. cerebri anterior
(ACA, A1 segment) A. cerebri
posterior (PCA)
A. cerebri anterior
(ACA, A2 segment)
A. superior
cerebelli (SCA)
A. ophthalmica

A. carotis interna
A. basilaris (BA)
(ICA, pars cerebralis)

A. carotis interna
(ICA, pars cavernosa);
A. inferior
siphon caroticum
posterior
cerebelli (PICA)
A. carotis interna Fig. 11.58 Magnetic resonance
(ICA, pars petrosa) angiography of the arteries
A. carotis interna A. inferior anterior A. vertebralis (VA)
supplying the brain. Lateral
(ICA, pars cervicalis) cerebelli (AICA) view, presentation of the Siphon
caroticum. [T786]

V. ophthalamica superior Sinus sagittalis inferior

Sinus cavernosus Vv. superiores cerebri

Sinus intercavernosus Sinus sagittalis superior

V. magna cerebri
[GALEN] Sinus sphenoparietalis

Plexus venosus Sinus rectus

foraminis ovalis

Sinus sigmoideus
Sinus petrosus inferior

Bulbus superior
Sinus petrosus superior venae jugularis
internae

Plexus basilaris
Sinus transversus

Sinus occipitalis

Sinus marginalis Fig. 11.59 Diagram of the Sinus

Confluens sinuum
durae matris in a projection
onto the cranial base.

gio-MRI has grown in popularity in the past few years, and is in- noses, vascular spasms or of a flow reversal. Combining the Dop-
creasingly used. In this procedure, which can be performed with pler ultrasound with the ultrasound image (‘B-scan’; conversion of
or without MRI contrast agent (iodine-free contrast agent), the echo intensity into shades of grey and thereby visualising anatomi-
cerebral vessels are displayed in three dimensions with high reso- cal structures), is called a ‘duplex ultrasound’ because 2 ultrasound
lution. In this way, the doctor will also gain an insight into the ana­ methods (Doppler and B-scan) are used at the same time. In the
tomical–topographic relationships (› Fig. 11.56, › Fig. 11.57, duplex ultrasound, the flow direction of the blood is often co-
› Fig. 11.58). It is conceivable that ‘stronger’ MRI devices (de­ lour-coded (‘Colour Doppler’).
vices with higher magnetic field strengths) and advances in calcu-
lation algorithms of MRI data will further improve the quality of Duplex ultrasound of the extracranial cerebral vasculature
the scan. The duplex ultrasound is very common in the investigation of the
A. carotis and its branches. Stenosis or calcification in the Sinus
Ultrasound examination of the vessels supplying the brain caroticus or in the proximal A. carotis interna, as well as a de-
A standard method for the examination of the blood vessels sup- creased blood flow, can thus be detected. The A. carotis interna is
plying the brain is the Doppler ultrasound. With this technique, distinguished from the A. carotis externa in that it has no vascular
the speed of blood flow in vessels can be determined to verify ste- branches in the neck area. Using a Doppler ultrasound, a flow re-

632
 11.5 Cerebral vessels

Dura mater cranialis

Vv. superiores cerebri,

vv. frontales A. callosomarginalis

Sinus sagittalis superior

Vv. mediae
superficiales cerebri A. sulci precentralis

V. anastomotica superior A. sulci centralis

Vv. superiores cerebri,

Vv. parietales Rr. paracentrales

A. sulci postcentralis
Granulationes arachnoideae
Bridging veins

A. parietalis posterior
Lacunae laterales
R. gyri angularis

R. precunealis

Vv. superiores cerebri,

Vv. occipitales R. parieto-occipitalis

Fig. 11.60 Superficial veins of the brain, bridging veins, Granulationes arachnoideae, Sinus sagittalis superior.

Foramen interventriculare

V. anterior septi pellucidi

V. thalamostriata superior
Nucleus caudatus

V. choroidea superior
Thalamus

Thalamus

Vv. internae cerebri

V. basalis

V. magna cerebri
V. lateralis ventriculi
lateralis
Fig. 11.61 Deep cerebral veins.
The blood from the inside of the
brain runs through the Vv. inter-
nae cerebri and Vv. basales into
the V. magna cerebri and from
there into the Sinus rectus.

633
11 General neuroanatomy

versal in the A. vertebralis (Trigonum arteriae vertebralis on the • the temporal ‘sound window’ (through the Squama ossis tempo-
atlas) or in the A. angularis (corner of the eye) can be demonstrat- ralis) for the study of the initial sections of the Aa. cerebri and
ed. In the A. angularis, a reverse flow means that the blood that the intracranial section of the A. carotis interna
normally flows from the A. angularis into the A. facialis now flows • the nuchal ‘sound window’ (through the Foramen magnum) for
into the A. ophthalmica and from there into the A. carotis interna. the study of the intracranial sections of the Aa. vertebrales and
The flow reversal in the A. angularis indicates an occlusion of the the A. basilaris
A. carotis interna. • the orbital ‘sound window’ (through the orbita) for the study of
the A. ophthalmica
Doppler ultrasound of intracranial brain vessels The transcranial doppler examination also allows the detection of
With the ultrasound you can – despite considerable loss of sound vasospasm of cerebral vessels, for example as a result of a subarach-
– also examine vessels in the skull when the skull bone is thin noid haemorrhage. In acutely ill patients with a subarachnoid hae-
enough. Important ‘sound windows’ in this case are: morrhage, a transcranial examination is therefore carried out on a
daily basis as ‘vascular monitoring’.

634
12 Special neuroanatomy
12.1 Telencephalon . . . . . . . . . . . . 637 12.4 Cerebellum
12.1.1 Overview Michael J. Schmeißer . . . . . . . . 673
Tobias M. Böckers . . . . . . . . . . 637 12.4.1 Overview . . . . . . . . . . . . . . . . . 674
12.1.2 Embryology 12.4.2 Embryology . . . . . . . . . . . . . . . 674
Tobias M. Böckers . . . . . . . . . . 637 12.4.3 Position and
12.1.3 Classification of external appearance . . . . . . . . 674
the telencephalon 12.4.4 Internal structure . . . . . . . . . . 676
Tobias M. Böckers . . . . . . . . . . 637
12.4.5 Neurovascular pathways . . . . 677
12.1.4 Fibre systems of
the telencephalon 12.4.6 Blood supply . . . . . . . . . . . . . . 678
Tobias M. Böckers . . . . . . . . . . 638
12.5 Cranial nerves
12.1.5 Neocortex Anja Böckers,
Tobias M. Böckers . . . . . . . . . . 638 Michael J. Schmeißer . . . . . . . . 679
12.1.6 Archicortex 12.5.1 Overview . . . . . . . . . . . . . . . . . 679
Thomas Deller,
Andreas Vlachos . . . . . . . . . . . . 643 12.5.2 Embryology . . . . . . . . . . . . . . . 681

12.1.7 Paleocortex 12.5.3 Arterial blood supply . . . . . . . 684

Thomas Deller, 12.5.4 N. olfactorius
Andreas Vlachos . . . . . . . . . . . . 650 (1st cranial nerve, N. I)
12.1.8 Subcortical nuclei Michael J. Schmeißer . . . . . . . . 684
Michael J. Schmeißer . . . . . . . . 652 12.5.5 N. opticus
(2nd cranial nerve, N. II)
12.2 Diencephalon Michael J. Schmeißer . . . . . . . . 685
Tobias M. Böckers . . . . . . . . . . 656 12.5.6 N. oculomotorius
12.2.1 Overview . . . . . . . . . . . . . . . . . 656 (3rd cranial nerve, N. III)
12.2.2 Epithalamus . . . . . . . . . . . . . . 657 Michael J. Schmeißer . . . . . . . . 685

12.2.3 Thalamus . . . . . . . . . . . . . . . . . 658 12.5.7 N. trochlearis

(4th cranial nerve, N. IV)
12.2.4 Hypothalamus . . . . . . . . . . . . . 660 Michael J. Schmeißer . . . . . . . . 687
12.2.5 Subthalamus . . . . . . . . . . . . . . 664 12.5.8 N. trigeminus
(5th cranial nerve, N. V)
12.3 Brainstem Anja Böckers . . . . . . . . . . . . . . 688
Michael J. Schmeißer,
Stephan Schwarzacher . . . . . . . 664 12.5.9 N. abducens
(6th cranial nerve, N. VI)
12.3.1 Mesencephalon . . . . . . . . . . . 664 Michael J. Schmeißer . . . . . . . . 695
12.3.2 Pons and 12.5.10 N. facialis
Medulla oblongata . . . . . . . . . 668 (7th cranial nerve, N. VII)
12.3.3 Functional systems Michael J. Schmeißer . . . . . . . . 696
of the brainstem . . . . . . . . . . . 672 12.5.11 N. vestibulocochlearis
12.3.4 Blood supply (8th cranial nerve, N. VIII)
to the brainstem . . . . . . . . . . . 673 Michael J. Schmeißer . . . . . . . . 699
12.5.12 N. glossopharyngeus 12.6 Spinal cord
(9th cranial nerve, N. IX) Anja Böckers . . . . . . . . . . . . . . 711
Anja Böckers . . . . . . . . . . . . . . 701 12.6.1 Overview . . . . . . . . . . . . . . . . . 711
12.5.13 N. vagus 12.6.2 Segmental structure
(10th cranial nerve, N. X) of the Medulla spinalis . . . . . . 711
Anja Böckers . . . . . . . . . . . . . . 704
12.6.3 Surface and
12.5.14 N. accessorius cross-sectional anatomy . . . . 712
(11th cranial nerve, N. XI)
Anja Böckers . . . . . . . . . . . . . . 708 12.6.4 Structure
of the Substantia grisea . . . . . 715
12.5.15 N. hypoglossus
(12th cranial nerve, N. XII) 12.6.5 Structure
Anja Böckers . . . . . . . . . . . . . . 709 of the Substantia alba . . . . . . 716
12.6.6 Blood supply . . . . . . . . . . . . . . 719
12.6.7 Motor functions
of the spinal cord . . . . . . . . . . 720
 12.1 Telencephalon

12.1 Telencephalon 12.1.2 Embryology
Tobias M. Böckers

The telencephalon develops from the telencephalic vesicles, which

Skills are further differentiated into 2 lateral telencephalic vesicles. These
After working through this chapter, you should be able to: completely grow over the rest of the brain in a ventrocaudal direc-
• provide the classification of the telencephalon by its parts, tion in a C-shaped growth curve and remain medially separated by
and name the division criteria the Fissura longitudinalis. As a result, parts of the lateral cortex are
• explain the essential fibre connections of the brain and their displaced deep into the Sulcus lateralis. This part of the brain is re-
function
ferred to as the insula area; the overlapping brain layers, in particu-
• describe the parts of the neocortex
• explain the position and function of the primary and sec- lar the frontal lobes, are also called the opercula. In later foetal de-
ondary cortical areas of the individual lobes velopment, the Lobus frontalis can be distinguished from the pari-
• define hemisphere dominance and examples of the clinical etal, temporal and occipital lobes. These cortical areas are initially
impact (in neurological/psychiatric terms) smooth and then become increasingly gyrified, i.e. the characteris-
• identify the macroscopic hippocampus and fimbria-fornix tic gyri and sulci of the brain surface are formed; these significantly
on frontal and horizontal sections and explain their relation- enlarge the cortex. In the course of development, bundles of fibres
ship to the ventricular system
grow out of the hemispheres, respectively reaching the correspond-
• name the areas belonging to the so-called hippocampal for-
mation and describe the signal flow through the hippocam- ing areas of the other hemisphere. These tracts are also known as
pal formation commissural tracts and connect the right and left hemispheres
• indicate the cingulate cortex and its parts in a dissection (Corpus callosum, Commissura anterior, Commissura fornicis).
and talk through your basic knowledge about its function In the context of the movement of growth, the lumina of the telen-
• indicate the areas of the paleocortex and olfactory cortical cephalic vesicles also expand to reach the winding lateral ventricles
areas on the dissection of the hemispheres, which are connected via the Foramina inter-
• explain the connections of the paleocortex with other areas
ventricularia with the IIIrd ventricle of the diencephalon.
of the brain, especially the limbic system
• explain the position and function of the most important sub-
The subcortical nuclei are formed from the basal plate in the ven-
cortical nuclei and identify them on sections of the brain tral section of the side wall of both hemispheres. After a massive
from a wide range of orientations regional cell division, a swelling (ganglionic hill) arises here, which
• explain, based on the knowledge acquired relating to neuro- further develops into the Corpus striatum.
nal configurations within the basal ganglia, the symptoms of
PARKINSON's and HUNTINGTON's diseases
12.1.3 Classification of the telencephalon
Tobias M. Böckers

12.1.1 Overview The telencephalon, due to morphological criteria (the minute struc-

Tobias M. Böckers ture of the cortex/stratification), can be divided into 3 sections: neo­
cortex (isocortex), archicortex and paleocortex. The basis for this
The telencephalon (endbrain, cerebrum) describes the two cere­ classification is the comparison of animal brains at various levels of
bral hemispheres (Hemispheria cerebri), the subcortical nuclei the biological system (i.e. different levels of evolutionary develop-
(Nuclei basales) and the Substantia alba (pulp of the cerebrum) in ment). This comparative anatomical approach also allows conclu-
the respective cerebrum area. The telencephalon makes up around sions to be drawn on how the human brain has developed through
80% of the total mass of the human brain, with the grey matter evolution and which parts of the brain are phylogenetically (Greek:
mainly located on the surface anatomy (Cortex cerebri). The grey phylon = stem, and genesis = origin) the ‘oldest’ and the ‘youngest’.
matter of the cortex, together with the underlying white matter, is A phylogenetically older part can thus be demonstrated in the brains
referred to as the pallium. of simpler mammals, whereas phylogenetically younger parts of the
Macroscopic examination shows the telencephalon as being by far brain can only be found in the brains of more advanced mammals
the greatest part of the brain surface. Even at first glance, the two and, in some cases, only in the human brain (› Fig. 12.1).
hemispheres of the brain can be distinguished, separated from each • Due to histological criteria, the neocortex (› Chap. 12.1.5) is
other by the Fissura longitudinalis cerebri. Their hemispheral also referred to as the isocortex. Its volume has greatly increased
rim make the two hemispheres protrude into the Fissura longitudi- in the course of human development, so the paleocortex has
nalis cerebri. The duplication of the Dura mater (Falx cerebri) is been shifted to the cranial base and the archicortex likewise to
embedded within this fissure; on the floor of the fissure, the Corpus the mediobasal side of the brain. The functions of the neocortex
callosum is visible. The 6 lobes of the endbrain are distinguished as are complex and include motor, sensory and associative tasks.
being separated by other prominent sulci (› Chap. 11.2.3, › Fig. The neurons in these cortex units form predominantly 6 layers.
11.16, › Fig. 11.17, › Fig. 11.18): • The predominantly 3-layered allocortex can be further divided
The endbrain is the youngest portion of the human brain and pro- into the following sections:
vides the basis for special human intellectual capacities. It controls – The archicortex (› Chap. 12.1.6 ) particularly describes
language and communication, provides the central control for in- parts of the hippocampal formation and histologically shows a
tentional movements and sensitivity, and it controls or influences 3-layered structure. The archicortex is a younger section of the
the emotions. It is also the part of the brain that is essential for the cortex, tasked with controlling the vegetative functions and
development of awareness, as well as for memory. learning and memory.
– The paleocortex (› Chap. 12.1.8), consists mainly of sections
of the olfactory brain, particularly at the base of the brain.
This also show a predominantly 3-layered structure.

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12 Special neuroanatomy

Neocortex Lobus parietalis with the Lobus occipitalis. The Fasciculus longi­
tudinalis inferior creates the connection between the Lobus tem-
Indusium griseum,
part of the archicortex
poralis and Lobus occipitalis; the Fasciculus uncinatus is found
between the Lobus frontalis and the Lobus temporalis; the Fasci­
culus arcuatus connects amongst other things the sensory language
area with the motoric BROCA's area (› Fig. 11.23a).
The important commissure tracts are the Corpus callosum, the
Commissura anterior and the Commissura fornicis (› Fig.
11.23b):
Striatum • The Corpus callosum is about 10 cm long and connects the Lobi
frontalis, parietalis and occipitalis of the two hemispheres with
each other. At the Corpus callosum we can distinguish a front
knee (genu) with a tapering Rostrum corporis callosi, a mid
trunk and a thickened rear bulge (Splenium). The trunk is con-
nected to the fornix and the Septum pellucidum. The fibre
strands turn off sharply in the Corpus collossum, becoming the
Forceps frontalis minor (passing in the Lobus frontalis) in the
Paleocortex
front portion and the Forceps occipitalis major in the rear por-
Fig. 12.1 Parts of the telencephalon. [L126]
tion.
• The Commissura anterior is in close proximity topographically
with the rostrum of the Corpus collossum or the front wall of
In addition to these parts of the cortex, developing from the telen- the IIIrd ventricle and contains, amongst other things, the fibres
cephalon there are also the subcortical nuclei (Chap. 12.1.9). of the olfactory system.
Amongst them are the striatum (consisting of the Nucleus cauda- • The Commissura fornicis is the commissural connection of the
tus and Putamen), of the Nucleus accumbens, the claustrum and leg portions of the fornix. Fibre bundles of the hippocampi of
parts of the Globus pallidus. Chap. 12.1.9 also describes the amyg- both hemispheres pass through this connection.
dala and the Nucleus basalis MEYNERT. The projection fibre systems form a fibre compartment, also called
a Corona radiata (fibre strands from or to the cortex). These fibre
NOTE connections are joined together in the area of the basal nuclei and
On the basis of histological-morphological and comparative-ana- are canalled through the subcortical nuclear areas at defined points
tomic criteria, the cortical sections of the telencephalon are divid- (somatotope classification). The highest density of the projection
ed into 3 parts: ­fibres can be found in the Capsula interna between the Globus pal-
• The neocortex is predominantly made up of 6 layers (isocortex)
lidus, the thalamus and the Nucleus caudatas. The Capsula interna
and is by far the largest part of the telencephalon.
• The archicortex includes the largely 3-layered parts (allocortex) of
is divided into a front leg (Crus anterius), a rear leg (Crus posteri-
the limbic system. us) and a knee (genu). The respective fibres pass through the Cap­
• The paleocortex is also mostly 3-layered (allocortex) and essen- sula interna to defined points and remain arranged in a somatotopic
tially encompasses the olfactory brain. order. Important descending fibres form the pyramidal tract
In addition, this includes the subcortical nuclei, embryologically (› Chap. 13.1); large ascending tract systems originate in particu-
formed from the telencephalon vesicles. lar from the thalamus as thalamocortical projections (› Chap.
13.2). The Capsula externa, a thin plate made of white matter, is
situated between the Nucleus lentiformis and the claustrum, and
laterally to the claustrum (up to the insular cortex) there is another
12.1.4 Fibre systems of the telencephalon fine plate of fibre, the Capsula extrema.
Tobias M. Böckers

Cortical and nuclear areas of the telencephalon are in close contact 12.1.5 Neocortex
with each other, so that the fibres under the cortex or between the Tobias M. Böckers
cortex and other parts of the CNS take up a great deal of space
(Substantia alba, white matter). Because of the source and target General
structures of the fibre strands, we differentiate between association The neocortex (isocortex) is the uniformly-designed, predomi-
fibres (Fibrae associationes), commissure fibres (Fibrae commissu- nantly 6-layer endbrain cortex, which, in its evolutionary develop-
rales) and projection fibres (Fibrae projectiones) (› Fig. 11.23, ment as a primate has undergone an impressive increase in volume
› Chap. 11.2.5 ). compared to the other parts of the brain. In humans, it accounts
Due to their length, association fibres can be divided into addi- for about half of the brain's weight ‒ approximately 90% of all cor-
tional subgroups (› Fig. 11.23a): tex areas of the brain are designed to be isocortex. Overall, the area
• short, so-called U-fibres (Fibrae arcuatae cerebri breves) con- of the cortex in humans is approximately 2,200 cm2.
nect with adjacent gyri, Functionally, the neocortex is divided into centres, of which the in-
• slightly longer fibre strands (Fibrae arcuatae cerebri longae) terplay implements the perceptions of all aspects of external stimu-
connect gyri which are located further away and li and/or leads to motivated actions. However, the definition of the
• long association tracts can connect lobes of the same hemi- functional fields serves as a very simplified way of explaining the
sphere. extremely complex capabilities of the human brain:
Examples can also be seen in dissections in the Fasciculus longitu­ • Primary fields describe cortex areas, receiving sensory informa-
dinalis superior, connecting the gyri of the Lobus frontalis and the tion directly from the thalamus and creating awareness (with the

638
 12.1 Telencephalon

exception of the olfactory system). They are therefore the prima- synaptic contacts. The Pia mater is attached to the Lamina mo-
ry point at which the corresponding sensory tracts end (e.g., au- lecularis via a superficial layer (Membrana limitans gliae superfi-
ditory pathway, visual pathway). The Gyrus precentralis is a pri- cialis). In this layer, small, so-called CAJAL-RETZIUS cells can
mary motor field from which direct movement is initiated via be identified. These play a special role in the formation and lami­
the Tractus corticospinalis (pyramidal tract). nation of the cortex (expression of Reelin).
• Secondary fields are often located directly next to the primary • Outer nuclear layer (Lamina granularis externa, lamina II):
fields. Here, the primary information is processed and brought Characteristically, these are tightly packed, small ‘non-pyramidal
up to the next level of integration. The information is thus, for cells’ (mainly GABAergic nuclear cells) with short apical den-
example, interpreted and allocated, and the first consequences of drites. In addition, there are a few glutamatergic pyramidal cells.
what has been experienced are initiated here. In terms of action, • Outer pyramidal layer (Lamina pyramidalis externa, lamina
movements, for example, are planned and motivated here. III): We can distinguish 3 sublaminae with an increasing num-
• Polymodal association fields are not explicitly allocated to a pri- ber of small pyramidal cells (IIIa–c). Apical dendrites can extend
mary centre, but reciprocally interconnected with several other up to lamina I, ending as an ‘apical cluster’. The laminae IIIa and
primary and secondary centres. We can suppose that here, for IIIb are affected in certain neurodegenerative diseases (e.g., par-
example, the various experiential components being experienced ticularly in ALZHEIMER's disease).
are reassembled. • Internal nuclear layer (Lamina granularis interna, lamina
IV): As in the lamina II, here there are small, tightly-packed
Lamination of the isocortex non-pyramidal cells (nuclear cells) which receive their primary
The cerebral cortex is usually approximately 4 mm thick, but in the afferents from the thalamocortical neurons.
primary visual cortex, for example, it is only 2 mm. The laminar • Internal pyramidal layer (Lamina pyramidalis interna, lami­
six-layer structure is best presented in histological dissections that na V): in this layer can be found pyramidal cells of varying sizes,
are cut perpendicular to the cortex surface. NISSL-staining is a which are very large in some cortex areas and are also called gi­
suitable dyeing method (staining the nuclei and the NISSL-­ ant BETZ cells. The axons of these glutamatergic neurons have
substance), as is myelin-staining (colouration of the myelin), strong myelin sheaths, and in the Gyrus precentralis they form
showing such laminations as being either cytoarchitectonic or the corticospinal and corticonuclear tracts.
myelo­architectonic (› Fig. 12.2). The layers are numbered from • Multiform layer (Lamina multiformis, lamina VI): This layer
outside to inside: is often divided into the lamina VIa with a high cell density and
• Molecular layer (Lamina molecularis, lamina I): In this layer, a lamina VIb which has fewer neurons. Smaller pyramidal cells
there are only isolated neurons (no pyramidal cells), with exten- of varying morphology can be found here.
sions running parallel to the surface anatomy of the cortex and
Cortical areas
GOLGI Myelinisation The essentially uniform layered structure of the isocortex is derived
Lamina NISSL STAINING IMPREGNATION dyeing
from an initially smooth cortical plate with progenitor cells for
neurons and glial cells. The subsequent changes in embryonic de-
I
velopment are determined by ingrowing axons and then by the mi-
gratory movements of the cortical neurons (proneurons): early de-
II
veloping neurons can be found later in deep layers of the isocortex,
with later developing neurons in higher layers (e.g., in the later lay-
er II). This type of layer formation is also known as ‘inside-out lay­
ering’.
The six-layered structure of the isocortex may vary significantly:
III
the individual layers can vary in width, and the cells within them
can differ in size and density. The layered structure of the human
brain has been laboriously analysed, so that areas with equal archi-
tectonic layers have been defined, thus creating a mapping of the
isocortex, leading to what are known as the BRODMANN areas
IV (numbered consecutively) starting at the Gyrus postcentralis,
› Fig. 12.3). The individual cortical areas are not only morpholog-
ically/histologically similar, but also assume functionally similar
tasks. Interestingly, in the cortical fields that serve as projection
fields (e.g., the auditory cortex), there are clearly visible granule cell
V ­layers, which are almost absent in the motor cortex.
An even smaller unit in the structure of the isocortex is that of fine
cell columns, which pass through the layers of the isocortex and
VI are made up of a network of around 100 neurons. These are re-
ferred to as primary modules and can be grouped into larger or-
ganisational units, which thus form larger functional units.

Classification of the neocortex

The neocortex is divided by the well-developed primary grooves
(› Table 12.1 into 5 externally visible lobi (the 6th Lobus limbicus
Fig. 12.2 Six-layered structure of the neocortex. [L240/S010-2-16] is only visible through a midline incision through the Corpus cal-

639
12 Special neuroanatomy

6 4 Table 12.1 Primary grooves of the cortex.

8 31
2
5 Sulcus Position/course
9 7a
Sulcus Runs between the frontal and parietal lobes; thereby separating the
7b ­centralis (motor) Gyrus precentralis from the (sensory) Gyrus postcentralis
Sulcus Separates the frontal, parietal and temporal lobes from each
46
10 ­lateralis other; the Fossa lateralis and insula lie in the depth
19
40
Sulcus parie- Passes from the Margo superior cerebri on the medial hemi-
44a 44 39
45 to-occipitalis sphere area up to the Sulcus calcarinus; separates parietal and
43 18
occipital lobes
52 41
47 42
11 Sulcus Runs like the Sulcus parieto-occipitalis on the medial surface,
22
­calcarinus limiting the cuneus
38 17
21 Sulcus Separates the Gyrus cinguli (Lobus limbicus) of the frontal and
­cinguli parietal lobes
37 19 18
20
Lobus frontalis
Fig. 12.3 Classification of the brain according to histological criteria The frontal lobe (Lobus frontalis) extends from the frontal pole of
(known as the BRODMANN areas). [S010-2-16] the brain to the Sulcus centralis. It can be divided into 3 main ar-
eas: the primary motor cortex (BRODMANN area 4), premotor
losum on the Facies medialis of the cerebrum. It includes the Gy- cortex (BRODMANN area 6) and prefrontal areas (including
rus cinguli located on the Facies mediales, as well as its continua- BRODMANN areas 9–12, › Fig. 12.3).
tion on the Facies inferior, the Gyrus parahippocampalis, which is
separated by the Sulcus collateralis from the Lobus temporalis): Primary motor cortex
• Lobus frontalis (frontal lobe) The primary motor cortex corresponds to the Gyrus precentralis,
• Lobus parietalis (parietal lobe) which is directly adjacent to the Sulcus centralis and extends via
• Lobus temporalis (temporal lobe) the Margo superior cerebri to the Fissura longitudinalis cerebri.
• Lobus occipitalis (occipital lobe) Within this gyrus, the impulses for the voluntary motor functions
• Lobus insularis (insular lobe) are located, which are canalled via the pyramidal tracts (› Chap.
13.1) into the periphery of the motor cranial nerve nucleus and the
anterior horn cells in the spinal cord. The Gyrus precentralis has a

Primary somatomotor cortex

Supplementary motor cortex Gyrus precentralis

(secondary somatomotor) Primary somatosensory cortex

Premotor cortex Gyrus postcentralis Fig. 12.4 Functional cortical

(secondary somatomotor) Secondary somatosensory cortex areas of the cerebral hemi-
Posterior parietal association cortex spheres. Higher cortical func-
Frontal eye fields tions such as language are
(coordination of WERNICKEʼs centre
eye movements) (sensory language centre) linked to the interaction of many
different parts of the cortex. Pri-
Prefrontal Association field mary fields (e.g., Gyrus precen-
association cortex Secondary visual cortex tralis, primary somatomotor cor-
tex) are differentiated from
Gyrus frontalis inferior, secondary and associated fields
Primary visual cortex
Pars opercularis (e.g., premotor cortex, supple-
mentary motor cortex). Primary
BROCAʼs area and secondary fields are there
Secondary auditory cortex
(motor language centre)
to serve a specific piece of sen-
Primary auditory cortex
a Gyri temporales transversi
sory information (e.g., the visual
cortex in the occipital lobes for
the perception and interpreta-
tion of visual pulses) and asso-
Primary somatomotor cortex Gyrus precentralis ciation fields (e.g., prefrontal
Primary somatosensory cortex association cortex) occupy the
Supplementary motor cortex Gyrus postcentralis
largest part of the cortex and are
(secondary somatomotor) there to serve the integration of
Secondary
different pieces of complex
somatosensory cortex
Prefrontal information. a Left view. The
association cortex Posterior parietal outline of the human-like char-
association cortex
acter (homunculus) reflects the
Secondary visual cortex somatotopic structure in the pri-
Primary visual cortex mary somatomotor cortex. b
Medial view. Primary and sec-
Sulcus calcarinus ondary auditory cortices, as well
Primary visual cortex as the WERNICKE's area, extend
b Secondary visual cortex over the top of the temporal
lobe, to its inner surface.

640
 12.1 Telencephalon

clear somatotope structure, which is also referred to as the homun- over to the opposite side before making contact with various places
culus and which, for example, illustrates the particularly strong in the area of the thalamic nuclei (Nucleus ventralis posterior thal-
representation of hand and facial muscles (› Fig. 12.4). Amongst ami, › Chap. 12.2.3) (› Chap. 13.3). As with the Gyrus precen-
others, this area receives afferents from the thalamus, the premotor tralis, a somatotopy and variable representation of the skin areas
areas, as well as the somatosensory cortical fields. are found on the Gyrus postcentralis. The visualisation of these
projections is referred to as (somatosensory) homunculus.
Premotor cortex • Behind the Gyrus postcentralis, a secondary sensory cortical
The premotor cortex (area 6) should functionally be a centre for field connects (S2), which is also somatopically divided and is
the selection and planning of movement programmes, which are especially significant for the interpretation of the sensitive stimuli.
then transmitted to the motor cortex to be implemented. It is addi- • In addition, it connects with the Gyrus postcentralis or with the
tionally assumed that motor programmes are registered in this secondary cortical field of the posterior parietal association
area, for example, based on the learnt interaction between basal cortex (areas 5 and 7). It receives a wide variety of afferents from
ganglia, the cerebellum and cortex units. other primary and secondary sensory areas and should in par-
Within the premotor cortex (sometimes also as a separate cortical ticular be meaningful for orientation in a three-dimensional
area), the frontal eye fields (area 8) can be delineated, which is space (non-dominant side).
crucial for the initiation and planning of conjugated eye move- • The cortical area under the Sulcus intraparietalis and/or around
ments (eye adjustment movements). the Gyrus angularis (area 39), and the Gyrus supramarginalis
In the Gyrus frontalis inferior of the left (in approximately 95% of of the dominant hemisphere is also referred to as the ‘mathemat-
people) frontal lobe, the BROCA's language area is found in the ical cortex’, as here, amongst other things, the ability to deal with
Pars opercularis and partially in the Pars triangularis. This centre is numbers is especially represented. The Gyrus angularis seems to
­activated by the concept of sentences and words, terminology, but be an important connection point between visual and audio in-
not the control of speech itself (premotor cortex). Verbal under- formation. Accordingly, damage in this area is associated with
standing is located in the so-called WERNICKE's area (area 22) reading and/or writing problems.
(located at the transition of the Lobus temporalis [see below] to the • The primary vestibular cortex is delineated close to the Gyrus
Lobus parietalis). postcentralis in the hand and mouth area. The afferents from the
vestibular nuclear areas of the brainstem terminate here; these
can be switched via thalamic nuclear areas (› Chap. 13.5).
Clinical remarks
With unilateral stimulation, the frontal eye field guides eye Lobus temporalis
movement to the contralateral side. Lesions of the frontal eye The temporal lobe (Lobus temporalis) is located under the Fissu-
field (e.g., due to hemorrhage or tumours) which are associat- ra lateralis of both cerebral hemispheres and merges rostrally with-
ed with unilateral failure of area 8, will lead to a deviation of out a clear delimitation into the Lobus parietalis.
both bulbi to the affected side (déviation conjugée); ‘The pa-
• An important area in the temporal lobe can be found on the dor-
tient views the lesion.’ In failures of the BROCA language area
(e.g., within the context of a cerebral infarction) language pro- sal surface of the Gyri temporales transversi. These are 2 trans-
duction is severely limited (BROCA's aphasia). However, the verse turns, which are also referred to as HESCHL's gyri (area
ability to name objects and also to understand speech often 41). This area represents the primary auditory cortex (› Fig.
remains intact. Syntax in affected patients is often incorrect 12.4). Terminating here is the auditory system (› Chap. 13.4),
and there are mistakes with articulation. which, based on relative frequencies, is represented tonotopical-
ly on special cortex areas. Lower frequencies are thus located
rostrolaterally, with higher frequencies caudomedially along the
Fissura lateralis. Its function as the primary cortical field in-
Prefrontal area volves perception of auditory stimuli, but these are not interpret-
The prefrontal area (prefrontal cortex) encapsulates the cortex areas ed (words are not perceived, for example); moreover, a variable
rostral of the premotor cortex (up to the Polus frontalis) and is close- activation could be shown if there are varying sound intensities.
ly associated with the higher intellectual, mental and social perfor- • Lateral to the HESCHL's gyri is the secondary auditory cortex,
mance of the human brain. It seems that here, located in this brain which receives its primary afferents from the primary auditory
area, are values, ideals and ethical behaviour, as well as the highest cortex. In these areas, sound takes on high levels of meaning:
parts of cognitive performance such as combinatorial and methodi- tones become melodies, words or phrases. With regard to the two
cal thinking (and also the development of motivation for actions). hemispheres, it should be noted that the WERNICKE's area is
­located in the dominant hemisphere; it is also known as the sen-
Lobus parietalis sory language area. In particular, the interpretation of language is
The parietal lobe (Lobus parietalis) extends dorsally from the Sul- significant. The appreciation for tunes (non-rational auditory im-
cus centralis to a line defined by the Sulcus parieto-occipitalis. This pressions) is notably located in the non-dominant hemisphere.
sulcus is very easily seen on the median side of the brain and it
continues on the lateral side. There are several sensory areas in the
Lobus parietalis:
Clinical remarks
• Extending directly behind the Sulcus centralis – parallel to the When the damage to the primary auditory cortex is only on one
­Gyrus precentralis – the Gyrus postcentralis (› Fig. 12.4) reaches side, it has a relatively low impact (e.g., impairment of direc-
similarly over the Margo superior cerbri into the Fissura longitudi- tional hearing, distinguishing between frequency/intensity).
nalis cerebri. This gyrus (S1, BRODMANN areas 3, 1, 2) is the pri- Failure of the WERNICKE's area (WERNICKE's aphasia) has a
significant impact on speech intelligibility. Language produc-
mary somatosensory cortical field of the body. The proprioceptive
tion and intonation are retained, but the spoken words often
and somatosensory information from the skin of the opposite side have no meaning and no sentence structure can be identified.
of the body end here, because the associated tract systems cross

641
12 Special neuroanatomy

Lobus occipitalis NOTE

Important functional centres in the lobi of the neocortex
Occipital lobe (Lobus occipitalis) is the area of the cortex running
from the Sulcus parieto-occipitalis up to the rear pole of the brain. • Lobus frontalis (frontal lobe)

In particular, the occipital lobe represents the cortical areas for the – Gyrus precentralis (primary motor cortex, BRODMANN area 4)
– premotor cortex (BRODMANN area 6) with frontal eye fields (area
visual system (› Chap. 13.3).
8, eye adjusting movements) and BROCA language area.
• On the medial side of the occipital lobe, there is a sulcus (Sulcus – prefrontal areas (including BRODMANN areas 9–12, ‘higher
calcarinus), the bordering gyri of which contain the primary vi­ brain performance’)
sual centre or the primary visual cortex (area 17). At the occipi- • Lobus parietalis (parietal lobe)
tal pole, these gyri extend slightly into the convexity of the brain – Gyrus postcentralis (primary sensory cortex, S1, BRODMANN
(› Fig. 12.4). Macroscopically, the cortex stands out relatively areas 3, 1, 2)
finely and contains a white stripe, also known as the lines of – secondary sensory cortical field (early processing of information)
GENNARI (or the bundle of VICQ D'AZYR). It is produced by – posterior parietal association cortex (areas 5 and 7, polymodal
association nerve fibres located in the 4th layer of this isocortex association field)
area, and the cortical field is also called the ‘Area striata’. The – Gyrus angularis (area 39) and Gyrus supramarginalis of the
optic radiation ends in the primary vision centre (afferents are dominant hemisphere (‘mathematical cortex’)
– primary vestibular cortex (afferents from vestibular nuclear
conducted primarily from the Corpus geniculatum laterale), i.e.,
­areas of the brainstem)
visual stimuli are consciously perceived here. This primary corti- • Lobus temporalis (temporal lobe)
cal field receives information from the retina in a clear retino- – Gyrus temporalis transversi (primary auditory cortex, HESCHL's
topic structure, so that each retinal area is assigned to an area in gyri area 41)
the primary visual cortex. The organisational structure of the – Secondary auditory cortex (early processing of information)
cortex into what are called columns is particularly obvious in the • Lobus occipitalis (occipital lobe)
visual cortex, because the stimulation of the visual cortex affects – Sulcus calcarinus (and the bordering gyri form the primary visu-
an entire column per retinal area, running vertically through all al centre area 17)
the cell layers. – secondary visual cortex areas (areas 18 and 19, early process-
• Around the primary visual cortex are the secondary visual cor­ ing of information)
• Lobus insularis (insular lobe)
tical areas (areas 18 and 19), arranged in crescent shapes, which
– general processing of viscerosensitive information
receive their afferents mainly from the primary visual centre
– particularly taste receptors, but also pain, position and move-
(area 17). In these areas, the visual impulses are processed (e.g., ment perception
recognition, memory) and transferred to other cortical areas.
Experimentally, it could be demonstrated that certain areas are
particularly activated when perceiving colour, while others are Hemispheric dominance
used, for example, for identifying faces. At first glance, both cerebral hemispheres function in exactly the
same way, but on closer inspection, morphological differences can
be seen: secondary gyri and sulci in corresponding cerebrum sec-
Clinical remarks tions are not distributed symmetrically, and their length, depth and
Damage to the primary visual cortex of a hemisphere (cortical shape is different. Furthermore, the left hemisphere has a larger
blindness) causes a homonymous hemianopsia. This means specific weight and in 70% of cases, the SYLVIAN fissure, the Sul-
that the visual field of the opposite side completely fails. cus lateralis, is broader. In addition, functional differences between
The consequence of damage to the secondary cortical areas is the two hemispheres have been established. This is referred to as
that the patient receives the visual stimuli, but can ‘neither
hemispheric asymmetry, which is not only observable in humans,
identify nor assign’ them (visual agnosia).
but also in other vertebrates. While many somatosensory and so-
matomotor functions are allocated symmetrically in the two halves
of the brain, BROCA had already observed that the hemisphere
Lobus insularis containing the ‘motor centre for speech’ is the opposite one to the
The insular lobe (Lobus insularis) is deeply embedded during preferred (dominant) hand – so for a right-handed person it is in
embryonic development. Located on the floor of the Fissura (Sul- the left half of the brain. This is sometimes also referred to as hemi­
cus) lateralis, it is covered with telencephalic structures, which are spheric dominance. It is probably not innate, but may be created
also known as the operculum, consisting of the Operculum fron- and mainly develops in the course of the first years of life alongside
tale, the Operculum parietale and the Operculum temporale. The language acquisition. This is also reflected in the fact that it is still
insular area is triangular in shape and is divided by a Sulcus centra- possible to learn language even after a cerebral hemisphere has
lis insulae into an oral and caudal pole (› Fig. 11.17). The insular been removed (hemispherectomy). After about the age of 15, the
area at the base of the brain passes into the olfactory brain (paleo- non-dominant side is no longer able to learn new linguistic func-
cortex). tions. The generalised rule established by BROCA only applies to
In this area of the brain, it is mostly general viscerosensory infor­ approximately 95% of right-handed people and 15% of left-
mation that is processed, particularly the taste receptors (› Chap. handers. In most left-handers, the language area is also sited in the
13.6, › Chap. 13.7), as well as the perception of pain, placement left hemisphere or, in 15% of them, is created bilaterally. Similarly,
and movement. The insular area is closely related to the Corpus it was shown that the posterior cortical area behind the primary
amygdaloideum and the hypothalamus, so that visceromotor infor- auditory cortex, known as the Planum temporale, where the sen-
mation also reaches the brainstem from the insula. sory language area (WERNICKE's area) is located, has been creat-
ed asymmetrically and is, in the dominant half of the brain (mainly
on the left side), significantly more extensive.
The findings on hemispheric asymmetry and the position of im-
portant functional centres are shown in the following studies:

642
 12.1 Telencephalon

• with what is referred to as the WADA method, a transient, phar­ 12.1.6 Archicortex

ma­cologically-induced hemispherectomy is performed. This pro- Thomas Deller, Andreas Vlachos
cedure has been used before when performing a hemispherectomy
to determine the dominant hemisphere by anaesthetising a hemi- General
sphere with a one-sided injection of a sedative into the A. carotis The term archicortex includes a part of the brain phylogenetically
interna. located between the paleocortex and the neocortex. It can be iden-
• with ‘split-brain’ patients, where the Corpus callosum, acting as a tified in reptiles, birds and mammals. In reptiles, the archicortex is
unifying element between the two hemispheres, is severed in an the actual control centre of the endbrain. Histologically, the archi-
operation (e.g., in order to treat an otherwise unmanageable case of cortex presents a predominantly three-layered structure. It there-
epilepsy). Roger SPERRY examined patients such as these and de- fore belongs to the allocortex. The archicortex includes, in particu-
termined that communication between the hemispheres relating to lar, the hippocampal formation and the cingulate cortex. The cin-
the impulses received and their processing after the operation, was gulate cortex is cytoarchitecturally a transition zone between the
no longer possible following the operation, and for the ‘split-brain’ archicortex and the neocortex and is therefore also sometimes re-
patients typically led to malfunctions (see Clinical remarks). ferred to as the periallocortex.
Additional findings also came from the precise examination of pa- Functionally, the archicortex is important for learning and mem­
tients with brain lesions in only one hemisphere, which led to spe- ory processes. It is also part of the limbic system and is connected
cific functional failures. Today, functional MRI provides more op- intensively via this with brain areas that are important for the con-
tions for specific research. trol of autonomic and emotional processes. It affects this area and
conversely is also influenced by it.
In clinical medicine and research, knowledge of the anatomy of the
Clinical remarks hippocampal formation has become increasingly important. The
The functions of the dominant and non-dominant hemispheres hippocampal formation:
are conveyed via a dense neural network to other cortical areas • plays a role in neurodegenerative diseases with memory loss
of the same or contralateral hemisphere, the basal ganglia or to (e.g., in ALZHEIMER's disease)
the limbic system. Damage to these connections is referred to • is involved in the clinical symptoms of major neuropsychiatric
as disassociative syndrome. An example of this is ‘split-brain’
disorders (schizophrenia, depression, autism)
patients, where the hemispheres independently receive and
process pulses. These patients are not significantly restricted in • is associated with a common form of epilepsy, temporal lobe ep-
their everyday lives, but in experimental situations, certain dis- ilepsy (see Clinical remarks).
sociative symptoms occur: if the image of an object from the left • serves as a landmark in radiological sectional images of the
visual field falls on the right retinal halves of both eyes, split- brain
brain patients are not able to name this item. The information • due to its relatively simple structure it has become a model in re-
will be routed to the primary visual cortex of the right occipital search for the study of the cortex. It can be taken from the brains
lobe. After separation of the Corpus callossum, this information
of young rodents and held in cell cultures (organotypical sec-
can no longer reach the language area located in the dominant
(left) hemisphere. However, the patients are able to identify an tional cultures). These brain cultures (‘brain in a dish’) continue
item placed in the dominant (right) hand. to mature and can be examined in a targeted manner.

Clinical remarks
Lesions of the dominant half of the brain often lead to problems with Temporal lobe epilepsy (TLE) is a common form of epilepsy. It
speech, and affect both the planning of complex movements (aprax- usually starts with an ‘aura’ (i.e. sensory interferences that
ia) as well as analytical thinking. The non-dominant hemisphere par- prefigure a seizure, e.g., in the form of unpleasant feelings in
ticipates in speech by forming or perceiving affective elements (e.g. the stomach), followed by motor symptoms (‘focal’ seizures,
e.g., in the form of smacking and chewing buccal motions, to
speech intonation). In addition, in lesions of the non-dominant
movements of the whole body) and loss of consciousness. In
hemisphere there are malfunctions of the non-verbal functions, e.g., the hippocampus of TLE patients, there is typically a ‘sclero-
visual-spatial thinking (parietal association cortex), the emotional sis’, i.e. a nerve cell death and a proliferation of glial cells. The
comprehension of language and experience, and the appreciation of hippocampal CA1 area (‘SOMMER sector’) is especially com-
music. There is evidence that the non-dominant half of the brain is mon here. To date, it has not been definitively established
involved in the processing of new, creative situations, while the dom- whether hippocampus sclerosis is the cause or the conse-
inant half of the brain is used instead for known, analytical, and tried quence of seizures.
TLE does not always respond to drugs. Therefore, in some cas-
and tested situations. While the left half of the brain primarily con-
es that cannot be treated with medication, parts of the hippo-
trols and processes attentiveness to the contralateral environment campal formation are removed on one side of the brain (‘epi-
field (visual field), the non-dominant half of the brain can also do so lepsy surgery’). This significantly reduces the number of sei-
bilaterally. Since the contralateral environment is predominantly zures, and some patients are seizure-free after the operation.
processed in the frontoparietal cortex, lesions – particularly those in
the non-dominant hemisphere of the brain – can lead to hemispa­
tial neglect syndrome, meaning that the patients do not perceive the
contralateral visual field and, to some extent, cannot even see their Hippocampal formation
own contralateral half of the body. Overview and terminology
It is generally accepted that hemispheric asymmetry, or the func- The term ‘hippocampal formation’ brings together several cortical
tional lateralisation of the cerebrum, is more pronounced in men areas cytoarchitecturally. According to significant neuroscientific
than in women. Here also the concentration of sex hormones (the authors, the hippocampal formation includes:
menstrual cycle in women) is thought to have a modulating effect • Area entorhinalis (also: ‘entorhinal cortex’)
on the level of lateralisation or interhemispheric communication. • Fascia dentata (also: ‘Gyrus dentatus’)

643
12 Special neuroanatomy

• Cornu ammonis (also: ‘Hippocampus proprius’) in the course of a year. The newly formed nerve cells play an im-
• Subiculum portant role in memory processes.
• Pre- and Parasubiculum The hippocampal formation is very characteristically situated in
These areas of the brain are largely unidirectionally connected to the lower medial temporal lobe. Its shape is created by an S-shaped
each other and form a functional unit. fold in the cortex (› Fig. 12.5). In this folding process, the Fascia
dentata comes away from the Cornu ammonis and sits on top of it
NOTE like a cap. Axons of the entorhinal cortex end up at the Dentata fas-
The shape of the hippocampus resembles the flipper of the mytho- cia by perforating the underlying layer of the subiculum and the
logical sea monster hippocamp (Greek: hippos, horse). Since this hippocampal fissure, and thus reach the surface of the Fascia den-
mythical creature was made up of a horse's head and fish's fin, it tata (› Fig. 12.11); these fibres are referred to as the Tractus per-
provided the name for the ‘sea horse’. Also, the hippocampus is of- forans (‘perforating tract’). This unusual projection tract enables a
ten compared to a sea horse.
circular flow of information through the hippocampal formation
from the entorhinal cortex to the Fascia dentata, and finally via the
The areas of the hippocampal formation are differentiated by their subiculum back to the entorhinal cortex. (› Fig. 12.11).
cytoarchitecture, i.e. their microscopic anatomical structure. The Attached to the archicortex, the archipallium continues as the cor-
superficially identifiable structures of the brain (gyri, sulci) are tical structure for the rotation of the hemispherical vesicle
variable in shape and are only approximate reference points for the (› Chap. 11.1). In humans, this shifts the main part of the hippo-
position of these cortical areas (› Chap. 12.1.5). The cortical areas campal formation into the medial temporal lobes. However, sec-
of the hippocampal formation are located mainly in the macro- tions of the hippocampus are located above and below the Corpus
scopic hippocampus (= bulging structure at the lower horn of the callosum. Thus the hippocampus continues from the temporal
lateral ventricle), the Gyrus dentatus and the Gyrus parahippocam- lobes onto the Corpus callosum, forming a thin grey layer (Indusi-
palis (with uncus). Occipitally, the hippocampal formation be- um griseum) and white matter (Striae longitudinales medialis and
comes thinner and finally continues as a thin layer of grey matter, lateralis); it finally reaches the subcallosal area below the Genu cor-
known as Indusium griseum, on the Corpus callossum. poris callosi. Below the Corpus callosum, the Fimbria hippocampi
forms the fornix (› Fig. 12.10).
Development and postnatal neurogenesis
The spatial arrangement of the structures of the hippocampal for-
mation is difficult to understand without reviewing the history of
Clinical remarks
its development. Already in the 9th week of pregnancy, the hippo- There is evidence that neuropsychiatric disorders (e.g.,
campal system is found in the developing cerebral hemispheres in schizophrenia, autistic spectrum disorders) go hand in hand
the medial area. In the 2nd trimester (15th–19th weeks of pregnancy) with developmental disorders of the hippocampus (as well as
there is evidence of the characteristic hippocampus subfields that other cortical areas).
have completely developed up to the Gyrus dentatus at the end of
the pregnancy (approximately the 34th week of pregnancy). In the
Gyrus dentatus, the cell count carries on growing until the 6th Macroscopy
month of life, i.e., this cortical area develops to a large extent post- The hippocampal formation lies in the medial temporal lobes and
natally. migrates in an arch shape above and along the Corpus callosum.
In the Fascia dentata (Gyrus dentatus), forming new nerve cells is a Depending on how they relate to the Corpus callosum, a distinc-
life-long process. This brain area is regarded as a ‘neurogenic tion is made between 3 macroscopic sections:
niche’ of the CNS. However, the ability to form nerve cells decreas- • Hippocampus retrocommissuralis: temporal lobe sections
es with age. It is estimated that in the adult Fascia dentata, up to • Hippocampus supracommissuralis: above the Corpus callosum
700 new nerve cells are formed each day; this means that approxi- • Hippocampus precommissuralis: below the Genu corporis callosi
mately 1.75 % of the nerve cells of this brain area could be replaced

Cornu ammonis Stratum pyramidale

Stratum oriens Gyrus dentatus

(Fascia dentata)
Isocortex
Stratum radiatum and
Fimbria
Stratum lacunosum-
hippocampi
moleculare

Gyrus dentatus Sulcus

(Fascia dentata) Subiculum hippocampalis

Presubiculum
Entorhinal cortex Cornu ammonis Isocortex and parasubi-
(and transition culum
Presubiculum and Subiculum areas)
parasubiculum Entorhinal
Sulcus cortex
hippocampalis
Allocortex

Fig. 12.5 Development of the hippocampal formation. The hippocampal formation is made up of an S-shaped fold of the mediobasal cortex.
Fascia dentata = black; Cornu ammonis CA1 = yellow; subiculum complex = green; pre- and parasubiculum = violet; entorhinal cortex = blue;
perirhinal cortex = red. [L126]

644
 12.1 Telencephalon

Polus temporalis

Tractus opticus

Gyrus parahippocampalis, Tuber cinereum

Uncus
Corpus mamillare
Sulcus collateralis
Fossa interpeduncularis
Gyrus temporalis
inferior
Substantia perforata
posterior
Gyrus
parahippocampalis
Mesencephalon

Isthmus gyri cinguli

Gyrus cinguli

Gyri occipitotemporales
medialis and lateralis
Fig. 12.6 Ridges (gyri) and
grooves (sulci) of the cerebral
hemispheres. Ventral view; after
sectioning the mesencephalon.

NOTE
• The hippocampus splits in two around the Corpus callosum: brain surface at this point looks bumpy or ‘warty’ (verrucae) under
above the Corpus callosum, the grey matter of the hippocampus a magnifying glass.
continues into the Indusium griseum. Below the Corpus callosum,
the Fimbria hippocampi continues into the fornix. Hippocampal formation from dorsomedial
• In clinical language (and also in this textbook) we use ‘hippocam-
In its anterior section, the medial temporal lobe exhibits several
pus’ to mean the Hippocampus retrocommissuralis.
smaller gyri and sulci (› Fig. 12.7, › Fig. 12.12), making the
anatomy of this area relatively complex. These gyri and sulci are
Due to their folding (› Fig. 12.5), the position of the hippocampal frequently observable on the brain surface and are important for
formation can only be partially understood by an analysis of the neurosurgical procedures in the temporal lobe area.
brain surface ventrally (› Fig. 12.6) and medially (› Fig. 12.7). The Gyrus parahippocampalis is ventromedially delimited by a
Only when opening the lower horn of the lateral ventricle, it be- small hollow, the Sulcus intrarhinalis, from the Gyrus ambiens.
comes possible to view the macroscopically visible hippocampus This, in turn, is separated by the Sulcus semiannularis from the
(› Fig. 12.8). Gyrus semilunaris. The Gyrus ambiens and the Gyrus semilunaris
contain olfactory cortices and are assigned to the paleocortex
Hippocampal formation from ventral (› Chap. 12.1.8). Lying caudally of this gyri is the ‘hook-shaped’
The Sulcus collateralis is located on the ventral side of the tempo- uncus of the Gyrus parahippocampalis. The uncus usually raises
ral lobe, separating the Gyrus occipitotemporalis lateralis from the 3 bulges, referred to from rostral to caudal as the
Gyrus parahippocampalis (› Fig. 12.7, › Fig. 12.6). The anterior • Gyrus uncinatus (transition cortex between the hippocampus
part of the Gyrus parahippocampalis is already a part of the hip- and the amygdala),
pocampal formation; the entorhinal cortex is located here. Due to • Limbus GIACOMINI (start of the Gyrus dentatus) and
the compact islands of cells in the lamina II of this cortical area, the • Gyrus intralimbicus (CA3 area of the Cornu ammonis)

Uncus gyri parahippocampalis

Gyrus uncinatus Limbus GIACOMINI Gyrus intralimbicus

(Uncus) (uncus bands) Sulcus corporis
callosi

Gyrus semilunaris Isthmus gyri

callosi
Sulcus
semiannularis Sulcus
calcarinus
Gyrus ambiens
Gyrus dentatus
Sulcus intrarhinalis
Sulcus
Sulcus rhinalis hippocampalis

Gyrus para-
Sulcus collateralis
hippocampalis
Fig. 12.7 Temporal lobes. Dor-
somedial view. [R247]

645
12 Special neuroanatomy

Fornix
Corpus
callosum

Indusium
griseum
Corpus
mamillare
Hippocampus
Indusium griseum a
Stria longitudinalis
medialis
Lobus frontalis

Stria longitudinalis
Stria terminalis
lateralis

V. thalamostriata
Ventriculus lateralis, superior
Cornu frontale

Taenia choroidea
Nucleus caudatus,
Caput
Taenia fornicis

Corpus callosum Digitationes hippocampi

Thalamus covered Caput

by Lamina affixa
Cauda Hippocampus

Lobus temporalis Corpus

Ventriculus lateralis,
Cornu temporale

Plexus choroideus

Ventriculus lateralis,
Cornu occipitale Fimbria hippocampi

Calcar avis
Lobus occipitalis

b Crus fornicis

Fig. 12.8 Opened lateral ventricle, hippocampus from dorsal. a Clear presentation of the brain to illustrate the three-dimensional nature of the
hippocampus. b Top view after opening the lateral ventricles dorsallyl and laterally. The hippocampus lies on the floor of the inferior horn of
the lateral ventricle and is covered by the Plexus choroideus on the left. This has been removed on the right side of the illustration. [L127]

Lying deeply caudal of the uncus and medial of the Gyrus parahip- In the macroscopic hippocampus, there are sections of the Fascia
pocampalis is the Fissura hippocampalis, which is the continuation dentata, the Cornu ammonis and the subiculum. The characteristic
of the Gyrus dentatus as well as the Fimbria hippocampi. When arrangement of these areas can be best understood on frontal sec-
these structures are followed caudally, we come across 2 horizon- tions in the middle of the hippocampus (› Fig. 12.9, › Fig. 12.11,
tally extending bulges, known as the Fasciola cinerea (end of the see below). Conversely, in the anterior hippocampus, orientation is
Gyrus dentatus) and the Gyrus fasciolaris (CA1-area). The latter much more difficult because the hippocampus turns medially here,
continues in the Indusium griseum on the Corpus callosum. and therefore some areas on frontal sections have multiple trunca-
tions (› Fig. 12.9).
Hippocampal formation from dorsal (opened side ventricle)
By opening the side ventricle dorsally and laterally, it is possible to Fimbria and fornix (arch)
see the cortical bulges that have given the macroscopic hippocam- The axons of the hippocampus form a layer of white matter on its
pus its name (› Fig. 12.8). The hippocampus is thickened at the surface anatomy, called the alveus. From here they run into the fi-
front (the ‘head’) and forms the Pes hippocampi with multiple ele- bre band of the fimbria, located on the hippocampus and the Gyrus
vations, referred to as the Digitationes hippocampi. This area is dentatus, and which accompanies it caudally (› Fig. 12.9, › Fig.
reminiscent of the flipper of the mythological creature, the ‘hippo- 12.10). Below the bar, the fimbria separates from the hippocampus
camp.’ In its centre, the hippocampus forms a barely structured and forms the vaulted columns of fornix, Columnae fornicis
bulge (the ‘body’) on the surface anatomy, which extends towards (› Fig. 12.10). Further along, the two Columnae fornices unite,
the splenium of the Corpus callosum, becoming thinner ( the forming the Commissura fornicis, in which commissure fibres, as
‘tail’). It passes into the Gyrus fasciolaris and continues into the In- well as other things, interchange between the two hippocampal
dusium griseum. The Fimbria hippocampi is located on the medial formations, and more rostrally the Corpus fornicis. However, this
side of the hippocampus, aligned with the Fissura hippocampi. divides again into 2 columns at the level of the Foramen interven-

646
 12.1 Telencephalon

Polus temporalis

Digitationes hippocampi Section plane Hippocampus, Gyrus dentatus

for caput Cornu (Fascia dentata)
ammonis
Sulcus hippocampalis
Ventriculus lateralis,
Cornu temporale
Entorhinal cortex

Uncus gyri
Gyrus dentatus parahippocampalis
Fimbria hippocampi
Section plane for corpus Hippocampus,
Pes hippocampi Cornu
Gyrus parahippocampalis ammonis Gyrus dentatus
(Fascia dentata)
Sulcus hippocampalis
Trigonum collaterale
Fimbria hippocampi
Fimbria hippocampi
Ventriculus lateralis, Section plane Hippocampus,
Cornu occipitale for cauda Cornu
Gyrus dentatus
ammonis
(Fascia dentata)
Sulcus calcarinus
a Calcar avis b

Fig. 12.9 Hippocampus. a Hippocampus in the lower horn of the opened side ventricle. b Cross-sections through the hippocampus in the area
of the head, body and tail. Differences in the arrangement of the principal cells are notable. In the area at the front, on the frontal sections, the
areas of the hippocampus are affected several times, while in the area of the body and tail the ‘classic’ arrangement of the hippocampus areas
is in place. [L127]

triculare (› Fig. 12.11a, b), from which 2 separate fibre bundles The connections within or between the hippocampal formations
split off, running in front of and behind the Commissura anterior: are in contrast to extrinsic connections, which on the one hand
• Fibrae precommissuralis (to septal nuclei, Regio preoptica, hy- connect the hippocampal formation with the cortex and on the
pothalamus) other with subcortical structures.
• Fibrae postcommissuralis (to Corpora mamillaria)
From a superior dorsal point of view, the rear section of the Com- Intrinsic connections of the hippocampal formation
missura fornicis with the two Columnae fornicis resembles an an- Information flow through the hippocampal formation
cient harp (David’s harp; also: ‘Psalterium’, › Fig. 12.10). In the entorhinal cortex, information is collected from cortical ar-
eas and the sensory organs. From there they get to the granule cells
Areas and connections of the hippocampal formation of the Fascia dentata via the Tractus perforans › Fig. 12.11c). The
Overview axons of these cells, known as mossy fibres, project mainly into the
The hippocampal formation is regarded as an interrelated structure CA3 area of the Cornu ammonis, from where the information –
(‘formation’), because the cortical areas it includes are very closely still in the Cornu ammonis – gets to the CA1-neurons (via the
related in terms of their anatomy and characteristics. Stimulating SCHAFFER collaterals), before they are passed from there to the
nerve cells form a circuit from the entorhinal cortex to the Fascia subiculum and then back to the entorhinal cortex.
dentata, to the Cornu ammonis, and via the subiculum back to the The connections of the hippocampal formation (and the flow of
entorhinal cortex. Since these connections are located within the information through the hippocampal formation) are most easily
hippocampal formation, they are also known as intrinsic connec- understood if one considers them in terms of a histological section
tions. The commissural axons can be viewed as a special case of made perpendicularly to the longitudinal axis of the hippocampus
these intrinsic connections, as they connect together the areas of in the midsection (the ‘body’) (› Fig. 12.8; › Fig. 12.11). In sec-
the hippocampal formations of both sides.

Fornix, Commissura Indusium griseum

(Psalterium)
Fornix, Corpus Striae longitudinales
mediales
Foramina interventricularia
Striae longitudinales
(Pars libera) laterales
Fornix, Columna
(Pars tecta)
Corpus callosum, Splenium
Commissura anterior
Gyrus fasciolaris
Corpus mamillare Fornix, Crus
Corpus amygdaloideum Taenia fornicis
Fig. 12.10 Anterior commissure
Fimbria hippocampi (Commissura anterior), fornix
Pes hippocampi Gyrus dentatus and hippocampus as well as
Indusium griseum. Lateral view.

647
12 Special neuroanatomy

Corpus callosum

Fornix

Hippocampus
a Corpus mamillare

Fornix

Septum nucleus
Stria longitudinalis

Fornix, Fibrae
precommissurales Cingulum

Commissura anterior Nucleus anterior

thalami

Fornix, Fibrae
Regio preoptica postcommissurales

Hypothalamus
Corpus mamillare
b
Regio entorhinalis

Fimbria Mossy fibres Alveus

Stratum granulare SCHAFFER collaterals

Stratum moleculare CA3 Stratum oriens Fig. 12.11 Connections of the

hippocampal formation; PAPEZ
Tractus perforans Stratum pyramidale circuit. a Overview. b PAPEZ cir-
CA2
GD Stratum radiatum cuit. c Areas of the hippocampal
PSub CA4
formation and their intrinsic
Strata lacunosum configurations. Frontal section
Sub and moleculare
MEC through the middle part (‘body’)
CA1 of the hippocampus; CA = Cornu
ammonis, GD = Gyrus dentatus,
Sub = subiculum, PSub = Pre-
PRC subiculum, MEC/LEC = medial/
LEC
TEC lateral entorhinal cortex, TEC =
transentorhinal cortex, PRC =
c SR perirhinal cortex, SR = Sulcus
rhinalis. a, b [L127], c [L141]

tions such as this, all the areas of the hippocampus and its typical cells in turn run as mossy fibres into the Cornu ammonis. There
fibre connections are found. they end at the dendrites of the pyramid cells of the CA3 area
(› Fig. 12.11c).
Entorhinal cortex The area immediately below the granule cells is referred to as the
The entorhinal cortex is the ‘gateway to the hippocampus.’ On the one subgranular zone. The neurogenic niche is located here, where
hand, it receives direct olfactory inputs (rostral entorhinal cortex) new nerve cells, even in the adult brain, can be formed.
and, on the other hand, inputs from many multimodal sensory asso-
ciation fields (i.e. sensory information that has already been pro- Cornu ammonis
cessed). Histologically, it is considered to be allocortex, which means The Cornu ammonis consists of 1–2 cell layers of pyramidal cells
that it is structured differently to the six-layered isocortex. The re- winding around the Fascia dentata (› Fig. 12.11c). Due to the cell
markable point about its structure is its division into a superficial and morphology and cell connections, the Cornu ammonis is divided
deep layer which is divided by a cell-free Lamina dissecans. In the su- into 4 sub-areas; of which the CA3 and CA1 areas are of particular
perficial layer, there are islands of cells found on the surface anatomy importance in understanding the information flow through the
of the Gyrus parahippocampalis, which are visible as small warts (see hippocampal formation:
above). The axons of the superficial nerve cells run as the Tractus per- • The CA3-pyramidal cells receive information via the mossy fi-
forans to the Fascia dentata and the Cornu ammonis (› Fig. 12.11c). bres of the granule cells. With their axons, they project out of the
hippocampal formation (via the alveus in the fimbria), still
Fascia dentata forming important collaterals, the SCHAFFER collaterals, that
The Fascia dentata sits like a cap on top of the Cornu ammonis. Its move within the hippocampus to the CA1-area.
nerve cells, the granule cells, are located in a densely packed band • The CA1-pyramidal cells behave in a similar manner, also pro-
of cells. The axons of the Tractus perforans reach the dendrites of jecting from the hippocampal formation, but also moving with
the granule cells in the molecular layer. The axons of the granule their collaterals to the subiculum complex (› Fig. 12.11c).

648
 12.1 Telencephalon

Subiculum complex areas to the hippocampus. This connection (‘septohippocampal

The subiculum, presubiculum and parasubiculum follow on from projection’) is important for learning and memory.
the CA1 area. The subiculum can be visualised histologically as a • Basal forebrain: A group of nuclei found basally in the frontal
wide band of cells. The nerve cells of this area project out of the part of the brain, is usually seen as part of the ‘basal forebrain‘.
hippocampal formation and back to the entorhinal cortex (› Fig. These include the septal nuclei/diagonal band of BROCA, the
12.11c). The function of this area remains unclear. Nucleus basalis (MEYNERT), the Substantia innominata as well
as the Nucleus accumbens. These nuclei contain many choliner-
Commissural connections of the hippocampal formation gic fibres, which branch out from the hippocampal formation
Both of the hippocampal formations are closely connected via the and many cortex areas, i.e. ‘diffusely’ innervating with acetylcho-
Commissura fornicis. In humans, the commissural connections are line (‘cholinergic system’). This cholinergic innervation controls
particularly found in the area of the subiculum complex and the the activity level of the nerve cells and is important for neural
entorhinal cortex. This strong link between the two hippocampal plasticity and thus for learning and memory.
formations is thought to be responsible for ensuring that serious • Corpora mamillaria: A powerful fibre connection runs via the
memory impairment only occurs if both hippocampi have failed at Fibrae postcommissurales from the subiculum to the Corpora
the same time. mamillaria. Here information from the hippocampus and the
amygdala join together and is then transferred to the thalamus
(Tractus mamillothalamicus; s. PAPEZ circuit). The exact func-
Clinical remarks tion of these nuclei and pathways is not understood; they do
To treat the fits in severe and drug-resistant temporal lobe epi- however play a role in memory formation and the recall of
lepsy, the affected parts of the hippocampal formation can be memory content, since the destruction of these nuclei or the
removed on one side. The removal of one hippocampus does Tractus mamillothalamicus is associated with severe amnesia (=
not lead to obvious memory impairment. The removal of both inability to register the content of new memories or recall them).
hippocampi, on the other hand, leads to a serious, mainly an-
• Amygdala: Multiple areas of the hippocampal formation, partic-
terograde amnesia, i.e. the inability to register new memories
and remember them. ularly the subiculum and the entorhinal cortex are connected to
the amygdala (› Chap. 1.10). The amygdala is an important
centre for controlling emotional and autonomic reactions and
significant for our emotional memory (e.g., fear response).
Extrinsic connections of the hippocampal formation • Modulating systems: The specific processing of information in
Cortical connections the hippocampal formation is influenced by pathways from the
The afferent connections of the hippocampal formation with the brainstem. These brainstem afferents end with their axons dif-
cortex run via the entorhinal cortex (see above) and the subiculum. fusely distributed via the hippocampal formation and influence
The Gyrus dentatus and the Cornu ammonis are ‘sealed off ’ from the activity status of the overall system. These include, among
the neocortex. This ensures that the information is processed se- other things, dopamine (from the Area tegmentalis ventralis),
quentially in the areas. noradrenaline (from the Locus caeruleus), serotonin (from the
The efferent connections of the hippocampal formation with the Raphe nuclei), as well as histamine. The clinical significance of
cortex also run via the entorhinal cortex and subiculum complex. the modulating systems is considerable, as the effect of many
The hippocampal formation projects back to the multimodal areas psychotropic drugs used in the treatment of neuropsychiatric
of the association cortex and reaches the neocortex via these wide diseases is based on the interaction of these systems (e.g., selec-
areas. In this way, knowledge that has been acquired via the hippo- tive serotonin re-uptake inhibitors [SSRI] for the treatment of
campal formation can be transferred permanently into the long- depression).
term memory. In the long term, memory traces are then stored in
the neocortex. NOTE
Connections of the hippocampal formation are:
Subcortical connections • neocortical connections (via the entorhinal cortex, the ‘gateway
The hippocampal formation is an ‘old’ structure of the brain (‘ar- to the hippocampus’; subiculum complex)
• intrinsic connections (entorhinal cortex – Fascia dentata – CA3 –
chicortex’). In relation to its ‘age’, it is directly linked with the sub-
CA1 – subiculum complex – entorhinal cortex)
cortical nuclear areas of the diencephalon and brainstem which are • commisural connections (especially entorhinal cortex and subicu-
phylogenetically just as old, frequently with links in both direc- lum)
tions. The younger neocortical connections are almost ‘mounted’ • subcortical connections (including septal nuclei, Corpora mamil-
onto this existing system and pass via the entorhinal cortex as its laria, amygdala, brainstem)
gateway (‘interface’) into the hippocampal formation.
The close connection with the subcortical structures, which in turn
are either part of the ‘limbic system’, or are in close connection with Clinical remarks
it, explains why the hippocampus receives information about the
A lack of thiamine (vitamin B1), e.g., due to chronic alcohol
autonomic and emotional states of our body and, conversely, can abuse, may lead to a bilateral atrophy of the Corpora mamillar-
have an influence on them (see below, ‘Functions of the hippocam- ia, the thalamus, the cerebellum and the frontal lobe. In the
pal formation’). Many (but not all) of these subcortical connections final stage of the resulting WERNICKE–KORSAKOFF syndrome,
reach and leave the hippocampus via the fimbria and the fornix. the patients suffer, amongst other things, from severe amne-
The main connections are listed below. sia (= memory disturbance), combined with spontaneous con-
• Septal nuclei: Fibres from all areas of the Cornu ammonis reach fabulation (= the recounting of objectively untrue stories) and
the septum via the Fibrae precommissuralis (see above). Con- ataxia (= disturbance in the coordination of movement).
versely, cholinergic (neurotransmitter: acetylcholin) and GABA­
ergic (neurotransmitter: GABA) axons from the septal nucleus

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12 Special neuroanatomy

Functions of the hippocampal formation Clinical remarks

The hippocampal formation is now one of the most well-­
Unilateral circulatory problems of the A. cerebri posterior can
researched cortical areas. Comparative neuroscientific research
result in temporary disturbances to the memory function (am-
(e.g., examinations of the hippocampus in animals) as well as the nesia). However, in clinical terms, other symptoms are para-
functional imaging of the human hippocampus, have contributed mount (‘foremost’) (e.g., visual disturbances), as unilateral
to this. As an overview, the following can be differentiated: hippocampus damage can be compensated for by the other
• Learning and memory functions: The hippocampus is important hippocampus.
for a portion of our learning and memory functions. It is needed Bilateral circulatory disorders of the Aa. cerebri posteriores
for our declarative memory. This includes the semantic memory can lead to equal damage to both hippocampi. The conse-
quences are acute and persistent, mainly involving antero-
that stores our ‘knowledge about the world’ (Shakespeare wrote
grade memory impairment.
‘Romeo and Juliet’), and the episodic-biographical memory that
retains the events of our own life.
• Spatial representation of the environment (‘satnav in the
brain’): parts of the hippocampal formation are responsible for Cingulate cortex
ensuring that we have an ‘internal representation’ of the room in The archicortical areas in the immediate vicinity of the Corpus cal-
which we physically find ourselves. losum surround it like a girdle running lengthways (Cingulum,
• Connections to the limbic system: Our nervous system stores Latin: belt, › Fig. 12.4).
not only events, but also the feelings associated with them. The Cytoarchitecturally, multiple areas are differentiated, some of
limbic system takes on the task of coupling hippocampal memo- which are aligned to the BRODMANN areas, and to which a vari-
ry performance with neuroendocrine, autonomic and emotional ety of functions can be assigned. These include from anterior to
functions (› Chap. 1.10). posterior:
• Regio subgenualis – sections of the Gyrus cinguli below the genu
of the Corpus callosum
Clinical remarks • anterior cingulate cortex – rostral section of the Gyrus cinguli
Neurodegenerative diseases lead to an insidious loss of nerve • posterior cingulate cortex – caudal section of the Gyrus cinguli
cells in the brain. The hippocampal formations are affected, • Regio retrosplenialis – continuation of the Gyrus cinguli below
and this leads to disturbances of spatial memory and orienta- the splenium of the Corpus callosum
tion skills. Also the ability to store new experiences and new The functions of the cingulate cortex have been studied using func-
knowledge is lost.
tional imaging. In summary, the following has been discovered:
The best-known neurodegenerative disease which damages
the hippocampal formations is ALZHEIMER's disease. In the • anterior cingulate cortex: cognitive (identification of errors, re-
brain of those affected by the disease, there are extracellular ward learning) and autonomous functions (including the linking
protein deposits (‘amyloid plaques’) and intracellular protein of emotions and autonomic reactions)
aggregation from hyper-phosphorylated Tau protein (‘neuro- • posterior cingulate cortex: biographical memory, self-confi-
fibrillary changes’). The latter will lead to nerve cell death and dence, self-reflection
atrophy of the cortex. In the early stages of the disease, the
hippocampal formation is affected. This results in spatial dis-
orientation (patients ‘wander off’ and ‘get lost’) and loss of Clinical remarks
memory retention. In later stages, the disease takes over the
neocortex and also deletes existing memories. At the end, the Disturbances in cingulate cortical areas lead to cognitive
patient cannot remember himself as a person nor events from change. The cingulate cortex is therefore involved in the com-
his life. plex symptoms of neuropsychiatric disorders (depression,
With Alzheimer's disease, the cholinergic system is affected at schizophrenia, anxiety disorders, impulse control).
an early stage. There is therefore a ‘lack of acetylcholine’ in
patients' brains. Since acetylcholine plays a part in learning
and memory, the level of acetylcholine is increased at the syn-
apses by treating patients with a course of inhibitors of acetyl-
cholinesterase, the enzyme that degrades acetylcholine. How- 12.1.7 Paleocortex
ever, this treatment is only effective in the early stages of the Thomas Deller, Andreas Vlachos
disease and generally has only temporary benefits.
Overview
In phylogenetic terms, the paleocortex is the oldest part of the cor-
tex. In the case of simple mammals, such as the hedgehog, it domi-
Blood supply of the hippocampus nates the brain. It consists mainly of the olfactory cortex and is
The blood supply to the hippocampal formation is clinically signif- closely associated with the olfactory system.
icant for temporal lobe epilepsy surgery. The macroscopic hippo- The structures of the paleocortex are:
campus is supplied by several vessels, due to its longitudinal exten- • Bulbus olfactorius
sion, which form anastomoses on its surface area. The two critical • Tractus olfactorius
vessels supplying it are the A. cerebri posterior (supply of the oc- • Nucleus olfactorius anterior
cipital two thirds of the hippocampus) and the A. choroidea ante­ • Tuberculum olfactorium
rior (supply of the rostral third). The relative amount with which • Septal nuclei
these vessels supply the hippocampus varies. This ‘variability in de- • Regio periamygdalaris
tail’ is typical of the blood supply to the brain surface (› Chap. • Regio prepiriformis
11.5). The Bulbus and Tractus olfactorius derive from the telencephalon
and are components of the brain. They are therefore phylogenetic
and anatomic-systematic parts of the paleocortex. Histologically,

650
 12.1 Telencephalon

they are clearly differentiated from the six layer isocortex and are Lobus frontalis
allocortex. Details on these paleocortical structures can be found Rostrally below the Lobus frontalis is the small, raised, pis-
in › Chap. 13.6. ton-shaped olfactory Bulbus olfactorius. The Tractus olfactorius
runs caudally here in the Sulcus olfactorius. It widens and forms
NOTE the Trigonum olfactorium, from which 2 bundles usually split off
Due to the functional importance of the paleocortex for the olfacto- as the Stria olfactoria medialis and the Stria olfactoria lateralis. The
ry sense, the term rhinencephalon is often used alongside the term striae may encompass a small polygonal structure, known as the
paleocortex. This term usually only covers the olfactory cortex in Tuberculum olfactorium.
the narrowest sense, i.e. the paleocortex without the Bulbus and Between the Striae olfactoriae lies the Substantia perforata anterior.
Tractus olfactorius.
Here, central blood vessels of the Aa. cerebri anteriores and mediae
are found, moving down into the depths and towards the nuclear
Macroscopic structures areas located inside the brain (› Chap. 11.5). The Substantia per-
Parallel use of nomenclature for macroscopic structures (e.g., gyri) forata anterior is delimited caudally by the diagonal band of BROCA
and microscopic areas (e.g. the BRODMANN areas) makes it difficult (nuclear area of the basal forebrain; › Chap. 13.10) and by the
to get to know the structures in the CNS. The macroscopically Tractus opticus.
identifiable structures are only vaguely identical to the histological-
ly delimited areas. They are however significant practically, since Lobus temporalis
they can become visible using imaging methods and can serve as Parts of the paleocortex were displaced into the medial temporal
important landmarks in surgery. lobes during phylogenesis, particularly in the area of the Gyrus
parahippocampalis, as well as in 2 smaller gyri medially located to
NOTE it, known as the Gyrus ambiens and the Gyri semilunaris (› Fig.
The macroscopically visible structures of the cortex (e.g., gyri and 12.12, › Fig. 12.7). Caudally of these is the uncus in which parts
sulci) serve as guides in the brain. These structures are variable in of the hippocampal formation (archicortex) are found (› Chap.
shape and are only vaguely identical to the histologically delimi- 12.1.6; › Fig. 12.7).
nated cortical areas (e.g. the BRODMANN areas).
Olfactory cortical areas
The basal paleocortex is located on the Facies basalis of the brain Cortical areas directly connected to the efferent nerve cells (mitral
(› Fig. 12.12). It extends from the basal frontal lobe (Lobus fron- cells) of the olfactory bulb are referred to in their entirety as the ol-
talis) to the medial temporal lobes (Lobus temporalis):

Tuberculum olfactorium

Stria olfactoria lateralis

Bulbus olfactorius

Gyrus ambiens Tractus olfactorius

Stria olfactoria medialis

Area prepiriformis

Chiasma opticum

Gyrus semilunaris

diagonal band
Sulcus intrarhinalis of Broca

Tractus opticus

Sulcus collateralis
Sulcus semiannularis

Gyrus uncinatus (uncus)

Gyrus parahippocampalis
(with Area entorhinalis) Fig. 12.12 Paleocortical (green)
Limbus GIACOMINI
(uncus bands) and adjacent archicortical struc-
Fissura hippocampalis Gyrus intralimbicus tures (purple) on the Facies
basalis of the brain. [L127]

651
12 Special neuroanatomy

factory cortex. These areas include mainly paleocortical as well as Clinical remarks
other cortical areas. Paleocortical parts are:
Important common neurodegenerative diseases (e.g., ALZHEI-
• Tuberculum olfactorium
MER’s disease, PARKINSON’s disease ), are associated early
• Septal nuclei and diagonal band of BROCA on with olfactory problems.
• Area prepiriformis Examination of the sense of smell by means of standardised
• Area periamygdaloidea olfactory testing is therefore discussed as a diagnostic early
Other areas are: marker for neurodegenerative diseases. Additionally, there
• Regio entorhinalis (lateral part) are hypotheses for the pathogenesis of neurodegenerative
• Nucleus corticalis anterior of the amygdala (part of the cortico- diseases that suggest that toxins or infectious particles may
penetrate into the central nervous system via the olfactory
medial nuclear group)
system. However, these hypotheses remain unproven.
The Tuberculum olfactorium corresponds macroscopically with a
small bulge, caudal to the Trigonium olfactorium or otherwise
sunk down within the Substantia perforata anterior. The septal nu­
clei lie below the Septum pellucidum, which in humans does not
contain any nerve cells. The Area prepiriformis is found in the 12.1.8 Subcortical nuclei
Gyrus ambiens and in cortical areas around the Stria olfactoria lat- Michael J. Schmeißer
eralis; the Area periamygdaloidea is located in the Gyrus semilu-
naris. In addition to these paleocortical areas, axons also run di- Overview
rectly from the Bulbus olfactorius to the Regio entorhinalis (part Subcortical nuclei refer to the groupings of grey matter created in
of the archicortex), located in the Gyrus parahippocampalis and the white matter of each hemisphere. These include primarily the
partly in the Gyrus ambiens, as well as in the Nucleus corticalis basal ganglia, an important nuclear group of the motor system. In
anterior of the amygdala. addition, there are other subcortical nuclei such as the amygdala
(also Corpus amygdaloideum) or the Nucleus basalis of MEYNERT.
NOTE Common to these nuclei is their ability to influence higher brain
Gyrus ambiens and Gyrus semilunaris functions such as learning and memory as well as motivation and
In the Gyrus ambiens and the Gyrus semilunaris, there are large the emotions.
parts of the Area prepiriformis and the Area periamygdaloidea. To
simplify matters, they are sometimes referred to as the cortical ‘ol- Basal ganglia
factory centre’ of the human brain. In a narrower sense, the following nuclear areas can be included in
the basal ganglia (› Fig. 12.13, › Fig. 12.14):
The term Area piriformis is a collective term that includes several • striatum (also Corpus striatum), consisting of the caudatus and
cortical areas forming the Lobus piriformis in simpler mammals. putamen
Located here is the olfactory cortex, which is particularly well-­ • pallidum (also called the Globus pallidus)
developed in macrosmatic animals (= animals with a highly-devel- Ontogenetically, the pallidum does not belong to the telencepha-
oped sense of smell; e.g., in rodents). The Area prepiriformis, the lon, but to the diencephalon. In addition, the Nucleus subthalam­
Area periamygdaloidea and the Area entorhinalis are included as icus of the diencephalon and the Substantia nigra of the mesen-
parts of the Area piriformis. In humans (microsmatic beings), cephalon are functionally associated with the basal ganglia. In aca-
these areas also receive a direct input from the Bulbus olfactorius demic literature, they are sometimes listed as a direct component
(olfactory cortex). of the basal ganglia.

Connections of the paleocortex Striatum

The paleocortex is characterised as a phylogenetically old cortical The Nucleus caudatus is a C-shaped arch that is divided into 3
structure because of 2 special features of its anatomical connec- parts: caput, corpus and cauda (› Fig. 12.13b). The rostrally lying
tions: caput is somewhat raised, whereas the corpus and cauda gradually
• Direct sensory information from the Bulbus olfactorius: The become narrower. Topographically, the Nucleus caudatus in its en-
olfactory cortical areas at the base of the brain have direct con- tirety is in the immediate vicinity of the respective side ventricle. In
nections to the Bulbus olfactorius. Conversely, the other senses the frontal lobe, the caput forms the base and lateral limit of the
only reach the cortex after interconnecting in the thalamus area. Cornu frontale [anterius] (› Fig. 12.13c). The corpus is located in
Thus it can be said that ‘smells go directly to the brain.’ the parietal lobe on the floor of the Pars centralis (› Fig. 12.13d)
• Close ties to different parts of the limbic system (› Chap. and the cauda is in the temporal lobe in the roof of the Cornu tem-
1.10 ): The brain areas of the limbic system are designed for the porale [inferius] (› Fig. 12.13c, d).
central control of autonomic and neuroendocrine bodily func- The putamen is located somewhat lateral and basal of the Nucleus
tions, basic emotional reactions and specific learning and mem- caudatus and is shaped like an oval disc. In brain sections, it is easy
ory processes. The close connection between the paleocortex to see that the putamen is located in the medulla of the insular cor-
and limbic system can be easily understood in phylogenetic tex and is flanked laterally by the Capsula externa and medially by
terms, since controlling the autonomic processes of the body is a the pallidum (› Fig. 12.13c, d).
very basic requirement for life as well as being an ‘old’ brain Ontogenetically, the Nucleus caudatus and the putamen arise from
function. Olfactory cortex areas have an effect on the other areas the same system and are increasingly separated from each other in
of the brain via connections to the limbic system, as well as part- the course of their development by the ingrowing fibres of the Cap-
ly via connections to the thalamus and the island area. sula interna running from rostral to caudal. The striped rostral
connections between the Nucleus caudatus and the putamen are
easily recognised in the frontal brain sections, and have been
named identically (Corpus striatum = striped body).

652
 12.1 Telencephalon

Corpus callosum Nucleus caudatus, Caput

Ventriculus lateralis, Cornu frontale
Ventriculus lateralis, Capsula interna
Ventriculus lateralis, Pars centralis
Cornu frontale
Nucleus caudatus, Corpus
Fornix (cut edge)
Septum pellucidum
Putamen

Ventriculus tertius Ventriculus lateralis,

Thalamus
Cornu occipitale
Fornix Plexus choroideus

Thalamus
Ventriculus lateralis, Nucleus caudatus,
Cornu occipitale Caput Putamen

Corpus Nucleus caudatus,

a Glandula pinealis b amygdaloideum Cauda
Ventriculus lateralis,
Cornu temporale

Polus frontalis
Ventriculus lateralis, Cornu frontale
Nucleus caudatus, Caput
Capsula interna, Crus anterius
Adhesio interthalamica
Capsula interna, Genu
Insula [Lobus insularis]
Laminae medullares medialis
Claustrum and lateralis

Putamen Ventriculus tertius

Capsula extrema
Globi pallidi medialis
and lateralis Capsula externa

Thalamus Capsula interna,

Crus posterius
Nucleus caudatus,
Capsula interna,
Cauda
Radiatio optica

Ventriculus lateralis, Pars centralis

Nucleus caudatus, Corpus

Ventriculus tertius
Putamen
Capsula extrema
Gyri insulae
Capsula externa

Claustrum Laminae medullares

medialis and lateralis
Globus pallidus lateralis

Globus pallidus medialis Capsula interna

Nucleus caudatus, Ventriculus lateralis,

Cauda Cornu temporale
Corpus amygdaloideum

d Thalamus Nucleus subthalamicus

Fig. 12.13 Macroscopic anatomy and sectional anatomy of subcortical nuclear structures. a, b Basal ganglia, thalamus and lateral ventricle.
c Horizontal section through the centre of the IIIrd ventricle. c Frontal section at the level of the Corpora mamillaria. a [L126]

653
12 Special neuroanatomy

Striatum,
Nucleus caudatus

Cortex

Striatum

Indirect DA Direct
path path

Pallidum Pallidum
laterale Substantia mediale
Thalamus nigra
(Pars Thalamus
Substantia
compacta) nigra
Nucleus (Pars
subthalamicus reticularis)

Basal ganglia
b Brainstem
Striatum,
Nucleus
Putamen
subthalamicus

Pallidum
laterale
Pars compacta
Substantia nigra
Pars reticularis

Pallidum mediale
a

Fig. 12.14 Topography and schematic drawing of the neuronal configurations within the basal ganglia. [L126]

The striatum can also be divided into a dorsal and ventral stria- NOTE
tum, with the dorsal striatum making up by far the biggest part. Under the term Nucleus lentiformis, the putamen and pallidum are
The ventral striatum includes only the anteroventral basal sections frequently conflated in academic literature, since they resemble
the shape of a lens (‘lens nucleus’) when seen together. Due to onto-
of the Caput nuclei caudati and of the putamen, which in this area
genetic and functional aspects, this is not very useful as a concept
are linked with each other by what is known as the Nucleus ac­ because the putamen is derived from the telencephalon and func-
cumbens. The Nucleus accumbens consists of two visible parts, as tionally belongs to the striatum, whereas the pallidum is derived
is seen in frontal brain sections: a Pars lateralis, the nucleus which from the diencephalon, making it functionally a separate entity.
resembles the ventral striatum, and a Pars medialis, the ‘shell’, rep-
resenting a transition to the neighbouring amygdala.
Internal structure and fibre connections of the basal ganglia
Pallidum Dorsal striatum
The pallidum, which appears in brain sections as relatively bright The striatum, as the main entrance point into the basal ganglia,
(pale nucleus), is located medially of the putamen and is morphologi- plays a key role. About 75% of its nerve cells are inhibitory, mid-
cally delimited from it by a Lamina medullaris lateralis (or externa) sized GABAergic neurons, of which the secondary dendrites are
(› Fig. 12.13). Furthermore, a distinction is made between a later- filled with many dendritic spines, hence the term ‘medium spiny
al and medial section (Pars lateralis or Pars medialis) which is di- neurons’, MSNs. At the end of these spines are:
vided by the Lamina medullaris medialis (or interna)(› Fig. • primarily the glutamatergic axons of the excitatory projection
12.13c, d). neurons of the cerebral cortex. These corticostriatal primary
afferents (› Fig. 12.14a, b, black fibres/arrows) originate, de-
Nucleus subthalamicus pending on where they are located within the dorsal striatum,
This is a biconvex nuclear area of the ventral diencephalon, medial from the ipsilateral frontal and parietal cortex areas and thus
to the Capsula interna and situated below the thalamus (› Fig. primarily from motor and sensory cortex areas, and they can at-
12.13d). tract the MSNs.
• also nigrostriatal primary afferents (› Fig. 12.14a, b, dark
Substantia nigra grey fibres/arrows). These dopaminergic axons of the projection
The Substantia nigra is a nuclear area in the mesencephalon and is neurons of the Substantia nigra, Pars compacta, can modulate
made up of two parts: the Pars reticularis and the Pars compacta. the activity of the MSNs.
For more information and details about the position and outer Currently, it is postulated that there are 2 groups and thus 2 projec­
form of the Substantia nigra, consult › Chap. 12.1.8. tion routes for the MSNs within the dorsal striatum – direct and

654
 12.1 Telencephalon

indirect routes (› Fig. 12.14b). What both routes have in common HUNTINGTON’s chorea is an autosomal-dominant inherited
is the fact that they end in the main output station of the basal gan- neurodegenerative disease with changes in the HUNTINGTON
glia, the pallidum-medial complex. This comprises the actual Pal- gene. The resulting pathophysiological effect on the corre-
lidum medial and the Substantia nigra, Pars reticularis, and con- sponding nerve cells is still not understood, despite intensive
research. Interestingly, in this disease in particular, we find a
tains large inhibitory GABAergic projection neurons, the axons of
degeneration of the striatal GABAergic projection neurons,
which go to neurons of the motor thalamic nuclei, and inhibit particularly initially affecting the neurons of the indirect path-
them (› Fig. 12.14a, b, yellow fibres/arrows). Amongst others, the way. This means that the activity of the direct pathway pre-
pallidum-medial complex dispatches efferents to the brainstem dominates, expressed clinically by involuntarily exaggerated
(› Fig. 12.14b, yellow fibres/arrows) and can thus impact the mo- movements with reduced muscle tone, so-called choreatic hy-
tor centres of the brainstem or the spinal cord. There are important perkinesia.
morphological and functional differences between the direct and Where there is a unilateral malfunction of the Nucleus subtha-
lamicus, e.g., as a result of ischemia, the activity of the indi-
indirect pathways:
rect pathway is acutely inhibited. Clinically, this is expressed
• MSNs of the direct pathway (› Fig. 12.14a, b, red fibres/ar- in proximally accentuated, lightning-fast, darting movements.
rows) project directly with their axons onto the inhibiting nerve This hemiballism affects the extremities of the contralateral
cells of the pallidum-medial complex and can inhibit them. Af- side of the body, because the motor fibres of the Tractus corti-
ter the corticostriatal activation of the direct pathway MSNs, an cospinalis, located downstream of the ‘basal ganglia loop’
‘inhibition of inhibition’ occurs– and thus the activation of the and finally taking control of the muscles of the extremities,
motor thalamus nuclei which results in the stimulation of cer- cross over in the Medulla oblongata from ipsilateral to contra-
lateral.
tain cortex areas. In general, this leads to an increase in motor
activity and ‘desirable’ movements are encouraged.
• MSNs of the indirect pathway (› Fig. 12.14a, b, green fibres/
arrows) initially project with their inhibitory axons onto inhibi- Ventrales striatum, Nucleus accumbens
tory GABAergic projection neurons of the Pallidum laterale, The ventral striatum occupies a special position within the basal
which are connected with the subthalamic nucleus, and of which ganglia, in which the Nucleus accumbens is most prominent. This
the neurons can in turn inhibit. However, the latter are excitatory part of the striatum also contains MSNs; unlike those primarily
and project glutamatergically into the pallidum-medial complex. found in the dorsal striatum, these MSNs are reached by glutama-
After corticostriatal activation of the indirect pathway MSNs, an tergic afferents from the prefrontal cortical and limbic areas such
‘inhibition of inhibition’ occurs – and thus the activation of the as the hippocampus and amygdala, and by dopaminergic afferents
Nucleus subthalamicus, which results in the activation of the from the Area tegmentalis ventralis of the mesencephalon. MSNs
pall­idum-medial complex, an inhibition of thalemic nuclei and of the ventral striatum project into the ventral pallidum segment,
finally the inhibition of certain cortex areas. In general, this leads which is connected with thalamic nuclei; these in turn send their
to an inhibition of motor activity and ‘unwanted’ movements efferents into the prefrontal and limbic cortex areas.
are suppressed.
Nigrostriatal dopaminergic fibres (› Fig. 12.14a, b, dark grey fi- NOTE
bres/arrows) can in this context increase the activity of the direct Due to its involvement with the limbic system, the ventral striatum
pathway via corresponding dopamine receptors and inhibit the ac- is particularly responsible for the control of emotion- and motiva-
tivity of the indirect pathway. tion-related motor behaviour. Here the mesolimbic dopaminergic
projection from the Area tegmentalis ventralis plays a special role.
The activity of these fibres is always particularly increased when
Clinical remarks external stimuli are presented, which are predictive of a reward
­upon completion of a certain motor reaction.
In PARKINSON’s disease, there is a degeneration of the dopa-
minergic neurons of the Substantia nigra, Pars compacta, and
therefore also a loss of nigrostriatal fibres. As a result, the ac- Further subcortical nuclei of the telencephalon
tivity of the indirect pathway is reinforced in the broadest Amygdala
sense, and the activity of the direct pathway is inhibited. This
The amygdala or the amygdala complex is located in front of the
results in the general inhibition of motor activity, and impetus
or incentive is lost. The resulting symptom is called akinesia hippocampus in the medial part of the anterior temporal lobe and
(physical inactivity), one of the 3 typical symptoms of PARKIN- laterally borders the Cornu temporale [inferius] of the side ventri-
SON's disease. In patients affected by the disease, the devel- cle (› Fig. 12.13d). Cytoarchitecturally, within the amygdala a dis-
opment is characterised in particular with small, scurrying tinction is made between morphologically and functionally differ-
steps and the absence of arm movement when running. In ad- ent nuclei and subnuclei. Particularly 3 nuclear groups are signifi-
dition, a one-sided tremor develops when the patient is at cant here: the superficial, laterobasal and centromedial nuclei:
rest, and generalised muscle stiffness or rigour. The underly-
• The laterobasal nuclei are the main entry point for afferents
ing reasons for this neurodegenerative disease are not well
understood, despite intensive research. For several decades from the limbic system, the thalamus, and from various sensory
the substance L-dopa has been used to treat it, passing cortex areas (e.g., auditory, visual, gustatory, visceral).
through the blood–brain barrier and metabolising in the CNS • The superficial nuclei predominantly receive olfactory afferents.
into dopamine. This is an attempt to compensate for the loss • The centromedial nuclei receive afferents from the hypothala-
of endogenous dopamine with drugs. Another treatment op- mus and the brainstem.
tion is the neurosurgical, stereotactic use of bilateral stimula- All the above-listed nuclei project efferents back into the same ar-
tion electrodes for deep brain stimulation. This method is
eas from where they receive their afferents; additionally, the lat-
used in the advanced stages of the disease, inhibiting the ac-
tivity of the subthalamic nucleus which leads to the weaken-
erobasal nuclei project into the dorsal and ventral striatum as well
ing of the indirect pathway and the strengthening of the direct as into the Nucleus basalis of MEYNERT (see below). In addition,
pathway. there are extensive connections between superficial and laterobasal
nuclei, as well as within the centromedial nuclei. Interestingly, in

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12 Special neuroanatomy

the superficial and laterobasal nuclei, primarily glutamatergic pro- thalami) and the Commissura posterior. Unlike the other parts
jection neurons are found, and in the centromedial nuclei it is of the interbrain, there are virtually no cortical projections leav-
principally GABAergic projection neurons that are found. ing the epithalamus.
Functionally, the amygdala is a crucial switching or relay station, • Thalamus dorsalis (› Chap. 12.2.3): It consists of a relatively
especially for emotional reactions, as it can integrate the most di- large, densely-packed nuclear complex, extending bean-shaped
verse afferent impulses and, via its efferent projections, can trigger on both sides of the IIIrd ventricle from ventral to dorsal. The
appropriate and proportionate somatomotoric, endocrine and vis- Corpora geniculata are also called metathalamus but they be-
ceral reactions to a given situation. long – also functionally – to the Thalamus dorsalis.
• The subthalamus (Thalamus ventralis) (› Chap. 12.2.5): It
Claustrum forms a transitional zone between the diencephalon and the
The claustrum is a narrow, sagittally positioned area of grey matter mesencephalon, and is also referred to as the motor zone of the
located between the Capsula externa and Capsula extrema in the diencephalon. Correspondingly, there are important nuclear
immediate vicinity of the insular cortex (› Fig. 12.13c, d). Its ac- ­areas here for controlling motor skills (Globus pallidus, Nucleus
tual function has not yet been clarified at the present time. Its es- subthalamicus). The nuclear areas of the subthalamus project
tablished anatomical qualities, however, show that there is a rela- mainly into the local diencephalic nuclear areas, but they receive
tively uniform neuron population, as well as extensive reciprocal afferents from the cortex.
connections with diverse cortex areas. • Hypothalamus (› Chap. 12.2.4): The lowest level of the dien-
cephalon consists of core areas and fibre tracts, which are found
Nucleus basalis of MEYNERT on the floor of the IIIrd ventricle or in the area of the lower side
This is a group of cholinergic neurons lying beneath the putamen walls of the ventricle. In particular, the neurons of the hypothal-
and pallidum and above the amygdala; this groups sends efferents amus project within the diencephalon, in the limbic area and up
to the entire cerebral cortex. These projections are very important to the brainstem. The hypothalamus also controls the endocrine
for selective attention processes in connection with visual stimuli, and autonomous control circuits and modulates emotions and
as well as for the storage of information to learn from long-term behaviours.
memories.
Embryology
The diencephalon (interbrain) is formed from the first primitive
Clinical remarks brain vesicles (prosencephalon) during embryonic development,
In neurodegenerative diseases associated with the develop- which continues to develop as part of further differentiation in the
ment of dementia, e.g., in ALZHEIMER's disease), frontotem- vesicle of the cerebrum (telencephalon) and of the interbrain (di-
poral dementia or LEWY body dementia, the cholinergic neu- encephalon) (› Chap. 11.1). The actual diencephalon develops
rons of the Nucleus basalis of MEYNERT degenerate. We are out of the interbrain vesicle with its different parts; also in the early
trying to counteract this loss pharmacologically with the sys-
stages, the optic vesicle develops from the diencephalon. Embryon-
temic administering of acetylcholinesterase inhibitors, in or-
der to increase the concentration of acetylcholine in the syn- ic differentiation begins in the area of what will later become the
aptic gap, thus promoting cognitive skills. hypothalamus (5th week), then the epithalamus develops (6th
week) and subsequently the subthalamus (Thalamus ventralis) as
well as the Thalamus dorsalis.

Position and external shape

12.2 Diencephalon Due to its development, the diencephalon (interbrain), has a close
Tobias M. Böckers topographical and direct functional relationship with the telen­
cephalon, which it borders in particular cranially and rostrally, and
into which it merges without any clear margins. Due to the massive
SKILLS growth of the telencephalic vesicles, the diencephalon becomes al-
After working through this chapter of the textbook, you should be most completely covered by the telencephalon. When dissecting
able to: the brain, parts of the diencephalon can be found at the base of the
• name the components and functional role of the diencephalon
• explain the organisational structure and function of the Thalamus
brain – after removing the Corpus callosum, the thalamus can be
dorsalis seen deep down and lateral of the IIIrd ventricle. In terms of its de-
• describe the different parts and functions of the hypothalamus velopmental history, the Globus pallidus belongs to the diencepha-
and epithalamus lon (subthalamus) and is displaced into the telencephalon in the
course of further brain development (› Chap. 12.1). Caudally, the
diencephalon (interbrain) joins with the mesencephalon with no
clear boundary.
12.2.1 Overview The diencephalon includes the IIIrd ventricle or forms the lateral
limit of this inner CSF space. In the interbrain, small, unpaired or-
Levels of the diencephalon gans are frequently found in the ventricle walls. These have a spe-
The diencephalon (interbrain) can be divided structurally and cialised ependymium with tanycytes; local vessel plexus are endo-
functionally into 4 ‘levels’, which in turn contain nuclear areas with thelial (known as circumventricular organs [CVOs]). In these or-
specific tasks. A distinction is made between, from dorsal to ven- gans the blood–brain barrier is therefore absent, so that agents
tral: from the nervous system can be exchanged directly with the blood
• Epithalamus (› Chap. 12.2.2): It is on the top level of the dien- (neurohemal area).
cephalon, lying on the thalamus. Also found here are the pineal The natural expansion of the interbrain and its structured levels is
gland, the habenulae (Nuclei habenulares, Striae medullares clearly visible in the midsagittal section of the brain

656
 12.2 Diencephalon

Corpus callosum
Ventriculus lateralis
Claustrum
Fornix
Ventriculus
tertius Zona incerta,
Nuclei campi perizonalis
Capsula
externa Putamen

Capsula Globus pallidus

interna medialis and lateralis

a Corpora mamillaria Nucleus subthalamicus b

Hypothalamus Thalamus Epithalamus

Fig. 12.15 Diencephalon. The layered arrangement and lateral extension of the individual interbrain parts is marked in colour. a Extent of the
diencephalon in the frontal section (level of the Corpora mamillaria). b Diencephalon in midsagittal view. a [L126]

(› Fig. 12.15b). The pituitary gland or neurohypophysis is con- NOTE

nected by the pituitary stem to the hypothalamus, which forms the The interbrain (diencephalon) has developed embryologically from
floor of the IIIrd ventricle. In the transition area, the pituitary stem the first primitive brain vesicle (prosencephalon). Later it is com-
pletely overgrown by the telencephalon, so that only very few parts
extends in a funnel-shape to the infundibulum. Ventral to the pitu-
can be recognised immediately at the base of the undissected
itary stem, the Chiasma opticum can be seen. In addition, the low- brain. Due to their specific position and function, the different nu-
er sections of the IIIrd ventricle border the hypothalamic nuclear clear areas and fibre tracts of the interbrain play an extraordinarily
areas laterally up to the Sulcus hypothalamicus. This groove marks important role in the modulation and control of the incoming and
the edge of the Thalamus dorsalis, the medial nuclear areas of outgoing nerve impulses to and from the cerebral cortex (particu-
which protrude into the ventricle. On both sides, ventral to these larly the thalamic nuclear areas). The diencephalon also acts as
medial nuclei is the Foramen interventriculare, which is the the overriding endocrine and autonomic regulation centre for the
central control of different hormonal and circadian control circuits
­connection of the IIIrd ventricle to the lateral ventricle. The pineal
for maintaining homeostasis (in particular the hypothalamus, epi-
gland, Commissura habenularum and the Commissura posterior thalamus).
can be seen over the thalamic nuclei, positioned dorsally › Fig.
12.15. In addition, the choroid membrane of the IIIrd ventricle can
be seen, attached to the Taenia thalami.
In a basal view of the brain (› Fig. 11.19), the outer limit struc- 12.2.2 Epithalamus
tures of the hypothalamus can be seen: it is located between the
Chiasma opticum and the Corpora mamillaria. Between these The epithalamus is located in the dorsocranial diencephalon and
structures, the funnel of the infundibulum with the suspended pi- also partially forms the roof of the IIIrd ventricle. The epithalamus
tuitary gland can be seen (› Fig. 12.16) (during dissection the pi- includes:
tuitary gland is often removed, making an open infundibular recess • The Glandula pinealis (epiphysis or pineal gland)
visible). • the Commissura posterior

N. opticus [II]
Chiasma opticum

Infundibulum Trigonum olfactorium

Tuber cinereum
Substantia perforata
Corpus mamillare anterior

Substantia perforata Tractus opticus

posterior
Crus cerebri
Tegmentum Pedunculus
Pars mesen-
reticularis cerebri
Substantia cephali
nigra Pars
compacta Corpus
geniculatum
Nucleus ruber laterale
Meta-
Corpus
thalamus
geniculatum Fig. 12.16 Parts of the hypo-
Aqueductus mesencephali
mediale
thalamus viewing the brain from
Substantia grisea centralis Pulvinar thalami basal (infundibulum, Corpora
mamillaria).

657
12 Special neuroanatomy

• The nuclei of the habenula (Nuclei habenulares) 12.2.3 Thalamus

• The Commissura habenularum
Overview
Glandula pinealis The thalamus (Thalamus dorsalis) describes a part of the dienceph-
The Glandula pinealis is a cone-shaped, neuro-endocrine organ alon consisting of densely packed, specialised nuclear areas, separated
where specialised neurons produce the hormone melatonin. The by fine lamellae of white matter. It is seen as an elongated rectangu-
pineal gland weighs approximately 100 mg and is located on the lar structure with parallel alignment on both sides of the IIIrd ven-
dorsal side of the IIIrd ventricle 'over' the quadrigeminal plate tricle. Simultaneously, it forms the floor of the Pars centralis of the
(› Fig. 12.15b). The production and release of the hormone is or- lateral ventricle. It spreads out somewhat up to the Foramina inter-
ganised via a polysynaptic reflex arc (› Fig. 12.17). The absence of ventricularia, delimited laterally by the Capsula interna or by nuclear
light/darkness is received through the eye, then the signal is routed areas of the telencephalon (Globus pallidus, putamen) (› Fig.
primarily via the Tractus retinohypothalamicus to the Nucleus 12.15). In more than 70% of cases, the medial thalamic nuclei bulge
suprachiasmaticus. From there, the neural reflex arc continues via on both sides into the IIIrd ventricle and touch each other (Adhe­
the Nucleus paraventricularis of the hypothalamus, the Nucleus sio interthalamica). However, this contact does not represent a
intermediolateralis in the spinal cord and the upper cervical gan- neural connection in the sense of a commissural tract.
glion (Ganglion cervicale superius) to the Glandula pinealis. The thalamus performs key tasks as part of the communication of
Darkness leads to the release of melatonin (darkness hormone), cortex areas with the periphery, and from the periphery to central
which provides the fine tuning for the day–night rhythm (circadian brain areas (‘gateway to awareness’). All sensory perceptions (up to
rhythm) via the Nucleus suprachiasmaticus, induces deep sleep the olfactory system) are thus switched in the thalamus; specialized
and influences other hormonal reflex arcs (e.g., the reproductive nuclear areas are involved in the controlling of motor skills and
capacity and annual rhythm in the animal world). ­incorporated into a variety of subcortical reflex arcs (e.g., in the
limbic system). In addition, the thalamus participates in autonomic
Commissura posterior and motor activities (› Fig. 12.18).
The Commissura posterior in particular provides a connection be- The thalamus consists of numerous nuclei (Nuclei thalami), which
tween the right and left Nuclei pretectales and contains fibres of are structurally divided by lamellae (Lamina medullaris medialis
the dorsal (DARKSCHEWITSCH) nuclei, the Commissura poste- interna) into 3 core areas or groups (› Fig. 12.19):
rior of the dorsal thalamic nuclei and the Colliculi superiores. The • ventrolateral group (Nuclei ventrolaterales)
particular importance of the Commissura posterior is in the coor- • medial group (Nuclei mediani)
dination of the bilateral pupillary reflex. • anterior group (Nuclei anteriores), here the Lamina medullaris
medialis interna separates into a Y-shape
Nuclei habenulares and Commissura habenularum Additionally, the intralaminar nuclei embedded in the Lamina
The Nuclei habenulares (medial and lateral) are located under the medullaris medialis interna are distinguished morphologically
ependyma of the IIIrd ventricle and receive amongst others afferent from the internal medial medullary lamina, the Nuclei mediani,
fibres from the olfactory brain and the hypothalamus via the Striae the occipitally-positioned pulvinar and the Nuclei reticularis
medullares thalami. There are also connections to the Globus (separated from the Nuclei ventrolateralis by the Lamina medullar-
­pallidus, the thalamus and the Substantia nigra. The Stria medullaris is lateralis). The respective key groups can often be divided into
thalami is formed dorsally on the habenulae, which then emerge as smaller functional units (in total over 100 individual nuclear areas).
the pineal stalk into the pineal gland. The Nuclei habenulares con-
nects on both sides via the Commissura habenularum with the
designated afferents. Cortex cerebri
The function of the habenular complex is predominantly pain pro- (Lamina IV)
cessing, endocrine regulation (including reproduction and the Glut-
sleep–wake rhythm) and reward learning. amat-
Nuclei reticularis
ergic
thalami

Melatonin GABAergic

Thalamus
dorsalis
Glandula
pinealis Glut-
Nucleus para-
ventricularis
amatergic

Brainstem Spinal cord Cerebellum

Nucleus supra-
chiasmaticus
Substantia nigra (GABAerg)
Nucleus caeruleus (noradrenerg)
Nucleus raphes posterior (serotonergic)
Retina
Nuclei tegmentales (cholinerg)
Sympathetic fibres Nuclei n. trigemini (glutamatergic)
Tractus retino-
(noradrenergic)
hypothalamicus
Globus pallidus (GABAergic)
Nucleus inter- Ganglion cervicale
mediolateralis superius
Fig. 12.18 Afferent and efferent compounds of the Thalamus dorsa-
Fig. 12.17 Circuit of the Glandula pinealis. lis. [L126]

658
 12.2 Diencephalon

Ventriculus lateralis, Cornu frontale

Capsula interna
Nuclei reticulares
Nuclei anteriores
Nuclei ventrales: Nuclei mediales
Nucleus ventralis anterior;
Nucleus ventralis intermedius; Nuclei mediani; Adhesio interthalamica
Nucleus ventralis posterolateralis;
Nucleus centromedianus
Nucleus ventralis posteromedialis
Nucleus parafascicularis

(Nuclei metathalami:) Nuclei dorsales: Nucleus posterior;

Nucleus corporis geniculati lateralis; Nuclei pulvinares
Nucleus corporis geniculati medialis

Ventriculus lateralis, Cornu occipitale

Fig. 12.19 Nuclei and cortex

projection of the thalamus. The
associated nuclei and cortical
areas are marked with the same
colours in each case. a Horizon-
tal section through the left cere-
bral hemisphere. b Left cerebral
hemisphere from the left side.
b c d c Right cerebral hemisphere
from medial. d View of both
thalami – oblique top view.

Here there are specific nuclei (palliothalamus), which control spe- (› Fig. 12.18). It is assumed that all cortical areas are connected to
cific cortical areas (primary cortical projection fields and associa- the thalamus. These fibre trunks, which can be represented macro-
tion fields), and unspecific nuclei (Truncothalamus), which project scopically, are referred to as thalamic radiations (Radiato thalami),
to the brainstem and several diffuse cortical areas (see below). linking the spinal cord, the brainstem and the cerebellum via the
thalamus to the Cortex cerebri. (› Fig. 12.20). Within these projec-
Important neural connections tion tracts, the Pedunculus thalami anterior (to the frontal lobe),
Thalamus radiation the Pedunculus superior (to the parietal lobe), the Pedunculus
The Thalamus dorsalis is central to many connection pathways be- posterior (to the occipital lobe) and the Pedunculus inferior (to the
tween the cortex and subcortically-located areas of the brain temporal lobe) can be identified. The corticothalamic and thalamo-

Nucleus caudatus, Corpus Fibrae corticospinales; Fibrae corticorubrales;

Fibrae corticoreticulares; Fibrae corticothalamicae;
Fibrae thalamoparietales
Genu capsulae internae,
Fibrae corticonucleares Radiationes thalami
centrales
Thalamus
Fibrae
temporopontinae
Crus posterius
Radiationes
Radiationes capsulae internae
thalami
thalami posteriores
Crus anterius anteriores
capsulae internae Tractus Fibrae parieto-
frontopontinus occipitopontinae
Radiatio optica

Tractus opticus Radiatio acustica

Pulvinar thalami
Colliculus superior
Pedunculus cerebri Colliculus inferior

Fig. 12.20 Thalamus radiation, Radiationes thalami, and internal capsule, Capsula interna. View from the left side; separated into 2 parts by
a frontal section. The thalamic nuclei project mainly to the cortex. Their tracts form parts of the Crus anterius and the Crus posterius of the Cap-
sula interna. The tracts include the Radiationes thalami anteriores and posteriores. Other tracts are the Fibrae corticothalamicae and the
Fibrae thalamoparietales.

659
12 Special neuroanatomy

cortical compounds are mainly glutamatergic, flowing into the lami- Nucleus ventralis posterolateralis and Nucleus ventralis pos-
na IV of the cerebral cortex and mainly developing reciprocally; the teromedialis
Thalamus dorsalis particularly receives afferents › Fig. 12.18from These nuclear areas have a specific projection onto the primary so-
the underlying brain areas (brainstem, spinal cord and cerebellum). matosensory cortex (via the upper thalamus stem). Both nuclei get
afferents from the Lemniscus medialis (sensory information) or
Specific and non-specific nuclei from the Lemniscus spinalis (temperature, pain). The efferents
The functional classification of the thalamus has not been consis- reach the primary (Gyrus postcentralis) and the secondary, so-
tently described and according to current research results, it un- matosensory cortex. The somatotopy is retained in this circuitry
dergoes constant change. A basic distinction is made between the chain and can be seen at each level of routing. These nuclei are
palliothalamus and the truncothalamus: therefore essential for the cortical routing of the information and
• The palliothalamus describes the thalamus nuclei which are the modulation of sensations (e.g., the pain experience).
specifically and systematically in contact with specialized cortex
areas (specific nuclei). Blood supply
• The truncothalamus, on the other hand, includes nuclear areas The arterial blood supply of the thalamus is carried out via multiple
which receive afferents from the brainstem and the basal ganglia arteries supplying the brain. The A. thalamoperforans anterior
(e.g., Nucleus centromedianus and intralaminar nuclei) and originates from the A. communicans posterior, mainly supplying
send their efferents to individual cortical areas or to the hippo- the rostral thalamus. The A. thalamoperforans posterior supplies
campal formation, as well as to other nuclear areas of the limbic a range of nuclear areas of the thalamus; a lesion results in severe
system (non-specific nuclei). Amongst others, they play a role cognitive disorders. The A. thalamogeniculata originates from the
in learning and memory processes. A. cerebri posterior; here a blockage leads to sensory disturbances
and restlessness.
Important specific nuclei are:
Nuclei anteriores
They are the hub between the Gyrus cinguli (limbic system) and the
Clinical remarks
Tractus mamillothalamicus. Macroscopically, they are located be- Bleeding in the thalamic nuclear areas due to lesions in the
tween the short arms of the Y-shaped split of the Lamina medullaris specific nuclear areas can lead to personality changes, motor
medialis interna. The nuclei can be further differentiated into the failures, as well as to cramping pain and discomfort (dysesthe-
Nuclei anterodorsalis, anteromedialis and anteroventralis. The Trac- sias). The painful attacks are also known as thalamic pain
syndrome. If non-specific nuclear areas are affected, this
tus mamillothalamicus ends in these nuclear areas ipsilaterally and
­often leads to a reduction in consciousness.
contralaterally. Other afferents originate from the cortex (fornix),
the brainstem and the Globus pallidus. Important efferents pass into
the Gyrus cinguli and the Gyrus parahippocampalis. It is significant
in the modulation of emotional behaviour and attention.
12.2.4 Hypothalamus
Nuclei mediodorsales and Nuclei mediani
These thalamic nuclei project into the prefrontal cortex. They are Overview and classification
divided into a large cell and small cell nuclear segments. Both parts The hypothalamus is located on both sides of the IIIrd ventricle be-
receive important afferents from the olfactory brain and the amyg- low the thalamus nuclei groups, as described in › Chap. 12.2.3, ven-
dala. In particular, the efferents reach the frontal cortex areas and trally of the subthalamus, and extends over the infundibulum to the
the Gyrus cinguli. Its function should principally be the modulat- posterior pituitary. This also forms the floor of the IIIrd ventricle. The
ing of emotions, but its importance in learning and memory pro- hypothalamus includes specific hypothalamic nuclear areas and the
cesses has also been shown. pituitary gland (more precisely: the posterior pituitary). Topographi-
cally, the hypothalamus is in close contact with the Nn. optici and/or
Pulvinar the Chiasma opticum. At the base of the brain, the expansion of the
The pulvinar is the hub between the visual system and associative hypothalamus defines the Chiasma opticum, the respective Tractus
visual cortex areas. It is a relatively large nuclear area taking up ap- optici and the Corpora mamillaria (› Fig. 12.15, › Fig. 12.16).
proximately one third of the Thalamus dorsalis. Important primary The hypothalamus is only about 0.3 % of the human brain; but, as a
afferents come from other diencephalon neurons (integration central control, regulates significant basal functions of the human
­nucleus) and there are important reciprocal links with the parietal body, such as temperature, fluid and electrolyte balance, food in-
and temporal lobes. The pulvinar is considered to be particularly take, the sleep–wake rhythm and hormone levels (homeostasis). To
important for symbolic thinking and speech comprehension in the a large extent, it also influences social behaviour (including emo-
context of integrating optical and acoustic impulses. tions and sexual behaviour) and also the autonomic nervous system
with the sympathicus and the parasympathicus. It controls and co-
Nucleus ventralis lateralis, Nucleus ventralis anterior and Nu- ordinates almost all neural and humoral communication systems.
clei ventrobasales The special feature of the hypothalamus is, amongst others, that
These nuclear areas carry out the specific projection onto the pri- neurons of the hypothalamic nuclear area adopt a neurosecretory
mary motor cortex with information from the basal ganglia, Sub- function and thus can transform stimuli into humoral signals.
stantia nigra and the cerebellum (also referred to as the motor thala­
mus), and thus are the most important relay stations of the motor Areas and zones
system in the brain. The ventral nuclei contain large and small cell The grey matter of the hypothalamus is very densely packed in
neurons, each receiving afferents from the Substantia nigra, pall- some areas (nuclei of the hypothalamus), as well as less dense in
idum or from the Nuclei cerebelli. The nucleus-specific efferents others (areas of the hypothalamus). Areas consisting mainly of
reach the motor, pre-motor or supplementary motor cortex. grey matter are also referred to as being non-myelinated, whereas

660
 12.2 Diencephalon

areas which are predominantly white matter (tractus) are referred hypophysialis]) in the neurohypophysis) and the Nuclei preoptici
to accordingly as myelinated. (participation in the regulation of blood pressure, body tempera-
A regulatory structure in the hypothalamus is created, initially by ture, sexual behaviour, menstrual cycle, gonadotropin).
organising the grey matter into areas from rostral to caudal in the • The intermediate nuclei group comprises the Nuclei tuberales,
sagittal section. As a result, the pre-optical or chiasmatic area is dorsomedialis, ventromedialis and arcuatus [infundibularis =
above the Chiasma opticum, followed by the intermediary (tuber- semilunaris] (production and secretion of releasing and re-
ale) area, then the posterior zone (› Fig. 12.21, › Table 12.2): lease-inhibiting hormones, participation in the regulation of wa-
• The chiasmatic nuclei group includes the Nucleus suprachias- ter and food intake).
maticus (central pace setter for the circadian rhythm, sleep–wake • The posterior nuclear group includes the Nuclei corporis mamil-
cycle, body temperature, blood pressure), the Nuclei paraventricu- laris in the Corpora mamillaria, which are integrated by affer-
laris and supraopticus (production of anti-diuretic hormone ents from the fornix and efferents from the thalamus (Fasciculus
[ADH] and oxytocin and axonal transport [Tractus hypothalamo-­ mamillothalamicus) into the limbic system. They modulate sex-
ual functions and play an important role in activities related to
Table 12.2 Structure of the hypothalamus into areas, zones, memory and emotions. They are connected via the Fasciculus
­important areas and nuclei. mamillotegmentalis with the Tegmentum mesencephali.
Periventricular zone Medial zone Lateral zone In the frontal section, the lateral expansion of these zones is also
divided into periventricular, medial and lateral zones.
Pre-optical/chiasmatic area
• Nucleus preopticus • Area preoptica media- • Area preoptica lateralis Functional division
medianus lis (Nucleus preopti- • Area hypothalamica The functional division of the nuclear areas of the hypothalamus is
• Nuclei periventricu- cus medialis) lateralis
the result of their specific functions in key hormonal reflex arcs. In
lares preopticus and • Area hypothalamica • Nuclei interstitiales
anterior anterior (Nucleus hypothalami anteriores
this case, a distinction is made between magnocellular and a parvo­
• Nucleus suprachias- anterior hypothalami) cellular neuroendocrine system.
maticus • Nucleus
­paraventricularis Magnocellular neuroendocrine system
• Nucleus supraopticus In this system, nuclear areas of neurosecretory neurons are encapsu-
• Nuclei interstitiales
lated, synthesising the pituitary hormones from the pituitary pos­
hypothalami
­anteriores
terior lobe (Pars neuronalis), and transporting them along their ax-
ons. These include the Nucleus paraventricularis and the Nucleus
Intermediary (tuberal) area
supraopticus (above the N. opticus) which produce the peptide
• Nucleus arcuatus • Nucleus • Area hypothalamica hormones vasopressin (anti-diuretic hormone, ADH or Adiuretin)
­ventromedialis lateralis
and oxytocin and bring them into the posterior pituitary gland via
• Nucleus • Nuclei tuberales latera-
­dorsomedialis les
the Tractus hypothalamohypophysialis. These hormones are modi-
• Nucleus tuberomamil- fied translationally in the axon endings, then stored and finally re-
laris leased on receiving specific signals. During histological dissection,
Posterior (mamillary) area the stored shape of these hormones stands out in the form of a
HERRING body. Vasopressin particularly regulates diuresis in the
• Nucleus periventricu- • Nuclei mamillares • Area hypothalamica
laris posterior medialis and lateralis lateralis
kidneys and is therefore significantly involved in the regulation of
• Area hypothalamica • Nucleus tuberomamil- water and electrolyte balance, and oxytocin stimulates smooth
posterior (Nucleus laris muscle cell contraction (including milk production in the mam­
posterior hypothalami) mary gland, and the postpartum contraction of the uterus).

Nucleus paraven-
tricularis
Area hypothalamica
lateralis Stria medullaris thalami

Nuclei preoptici Nucleus dorsomedialis

Nucleus dorsalis
Nucleus anterior hypothalami
hypothalami
Area hypothalamica
Tractus paraven- lateralis
triculohypophysialis
Fasciculus
Nucleus mamillothalamicus
suprachiasmaticus
Fasciculus
Nucleus supraopticus mamillotegmentalis
Nuclei tegmentales
Tractus supra-
opticohypophysialis Nucleus ruber

Tractus hypotha- Nucleus posterior

lamohypophysialis hypothalami Fig. 12.21 Hypothalamus with
(Nuclei corporis nuclei (drawn transparently).
Adenohypophysis mamillaris) Medial view. The nuclear areas
Neurohypophysis Nuclei tuberales and Nucleus ventromedialis
of the hypothalamus are divided
arcuati [infundibulares] hypothalami into chiasmatic, intermediate
and posterior nuclear groups.

661
12 Special neuroanatomy

Clinical remarks Important hypothalamic nuclei and neural connections

Nucleus suprachiasmaticus
Changes in hypothalamic hormone concentrations can have
The Nucleus suprachiasmaticus found directly above the Chiasma
serious effects on the body's homoeostasis. For example, cen-
tral diabetes insipidus can arise when the pituitary gland opticum (periventricular zone), is central to the regulation of the cir­
stem (Tractus hypothalamohypophysialis) is torn by a skull cadian rhythm in the organism. Neurons of the Nucleus suprachi-
fracture. This disrupts the production or release of vasopres- asmaticus can synthesise different peptide hormones (e.g., ADH,
sin (antidiuretic hormone, ADH) from the pituitary posterior TRH). They both express what are known as clock genes and mela-
lobe. ADH is a peptide hormone (9 amino acids), which re­ tonin receptors. On the basis of melatonin levels in the blood, they
duces diuresis in the urine by promoting the incorporation of integrate day–night information, but are also directly neurally con-
aquaporins in the collecting ducts of the kidneys. Central dia-
nected with retinal neurons. Neurons of the Nucleus suprachias-
betes must be differentiated from renal diabetes insipidus,
which is expressed for example by a congenital or acquired maticus can generate an endogenous, genetically fixed rhythm of
resistance of the kidney to ADH. spontaneous activity (the internal clock), which can be transmitted
via hormonal and neural pathways to other brain structures (syn-
chronisation). Afferents are received by the nucleus from the Trac-
tus retinohypothalamicus as well as from the limbic cortex and the
Parvocellular neuroendocrine system Raphe nuclei. The efferents remain largely local and innervate the
This system includes nuclear areas which control the secretion activi- neurons of other hypothalamic nuclei.
ty of the anterior and mid-pituitary lobe (anterior pituitary) via the
releasing or inhibiting hormones (liberins and statins, e.g., thyro- Nuclei tuberomamillares
tropin-releasing hormone [TRH] or corticotropin-releasing hor- The Nuclei tuberomamillares can be found in the posterior or ma-
mone [CRH]). In terms of its historical development, the anterior millary part of the hypothalamus. Here there are histamine and ad-
pituitary gland does not originate from the diencephalon; instead it enosine-producing neurons, which are particularly involved in the
accumulates as an adherence of epithelium from the back of the reflex arcs of sleeping, waking, alertness and the circadian rhythm.
throat of the posterior pituitary. Thus the anterior pituitary cells are Afferents reach the Nuclei tuberomamillares from the Medulla ob-
regulated by a fine mesh of venous vessels (portal vascular sys­ longata, the hypothalamus and the forebrain. Their projections
tem), located at the bottom of the infundibulum and the median reach other hypothalamic nuclei, the cerebellum and cortex areas,
eminence. Here the axons of parvocellular neurosecretory neurons which are thereby activated. Specific hypothalamic neuropeptides
end, so the peptide hormones which are produced reach the fine associated with sleep (e.g., orexin), may influence the activity of the
blood flow of the portal vessels (from the A. hypophysialis superi- neurons of the Nuclei tuberomamillares.
or) (no blood–brain barrier!). The subsequent second drainage
area of the portal vein is found in the anterior pituitary; thus its
hormone-producing cells are reached by the respective liberins and
Clinical remarks
statins. The production and secretion of the hormone cells of the Narcolepsy is a condition mainly characterised by excessive
anterior pituitary are under close hypothalamic control. In terms of daytime sleepiness, cataplexy (sudden loss of muscle tone),
hormonal ‘feedback mechanisms’, the system is autonomously reg- sleep paralysis and hypnagogic hallucinations. The reason is
ulated according to the circulating hormone concentrations. very likely due to the selective loss of hypocretin/orexin cells
in the hypothalamus. In the brain of the affected patient, only
The parvocellular system includes the Nucleus infundibularis (or
very low levels of orexins (orexin 1 and 2) can be measured.
Nucleus arcuatus), of which the cricoid shape surrounds the funnel Interestingly, narcolepsy is also known in dogs, accompanied
entrance to the pituitary gland. The neurons of the Nucleus infun- by a mutation of the hypocretin-(orexin-)2 receptor.
dibularis form a protrusion on the basal side of the hypothalamus
(Tuber cinereum). With its thin, myelin-free axons, these nerve
cells represent the main contingent of the small cell hypothalamo-
hypophyseal system (Tractus tuberoinfundibularis). Hypotha- Nuclei mamillares
lamic hormones are brought to the portal vascular system at the The Nuclei mamillares (lateralis and medialis) are neuron groups
Eminentia mediana via this tract. In addition, the Nucleus ventro­ in the posterior part of the hypothalamus, which raise the external
medialis, which borders the Nucleus infundibularis dorsally and structure of the Corpora mamillaria bodies on the basal side of the
laterally, can be attributed to the system. It predominantly receives brain. These nuclear areas receive afferents from the hippocampus
afferents from the limbic system and plays a role in the regulation and the brainstem via the fornix and the Pedunculus mamillaris.
of hunger and satiety. Finally, the Nucleus periventricularis, the Important efferents leave these nuclear areas via the Fasciculi ma-
Nucleus paraventricularis (small cell content), the Nucleus su­ millothalamicus and mamillotegmentalis, moving to the Nuclei an-
prachiasmaticus and the Nucleus dorsomedialis are included in teriores thalami and the Nuclei tegmentali anterior and posterior.
the parvocellular system. Via these afferents and efferents, these nuclei are part of the PAPEZ
circuit or the limbic system. The neurons are involved in the regu-
NOTE lation of the subcortical motor system.
The portal vein circulation of the pituitary gland is supplied by the
A. hypophysialis superior. The first venous drainage area is located Nucleus infundibularis/Nucleus arcuatus
on the Eminentia mediana of the hypothalamus, the terminal zone In addition to its role in the parvocellular regulation system (see
of the neurosecretory axons of the parvocellular neurons). They re- above), the nuclear area also has an important function in the regula-
lease their statins and liberins here (the releasing and inhibiting
hormones) into the blood of the portal vascular system. The sec-
tion of appetite and growth. In this way, neurons which synthesise
ond drainage area is found in the anterior pituitary. Here, the se- the orexigenic neuropeptides NPY (neuropeptide Y) and AgRP
cretion-active hormone cells are achieved in their entirety, and fine (agouti-related protein) can be identified. It is believed that, due to
adjustment takes place. the expression of leptin receptors, these neurons are involved in the
regulation of hunger and/or satiety. They are directly distributed in

662
 12.2 Diencephalon

proportion to the levels of ghrelin and leptin in the blood. Primary NOTE
The pituitary gland develops from various parts of the brain (also
afferents receive neurons from other hypothalamic nuclear areas › Chap. 11.1.2):
and from the limbic system. • The pituitary posterior lobe (Pars nervosa) grows from the dien-
cephalon and forms the neurosecretory release area for oxytocin
NOTE and vasopressin (anti-diuretic hormone, ADH) of the axons from
Food intake (feelings of hunger) is regulated by a complex interplay the Nuclei supraoptici and paraventriculares.
of peripheral and centrally-produced and secreted signal molecules. • The anterior pituitary lobe (adenohypophysis) accumulates as an
One of these signal molecules is leptin, which is produced in fatty enfolding of the posterior pituitary by epithelial cells from the back
tissue. A lack of leptin is received centrally in the hypothalamus via of the throat. In its mid-section, cystic structures are frequently
specific binding sites and triggers sensations of hunger. There is an found; these are residues of the lumen of RATHKE's pouch.
interplay between various nuclear areas in the hypothalamus in an
orexic network. Also included in this are the Nucleus paraventricula-
ris and the Nucleus arcuatus. Other peptides involved in the regula- Table 12.3 Afferents and efferents of the hypothalamus.
tion of food intake are the peptide galanin, which reinforces fat in- Important afferents of the hypo- Important efferents of the hypo-
take, and opioid peptides which increases protein intake. Neuropep- thalamus thalamus
tide Y (NPY) is arguably the most well-known stimulator for food in-
take. The corticotropine-releasing hormone (CRH) is one of the • Limbic system • Cerebral cortex, thalamic core areas
known antagonists of NPY in regulating hunger. • Hippocampus • Cranial nerve nuclei, Formatio reticu-
Orexigen’s (appetite-stimulating) effect: neuropeptide Y (NPY), – Corpus amygdaloideum laris
agouti-related peptide (AgRP), galanin, orexin A and B, opioids, – Septum area • Spinal cord
melanin-concentrating hormone (MCH), noradrenaline (α2 recep- – Olfactory cortex • Within the hypothalamus
tor), gamma-amino-butyric acid (GABA), ghrelin, β-Endorphin. • Formatio reticularis, horn of the spi- • In the framework of the magnocellu-
Anorexigen’s (appetite-limiting) effect: melanocyte-stimulating nal cord, sensitive cranial nerve lar system for the posterior pituitary
hormone (α-MSH), corticotropin-releasing factor (CRF), gluca- nuclei
gon-like peptide 1 (GLP-1), glucagon, cocaine- and amphet- • Retina
amine-regulated transcript (CART), thyrotropin-releasing hormone • Within the hypothalamus
(TRH), interleukin β (IL-β). • Insular cortex

Table 12.4 The anterior pituitary (adenohypophysis) hormones.

Anterior hypothalamic area
This area includes the Nuclei anteriores hypothalami and the Hormone Staining Function Hypothalamic
Area preoptica medialis. The nuclear areas are included in the characteris- regulation via
chiasmatic part of the hypothalamus, and, among their other roles, tics
are involved in heat regulation and sexual behaviour. Interestingly, Pars distalis
it was shown that these nuclear areas are not of the same size in men Prolactin (PRL) Acidophilic Milk synthesis Prolactostatin
and women, so it is thought that they contribute to gender identity. (dopamine)
Growth hormone Acidophilic Growth GHRH
Areae hypothalamicae lateralis and posterior (GH, STH) (somatoliberin)
They are found in the posterolateral hypothalamus. The Area hy­
Corticotropin Basophilic Stimulation of the CRH (corticoliberin)
pothalamica lateralis is the name given to the border between the (ACTH) adrenal gland
hypothalamus and the telencephalon. Here, there are afferents and
Melanotropin Basophilic Skin pigmentation CRH (corticoliberin)
efferents on the brainstem, cerebellum and spinal cord. The Area
(α-MSH)
hypothalamica posterior (AHP) is located in the posterior part of
β-endorphine Basophilic Opioid receptor CRH (corticoliberin)
the hypothalamus and has fibre connections to the mesencephalon.
These nuclear areas are also involved in the regulation of food Follicle-stimulat- Basophilic Maturation of GnRH
­intake and respond, for example, to changes in the glucose concen- ing hormone (FSH) ovum/sperm

tration in the blood. Luteinising hor- Basophilic Ovulation, formation GnRH

mone (LH) of Corpus luteum

NOTE Thyroid-stimulat- Basophilic Stimulation of thy- TRH (thyroliberin)

The core areas of the hypothalamus are connected via many affer- ing hormone (TSH) roid cells
ent/efferent (mostly reciprocal) connections with other areas of the Pars intermedia
brain (in particular parts of the limbic system). The main configura-
Corticotropin Basophilic Stimulation of the CRH (corticoliberin)
tions are shown in › Table 12.3.
(ACTH) adrenal gland
Melanotropin Basophilic Skin pigmentation CRH (corticoliberin)
(MSH)
Pituitary gland β-endorphin Basophilic Binds to opioid CRH (corticoliberin)
The pituitary gland is located in the Fossa hypophysialis of the Sella receptors
turcica and is separated by a Dura mater (Diaphragma sellae)
Pars tuberalis
from the actual central nervous system. The pituitary stem acts as a
Pars tuberalis Chromophobic Circadian/circannu- ? (melatonin)
connecting structure for the hypothalamus (made up of axons of
specific cells al rhythm
magnocellular neurons) which runs through a fine recess of the
Diaphragma sellae.
The anterior pituitary gland is also a central endocrine organ and
can be divided into 3 parts (Pars distalis, Pars intermedia, Pars tu-
beralis). Hormone production (› Table 12.4) and secretion is con-

663
12 Special neuroanatomy

trolled by the neurons of the hypothalamus (liberins, statins) 12.2.5 Subthalamus

which reach the anterior pituitary via the portal circulatory system:
• Pars distalis: It makes up the largest part of the anterior pitu- The subthalamus can be found beneath the thalamus, behind the
itary. Within it there are cells capable of the production and se- hypothalamus and caudally of the epithalamus (› Fig. 12.15a).
cretion of hormones (› Table 12.4). ACTH, α-MSH and β-en- Caudally, however, it borders the mesencephalon. The neurons of
dorphin are produced in a cell type of the anterior pituitary from the subthalamus are in close contact with the Thalamus dorsalis.
a common precursor molecule (pro-opiomelanocortin, POMC, The Nucleus subthalamicus is important for the coordination of
which is split into the respective active peptides). movement and is closely connected by fibres to the pallidum (in
• Pars intermedia: The Pars intermedia consists of an irregular terms of its developmental history it is also part of the diencepha-
cell band, and in humans is often only rudimentary. lon, › Chap. 12.1.8).
• Pars tuberalis: The Pars tuberalis wraps itself around the pitu-
itary stem (Tuber cinereum) and attaches itself to the hypothala-
mus. The chromophobic specific cells express melatonin recep- 12.3 Brainstem
tors and produce subunits of thyreotropin. Michael J. Schmeißer, Stephan Schwarzacher

Clinical remarks SKILLS

There are various kinds of benign or malignant tumours of the After working through this chapter, you should be able to:
• name the 3 parts of the brainstem and describe their respective
anterior pituitary gland, which can be functionally or histolog-
ically/anatomically classified. The most common secretory embryological, topographical and morphological features
• explain the functional systems of the brainstem, including the
tumours secrete prolactin, followed by growth hormone (GH)
and corticotropin (CRH). There are also hormonally inactive most important brainstem reflexes and neurotransmitter systems
• explain the importance of the two clinical terms ‘midbrain syn-
tumours:
• Prolactinomas (prolactin-producing adenomas) lead to in- drome’ and ‘WALLENBERG's syndrome’, using basic anatomical
fertility in women with signs of masculinisation (change of terms
hair distribution, hirsutism), cessation of periods (amenor-
rhoea) and milk production in the mammary gland (galactor- The brainstem (Truncus encephali) consists of the midbrain (mes­
rhoea). encephalon), the pons and extended marrow (Medulla oblonga­
• The hypersecretion of growth hormone (GH or STH) in the ta). This macroscopic division is located opposite the division de-
early growth stages of the body can lead to extreme body
rived from the brain's development. Ontogenetically, the mesen-
growth (gigantism). In adults, this is shown by acromegaly
with enlarged nose, tongue, jaw, hands and feet (› Fig. cephalon (› Chap. 12.3.1) therefore arises from the middle vesicle
12.22). of the brain's 3 primary vesicles; conversely the pons and the Me-
• The rare ACTH -producing tumours stimulate the adrenal cor- dulla oblongata (› Chap. 12.3.2) (and the cerebellum, › Chap.
texes with signs of excessive steroid hormone production 12.4) arise from the lower vesicle.
(including cortisol). The clinical pattern is referred to as cen- The inside of the brainstem consists of nuclei (grey matter) and
tral Cushing's syndrome and is accompanied by hyperten- tracts (white matter). In the nuclei, there are essentially the prima-
sion, striae, abdominal obesity and redness of the cheeks. ry sensory and motor cranial nerve nuclei (III–XII). In addition
Large tumours can compress the Sinus cavernosus or the Chi-
asma opticum as they are topographically very closely-related
there are relay nuclei, processing information to and from the cra-
areas: nial nerve nuclei (e.g., the nuclei for eye movement coordination,
• A compression of the Sinus cavernosus can be observed, for the auditory system, the vestibular system), but also important au­
example, in cranial nerves III or IV tonomic centres such as the respiratory and circulatory centres
• When there is compression of the Chiasma opticum, the and the so-called Formatio reticularis. In addition, there are relay
crossing fibres of the optic nerve are selectively interrupted nuclei for cerebellum afferents and nuclei that are monoaminergic
and this creates a bitemporal hemianopsia (tunnel vision). neurotransmitter systems (serotonin, noradrenaline, dopamine).
Surgery can be undertaken for the tumours described, initially
using nasal access, then using keyhole surgery to reach and
remove the tumour.
12.3.1 Mesencephalon

Overview
The midbrain (mesencephalon) borders the diencephalon to cra-
nial and caudal as the top section of the brainstem and continues to
the pons. It is divided into three sections, which are clearly differ-
entiated when seen in cross-section:
• Basis mesencephali: It is in an anterior position and contains
the Crura cerebri, where large descending tracts, such as the py-
ramidal tracts, run.
• Tegmentum mesencephali: The covering of the mesencephalon
borders the base of the midbrain and contains, amongst others,
the Substantia nigra with dopaminergic neurons and the
­Nucleus ruber, both important nuclei of the extrapyramidal
motor system, and the nuclei of cranial nerves III and IV, the
Fig. 12.22 Acromegaly. The foot of a patient with acromegaly mesencephalic Raphe nuclei, the Substantia grisea centralis
(left) compared to the foot of a healthy patient of the same height. and the Aqueductus mesencephali, the connection between the
[R236] IIIrd and IVth ventricles.

664
 12.3 Brainstem

• Quadrigeminal plate of the Tectum mesencephali: It is posi- It is fundamentally important for the structure of the brain and the
tioned at the posterior, and contains important relay stations for positioning of the brain in the skull.
the visual and auditory systems in its colliculi.
NOTE
Embryology Morphogenic or transcription factors such as the pax genes are al-
The mesencephalon develops from the middle vesicle of the 3 pri- so involved in the further differentiation of the CNS and the forma-
mary brain vesicles, the mesencephalon vesicle. Measured against tion of various nuclear areas. In research, the expression pattern of
the other sections of the brain, the mesencephalon grows less these genes is taken into account for determining detailed nuclear
groups.
quickly in the course of the brain's development, and thus remains
close to the isthmus (Isthmus cerebri). The delimiting of the mes-
encephalic vesicle and the caudal rhombencephalic vesicle is the Seen in the horizontal plane looking inwards, the wall of the tube
first early embryological structuring of the rostral neural tube and thickens due to the migration of cells from the base and alar plate,
is regulated by morphogenes of the embryonic isthmic organiser. and the formation of nuclear areas. The neural canal later becomes

Corpora mamillaria Brachium colliculi inferioris

Corpus geniculatum
mediale Brachium colliculi
superioris
Corpus geniculatum
Substantia perforata laterale Glandula pinealis
posterior Tractus opticus
Tractus opticus Colliculus superior
Crus or
N. oculomotorius [III] Crus or Colliculus inferior
Pedunculus cerebri
cerebral peduncle
Trigonum lemnisci
Sulcus lateralis lateralis
Pons
mesencephali
N. trochlearis [IV]
Pons

a b

Glandula pinealis
Pulvinar thalami
Brachium colliculi superioris
Corpus geniculatum mediale
Brachium colliculi inferioris
Corpus geniculatum laterale
Trigonum lemnisci lateralis
Colliculus superior
Sulcus lateralis mesencephali
Colliculus inferior
N. trochlearis [IV]

Fig. 12.23 Mesencephalon. a Ventral view. b Lateral view. c Dorsal view. [L238]

665
12 Special neuroanatomy

the Aqueductus mesencephali. Neuroblasts from the alar plate Rostrally, the mesencephalon borders the diencephalic Pulvinar
form the colliculi in the Tectum mesencephali, while neuroblasts thalami as well as the habenulae with the Glandula pinealis; cau-
from the base plate form the nuclear motor groups in the Tegmentum dally the upper cerebellar peduncles, together with the upper cere-
mesencephali (e g., Nucleus ruber, Substantia nigra, oculomotor bellar sail, form the demarcation with the pons.
cranial nerve nuclei [III and IV]). The corticopontine, corticonu-
clear and corticospinal fibres running within the Basis mesencepha­
li arise from the cerebral cortex and thus ontogenetically from the
Clinical remarks
telencephalon. Thus they follow the general principle that axons The mesencephalon pushing through the Incisura tentorii is
always sprout from the somata of nerve cells, and that the fibres surrounded in this area by the free edge of the Tentorium cere-
(axons) of all tracts arise ontogenetically from their associated so- belli and by fluid from the Cisterna ambiens. Due to the topog-
mata. It follows that tracts (with white matter) generally arise later raphy, medial parts of the temporal lobes can be compressed
into the respective gaps between the mesencephalon and the
as nuclear areas (with grey matter). Accordingly, after they arise,
Tentorium cerebelli and become trapped (‘upper entrapment’)
nuclear areas are often crossed through by fibres (e.g., taking the where there are supratentorial processes demanding space
ascending fibres of the Lemniscus medialis from the rhomben- (e.g., bleeding, tumor). This may result in numerous neurolog-
cephalon through the Tegmentum mesencephali). ical symptoms, such as:
• failure of the ipsilateral N. oculomotorius [III] with widening
Location and external appearance of the pupils
Observed ventrally or basally, (› Fig. 12.23a) we can see the two • compression of the pyramidal tract in the Crura cerebri with
accompanying motor paralysis, spasms of the extremities
caudally converging crura or Pedunculi cerebri at the mesenceph-
and exaggerated proprioceptive reflexes
alon, with the Fossa interpeduncularis lying between them. The • a compression of the internal pathways and autonomous cen-
oculomotor nerve [III] exits and the Aa. centrales posteriores en- tres of the Substantia grisea centralis of the mesencephalon,
ters in the Fossa interpeduncularis. If the meninges are removed which may lead to circulatory dysregulation, autonomic lapse
during the dissection of the brainstem, these entry points create an or loss of consciousness, known as midbrain syndrome.
area with small holes, referred to as the Substantia perforata pos­
terior. Rostral from here are the medially-positioned Corpora ma-
millaria, as well as the Tractus optici of the diencephalon running a
little further laterally; caudal of the Crura cerebri is the transversal- Internal structure
ly running fibre bundle of the pons. In cross-sectional images (› Fig. 12.24), the three sections of the
Viewed laterally (› Fig. 12.23b), each Crus cerebri is detached by mesencephalon are clearly delimited from ventral to dorsal:
the Sulcus lateralis mesencephali, forming the externally-visible • Basis mesencephali with the Crura cerebri
demarcation of the Tegmentum mesencephali. On the dorsal side • Tegmentum mesencephali
is the Trigonum lemnisci lateralis, under the surface of which are • Tectum mesencephali
parts of the auditory system (Lemniscus lateralis).
Viewed dorsally, (› Fig. 12.23c) the Tectum mesencephali can be Basis mesencephali with the Crura cerebri
recognised by its signature surface relief, known as the quadrigem- The Crura cerebri consist of projection fibres. These can be as-
inal plate (Lamina quadrigemina or Lamina tecti). Here, a dis- signed to specific tracts. In each crus, the following can be basically
tinction is made between the two larger ‘upper hills' (Colliculi su­ distinguished:
periores) and the two smaller ‘lower hills’ (Colliculi inferiores). • Projection fibres of the cerebrum to the Fibrae corticopontinae
On each side, the Colliculus superior is connected via the Brachi­ • Projection fibres of the pyramidal tract, which pass from the ce-
um colliculus superioris with the Corpus geniculatum laterale rebrum to the cranial nerve nuclei or to the spinal cord (Fibrae
(optic tract), and the Colliculus inferior via the Brachium colliculi corticonucleares and corticospinales)
inferioris with the Corpus geniculatum mediale (auditory sys- Within a Crus cerebri, these fibres are arranged by somatopes. Fi-
tem) of the thalamus. Directly caudal to the Colliculi inferiores, the brae corticopontinae run quite medially from the frontal cortex;
N. trochlearis [IV] exits as the only cranial, dorsal nerve emerging they are then joined laterally by Fibrae corticonucleares, then by
on both sides from the brainstem, running around the lateral sur- Fibrae corticospinales, and running completely laterally are Fibrae
face of the mesencephalon in the Cisterna ambiens to the front. corticopontinae from the parietal and occipital cortex. In this way,

Colliculus superior Aqueductus mesencephali

Nucleus mesencephalicus Substantia grisea centralis

nervi trigemini [V] Lemniscus lateralis
Brachium colliculi inferioris Nucleus raphe dorsalis
Nucleus accessorius Lemniscus medialis
nervi oculomotorii [III]
Nucleus ruber
Nucleus nervi
oculomotorii [III]
Pars compacta Substantia
N. oculo- Pars reticulata nigra
motorius [III]
Crus or Pedunculus cerebri

a Substantia perforata posterior Area tegmentalis ventralis b

Fig. 12.24 Cross-section through the rostral mesencephalon at the level of the exit of the N. oculomotorius. a Diagram [L126]. b Anatomical
dissection [R247].

666
 12.3 Brainstem

the projection fibres of the pyramidal tract are flanked within the Aqueductus mesencephali and Substantia grisea centralis
Crura cerebri by the respective corticopontine fibre system. Exactly in the middle of the dorsal tegmentum is the Aqueductus
mesencephali. This canal like structure links the IIIrd ventricle
Tegmentum mesencephali within the diencephalon to the IVth ventricle within the rhomben-
Substantia nigra cephalon.
Directly dorsal of the Crura cerebri is the Substantia nigra, an im- The Aqueductus mesencephali is surrounded by a collection of
portant nuclear area, especially for the dopaminergic system. Macro- grey matter, the periaqueductal grey (Substantia grisea centralis).
scopically it appears to be black due to the high melanin content in This is a complex integration centre for primarily autonomic func-
the perikarya of the local dopaminergic neurons and can therefore tions. Morphologically, it mostly maintains numerous reciprocal
be easily recognised in mesencephalic segment dissections. Micro- connections with the hypothalamus and structures of the limbic
scopically, 2 parts are distinguished: system, with the autonomic nerve centres of the pons and Medulla
• The Pars compacta is the larger part of the Substantia nigra, ly- oblongata and various cranial nerve nuclei. Functionally, the Sub-
ing further dorsally. Here the dopaminergic neurons are found, stantia grisea centralis is involved, amongst others, in the central
tightly packed together. autonomous control and coordinates anxiety and, fight or flight,
• The Pars reticulata is the smaller part of the Substantia nigra, reflexes, as well as various cranial nerve nuclei for voice projection.
located further ventrally. The GABAerg neurons are located here It has another central role in endogenous pain inhibition because
and are not as tightly packed as in the Pars compacta. its corresponding neurons project via Raphe nuclei into the spinal
The Substantia nigra receives afferents from both the motor and the cord, in order to inhibit pain impulses by activating inhibitory in-
premotor areas of the cerebral cortex as well as from the striatum. terneurons (also › Chap. 13.8).
Efferent is projected by the dopaminergic neurons of the Pars com-
pacta into the striatum (Fibrae nigrostriatales), and by the GABA­
ergic neurons of the Pars reticulata, primarily into the thalamus.
Clinical remarks
Pharmacologically, the neuroanatomical circumstances of the
Substantia grisea centralis are used in central pain treatment,
Clinical remarks as the endorphinogenic afferents of the endogenous pain-­
In PARKINSON's disease, neuropathological dissection re- relieving system end at the local nerve cells. Endorphins are
veals a definite blanching of the Substantia nigra (Pars com- effective via opiate receptors. In the context of central pain
pacta). This is caused by the morphological loss of the local treatment, opiates such as morphine or derivatives of mor-
dopaminergic neuron population. phine can target these receptors and, by stimulating neurons
in the Substantia grisea centralis, activate the endogenous
pain inhibition system.

Area tegmentalis ventralis

Medial to the Substantia nigra there is another primarily dopami- Nucleus raphe dorsalis
nergic neuronal population, the so-called Area tegmentalis ventra- Ventral of the Substantia grisea centralis, the serotonergic mesen-
lis. From here, primarily efferent projection fibres go into the corti- cephalic Raphe nuclei, also referred to as the Nucleus raphe dorsa-
cal and limbic areas, such as the prefrontal cortex, the hippocam- lis, lie in the midline (› Chap. 12.3.3). They project locally into
pus, amygdala and the Nucleus accumbens, and form the the mesencephalon, mainly ascending into the diencephalon and
mesocorticolimbic dopaminergic system. telencephalon.

Nucleus ruber Cranial nerve nuclei and pathways

Directly dorsal of the Area tegmentalis ventralis is a nuclear area In the rostral mesencephalon, the Nucleus nervi oculomotorii
that appears reddish in a freshly sectioned dissection, due to the [III] are located ventrally of the Aqueductus mesencephali next to
high iron content of the neurons found there, called the Nucleus the midline and directly dorsal of the Nucleus accessorius nervi
ruber, stretching rostrocaudally from the approximate border of oculomotorii EDINGER-WESTPHAL. The Nucleus nervi trochle­
the diencephalon up to the caudal margin of the Colliculi superi- aris [IV] is located in the caudal mesencephalon, lateral to the
ores. Microscopically, 2 parts are distinguished: mesencephalic Raphe nuclei. Directly lateral to the Substantia gri-
• The Pars parvocellularis is located further rostrally and contains sea centralis is the Nucleus mesencephalicus nervi trigemini [V]
small neurons, which are primarily reached via the Capsula inter- with its characteristically large somata seen in a histological dissec-
na by afferents from the ipsilateral cerebral cortex (Tractus corti­ tion. This is the perikarya of the proprioceptive pseudo-unipolar
corubralis), and also to a small extent via the upper cerebellar neurons from the chewing muscles. The following systems or
stem by afferents from the contralateral Nucleus dentatus of the ducts also pass through the Tegmentum mesencephali: Formatio
cerebellum. The neurons project efferents via the Tractus tegmen­ reticularis, Lemniscus medialis, Lemniscus lateralis, Tractus spi-
talis centralis ipsilaterally to the lower olive, thereby belonging to nothalamicus, Tractus tegmentalis centralis, Tractus tectospinalis,
the extrapyramidal-motor cortico-rubro-olivo-cerebellar system. Fasciculi longitudinales medialis and posterior, Decussationes pe-
• The Pars magnocellularis lies caudally and in humans tends to dunculorum cerebellarium superiorum.
be poorly formed. It is reached via the upper cerebellar stem,
particularly by afferents from the contralateral Nuclei globosus Tectum mesencephali
and emboliformis of the cerebellum. To a lesser extent, afferents The Tectum mesencephali consists of the Lamina quadrigemina.
from the ipsilateral cerebral cortex end here. The neurons of the This, in turn, is constructed from the two Colliculi superiores and
Pars magnocellularis project via the Tractus rubrospinalis the two Colliculi inferiores.
(which in humans tends to be poorly formed) into the contralat-
eral spinal cord in particular.

667
12 Special neuroanatomy

Colliculi superiores It is the first rostrocaudal segmentation of the neural tube in the
The Colliculi superiorus each consist of 7 layers and are an import- brain structure. Initially, the rhombencephalon is arranged in 8
ant optic reflex centre. Respectively, they primarily receive afferents rostrocaudally arranged rhombomeres. But this structure is largely
from the visual system via the Brachium collicullis superior, in- lost during development, in contrast to the somite-induced seg-
cluding retinotectally directly from the N. opticus and/or the Trac- mental structure of the spinal cord. The cerebellum only forms rel-
tus opticus, from the occipitally located visual cortex and from the atively late on dorsally. Parallel to it, the Nuclei pontis develops in
frontal field of vision, as well as from the spinal cord and the Col- the ventral rostral area. Later on, these form the characteristic ven-
liculi inferiores. The Colliculi superiores are connected efferently tral swelling at the Pars basilaris pontis. Laterally, they continue
with the motor nuclei of the brainstem via the Tractus tectobul­ into the middle cerebellar peduncles (Pedunculi cerebellares me­
baris, and via the Tractus tectospinalis with the motor neurons of dii) which span the original rhombencephalon (the dorsal part of
the spinal cord. the pons) like a bridge, to pass dorsally into the cerebellum. Corre-
Due to these links, in the case of acute visual stimuli such as a flash sponding with its later shape, the pons and cerebellum are referred
of light, the Colliculi superiores can cause the eyelids to close and/ to as the hindbrain (metencephalon) and is delimited from the af-
or the head to turn away. On the other hand, they also play a deci- terbrain (myelencephalon and/or Medulla oblongata).
sive role in turning the head and eyes towards an acoustic stimulus.
In addition, they are very important for the coordination of rapid Pons
eye movement, known as saccades. The integration function of the Position and external appearance
Colliculi superiores means that a look can be directed as quickly as The pons is above the clivus and is cranially adjacent to the Crura
possible to corresponding targets and that the eye is assisted in fol- cerebri and caudally adjacent to the bulbus of the Medulla oblon-
lowing moving objects. gata, from which it is separated by the transverse Fissura ponto-
medullaris. At the ventral surface (› Fig. 12.25a), transverse fibre
Colliculi inferiores bundles dominate, and these each merge laterally into the middle
The Colliculi inferiores are an important relay station in the audi- cerebellar peduncle (Pedunculus cerebellaris medius). Medially,
tory system and consist respectively of one large and 2 smaller nu- there is a longitudinal furrow, the Sulcus basilaris, in which the A.
clei: Nucleus centralis, Nucleus pericentralis and Nucleus externus. basilaris runs. Right and left of this sulcus, there are 2 horizontal
The Lemniscus lateralis of the auditory system ends afferently at bulges generated by the longitudinally-running pyramidal fibres.
the tonotopically-structured Nucleus centralis; its efferents pass via Laterally, on each side at the transition from the pons to the middle
the Brachium colliculi inferioris to the Corpus geniculatum medi- cerebellar peduncle, the N. trigeminus exits with its Radix motoria
ale of the thalamus, where they are switched onto the neurons of and Radix sensoria; exiting ventrally at the lower edge of the pons
the auditory system that reach the auditory cortex. in the medial area of the Fissura pontomedullaris are the N. abdu-
cens and, at the lateral margin of the pons, the N. facialis and N.
vestibulocochlearis in the so-called cerebellopontine angle (› Fig.
12.3.2 Pons and Medulla oblongata 12.25b). This is positioned between the lower margin of the pons,
the lower edge of the middle and lower cerebellar peduncle (Pe­
Overview dunculus cerebellaris inferior), as well as rostral and dorsal of the
The pons and the extended medulla (Medulla oblongata) is as- lower olive of the Medulla oblongata.
signed along with the cerebellum to the rhombencephalon. The The dorsal surface of the pons (› Fig. 12.25c) is the rostral half of the
rhombencephalon received its name from the Fossa rhomboidea, rhomboid fossa and is only visible after removal of the cerebellum.
the rhomboid-shaped confined dorsal surface of the pons and Me- Among other things, the Colliculus facialis, is notable here as a pro-
dulla oblongata, forming the ‘floor’ or the front wall of the IVth ven- trusion caused by the bend in the facial nerve (Genu nervi facialis).
tricle. Rostrally, the rhombencephalon is marked-off topographically
from the mesencephalon by the Tentorium cerebelli. Caudally, it Internal structure
merges at the Foramen magnum with the spinal cord. The pons and The pons and the Medulla oblongata emerged ontogenetically as a
Medulla oblongata are reached and infused by the rising and de- single unit; accordingly, the internal structures show continuity and
scending ducts connecting the rostral brain sections with the cere- the Fissura pontomedullaris is not a clear internal boundary. The
bellum and the spinal cord. They contain the nuclei of the subtento- pons is divided into a front section, the Pars basilaris pontis, and a
rial cranial nerves (V–XII), vital autonomous centres for respiration, rear section, the Pars dorsalis pontis. This can be particularly clear-
circulation and digestion, the caudal sections of the hearing and bal- ly visualised in cross-section (› Fig. 12.26). The Pars basilaris,
ance system as well as the nuclei of the afferent cerebellar pathways. which determines the mighty ventral swelling at the pons, takes up
around two-thirds of the ventral surface. Dorsally, the original pon-
tine part of the rhombencephalon joins with the Pars dorsalis,
Clinical remarks forming the rostral continuation of the Medulla oblongata.
Clinically, injury to the pons and Medulla oblongata is frequent-
ly dramatic, as they may often lead to life-threatening distur- Pars basilaris pontis
bances of breathing and circulation, as well as the interruption In the white matter of this pons section there are fibres running in
of descending motor control or the ascending sensory pathways. both a longitudinal and transversal direction (Fibrae pontis longi­
tudinales and transversae), and in the grey matter embedded in
between them, there are numerous Nuclei pontis. The Fibrae pon-
tis longitudinales continue the fibre tracts of the Crura cerebri and
Embryology therefore contain the pyramidal tracts routed through the pons and
Ontogenetically, the rhombencephalon originates from the most corticopontine projections that end at the neurons of the Nuclei
caudal of the 3 primary brain vesicles, the rhombencephalic vesi­ pontis. In turn, their axons run as Fibrae pontis transversae to the
cle. Its delimitation from the mesencephalon occurs very early on. opposite sides and reach the cerebellar cortex via the Pedunculus

668
 12.3 Brainstem

Sulcus basilaris

Radix motoria Pedunculus

N. trigeminus [V]
Radix sensoria cerebellaris superior

Pedunculus
cerebellaris medius
N. facialis [VII]
N. vestibulocochlearis [VIII] Pedunculus
N. abducens [VI] cerebellaris inferior
Fissura pontomedullaris
N. hypoglossus [XII] Cerebellopontine angle
Pyramis
Oliva inferior
Sulcus retroolivaris with
Decussatio pyramidum N. glossopharyngeus [IX];
N. vagus [X]; Radix cranialis
N. accessorii [XI]

a b

Pedunculus cerebellaris superior

Colliculus facialis
Pedunculus cerebellaris medius

Pedunculus cerebellaris inferior Striae medullares ventriculi quarti

Tuberculum cuneatum

Obex Tuberculum gracile

Fig. 12.25 Pons and Medulla oblongata. a Ventral view. b Lateral view. c Dorsal view. [L238]

Locus caeruleus
Nucleus mesencephalicus Pedunculus cerebellaris
nervi trigemini [V] superior

Nucleus motorius
nervi trigemini [V] Nucleus parabrachialis
medialis, KÖLLIKER-FUSE
Nucleus principalis nucleus
nervi trigemini [V]
Nuclei raphes
Lemniscus lateralis pontis
Lemniscus medialis
Pedunculus
N. trigeminus [V] cerebellaris medius

Pars basilaris pontis

a Tractus corticospinalis with Nuclei pontis b

Fig. 12.26 Cross-section through the rostral pons at the level of the exit of the N. trigeminus. a Diagram [L126]. b Anatomical dissection.
[R247]

669
12 Special neuroanatomy

cerebellaris medius. At its entry point at the Pars basilaris pontis, • In the caudal half, directly dorsal of the Nuclei pontis of the Pars
the pyramidal tract separates into numerous fascicles, which push basilaris, is the Corpus trapezoideum and lateral from here lies
through the grey matter, and after passing through the pons reunite the upper olive (Nucleus olivaris superior), both being nuclear
into a common structure, the pyramid. areas of the auditory system (› Table 12.5, also › Chap. 13.4).
Positioned ventrally along the midline is the Raphe pontis with
Pars dorsalis pontis the pontine serotonergic Raphe nuclei positioned caudally. Located
The dorsal part of the pons, like the caudally-joining Medulla ob- ventrolaterally is the Nucleus nervi facialis [VII]. The axons of
longata, is divided into a medial raphe and lateral parts, containing the motor neurons localised within the pons run initially dorsally
numerous nuclear areas of the brainstem system, the Formatio and then entwine the Nucleus nervi abducentis [VI], which sits
­reticularis and the pontine cranial nerve nuclei (V–VIII). Laterally, it on the dorsal surface, caudally and medially, subsequently run-
includes the area of the cerebellar peduncle. In contrast to the Pars ning laterally to the ventral surface of the pons, and exiting from
basilaris, which has a similar cross-section structure at all l­evels, the brainstem together with the N. vestibulocochlearis in the
significant differences can be found in the Pars dorsalis pontis, de- cere­bellopontine angle. The vestibular nuclei lie dorsally on the
pending on the level of the relevant cross-section: floor of the rhomboid fossa in the pontomedullary transition
• In the rostral half, trigeminal nuclear complexes are found. area. We can differentiate between 4 subnuclei – the Nuclei ves-
These include the dorsolaterally located Nucleus motorius nervi tibularis medialis, lateralis, superior and inferior, all of which re-
trigemini, and further laterally, the Nucleus principalis nervi tri- ceive nerve fibres from the vestibular part of the N. vestibulo­
gemini. Dorsal from here are the Tractus mesencephalicus nervi cochlearis and send axons to the cerebellum (› Table 12.5, also
trigemini and the caudal sections of the Nucleus mesencephali- › Chap. 13.5). Ventral of the Nuclei vestibulares are the Nuclei
cus nervi trigemini. In the area of the midline are the Nuclei ra­ cochleares dorsalis and ventralis (also › Chap. 13.4).
phes pontis as well as caudally and ventrally of the upper cere- The following systems or ducts pass through the Pars dorsalis: Lem-
bellar peduncle (Pedunculus cerebellaris superior), the pig- niscus medialis, Lemniscus lateralis, Tractus tegmentalis centralis,
mented Locus caeruleus, an essential part of the central Fasciculi longitudinales medialis and posterior, Tractus mesen-
catecholaminergic system. In addition, directly lateral and also cephalicus and spinalis nervi trigemini. The fibres of the Lemniscus
ventral of the upper cerebellar peduncle are the Nuclei parabra­ medialis, which cross in the Decussatio lemniscorum of the Medulla
chiales medialis and lateralis and the KÖLLIKER-FUSE nucle­ oblongata, initially pass dorsally along the Corpus trapezoideum in
us. These nuclear areas form the pontine respiratory group for the caudal pons right next to the midline. Along their rostral pathway,
the central regulation of breathing. they move increasingly laterally, reaching the dorsolateral surface in

Table 12.5 Overview of the functional anatomy of the brainstem.

Centre/system Function/reflex Nuclear area or brain area Participating afferent cranial Participating efferent cranial
nerves nerve nuclei or spinal cord

Eyes/Vision Pupillary reflex Area pretectalis N. opticus [II] Nucleus accessorius nervi oculo-
motorii
Ocular motor function Pre-occular motor centres, Colliculi N. opticus [II] Nucleus nervi oculomotorii [III],
superiores Nucleus nervi trochlearis [IV],
Nucleus nervi abducentis [VI]
Corneal reflex, eyelid movement Nucleus principalis nervi trigemini Nucleus nervi facialis [VII]
[V]

Ears/hearing Directional hearing, movement of Nucleus olivaris superior, Corpus Nuclei cochleares [VIII] Spinal cord (cervical anterior horn)
the head towards the source of the trapezoideum, Colliculi inferiores
sound

Balance Posture, spatial orientation Nucleus olivaris inferior, cerebellum Nuclei vestibulares [VIII] Spinal cord

Nose Sneezing reflex Respiratory centre, ventrolateral Nucleus principalis nervi trigemini Nucleus ambiguus (IX, X), spinal
Medulla oblongata [V/2] cord (anterior horn)

Gastrointesti- Taste, saliva Rostral part of the Nucleus tractus Nucleus salivatorius superior [VII]
nal tract solitarii (VII, IX, X) and inferior [IX]
Swallowing Swallowing centre, ventrolateral Nucleus principalis nervi trigemini Nucleus motorius nervi trigemini
Medulla oblongata (V/2, V/3), medial Nucleus tractus [V/3], Nucleus nervi facialis [VII],
solitarii (IX, X) Nucleus ambiguus (IX, X), Nucleus
Nervi hypoglossi [XII]
Vomiting Area postrema Medial Nucleus tractus solitarii [X] Nucleus dorsalis nervi vagi [X]
Digestion (including secretion of Medial Nucleus tractus solitarii [X] Nucleus dorsalis nervi vagi [X]
gastric juices, bile, pancreatic juic-
es and peristalsis)

Breathing Respiratory reflexes (including lung Respiratory centre, ventrolateral Lateral Nucleus tractus solitarii [X] Nucleus ambiguus (IX, X), Nucleus
expansion reflex, cough reflex) Medulla oblongata nervi hypoglossi [XII], spinal cord
(ventral horn)

Heart/circula- Circulatory reflexes (including Circulation centre, rostral ventrolat- Dorsolateral Nucleus tractus soli- Nucleus ambiguus, external forma-
tion baroreceptor and chemoreceptor eral Medulla oblongata (RVLM) tarii (IX, X) tion [X], sympathicus, spinal cord:
reflexes) lateral horn

670
 12.3 Brainstem

the caudal mesencephalon. In the rostral pons, they incorporate the Rostral half
fibres of the Nucleus principalis nervi trigemini. The Lemniscus lat- In the rostral half (open part of the Medulla oblongata = caudal
eralis joins laterally. Ventrally the Fasciculus longitudinalis medialis half of the Fossa rhomboidea), the pyramid and the lower olive are
runs near the midline on the floor of the rhomboid fossa. notable ventrally. Positioned dorsally are the nuclei of the posterior
column tract, the Nuclei gracilis and cuneatus, and laterally, the
Medulla oblongata Pedunculi cerebellares inferiores pass to the cerebellum.
Position and external appearance On the cross-section, the lower olive is highly visible macroscopi-
The Medulla oblongata is the caudal part of the rhombencephalon. cally as the largest nuclear area of the Medulla oblongata. The wind-
Ventrally it sits on the clivus and extends caudally to the Foramen ing, snake-like tracts are characteristic, formed from numerous
magnum. The ventral surface (› Fig. 12.25a) of the bulbus is char- small and densely-packed somata, wherein a number of sub-nuclei
acterised medially by the longitudinal tracts of the pyramid, Pyra­ can be distinguished. Overall, the lower olive is a relay nucleus in
mis. Both the pyramids taper caudally, and the majority of de- front of the cerebellum, primarily processing spinal and vestibular
scending fibres of the Tractus corticospinalis cross over in the De­ information.
cussatio pyramidum, which marks the boundary with the spinal Directly around the central canal or at the bottom of the IVth ven-
cord. Directly to the side of the pyramid, the lower olive (Oliva in­ tricle is the Nucleus nervi hypoglossi [XII]. It consists of ventral
ferior) joins; it is well-defined on the outer surface as an ovoid nu- and dorsal subnuclei representing different tongue muscles. Dor-
clear area. It serves as a good ventral landmark: its expansion corre- sally of the Nucleus nervi hypoglossi is the Nucleus dorsalis nervi
sponds exactly with the 'open' rostral Medulla oblongata, i.e. it vagi [X] and dorsally thereof is the Nucleus tractus solitarii (IX,
starts at the Fissura pontomedullaris and extends caudally to the X), which also contains taste buds in the rostral section.
obex. Between the pyramid and lower olive, the roots of the N. hy- Located directly on the obex, medially dorsal of the central canal, is
poglossus [XII] exit; dorsally of the lower olive in the Sulcus ret­ the small Area postrema with right and left lateral offshoots which
roolivaris, the roots of the N. glossopharyngeus [IX] and the N. are in direct contact with the Nucleus tractus solitarii. The Area
vagus [X], as well as the Radix cranialis of the N. accessorius [XI] postrema contains vagal visceroafferents and is the central vomit-
(› Fig. 12.25a, b) exit. Dorsally, the Medulla oblongata lies on the ing centre. In the Area postrema, the blood–brain barrier is sus-
cerebellum, with which it is connected via the two lower cerebellar pended.
peduncles (Pedunculi cerebellares inferiores). In the area of the Located dorsolaterally are the sensory Nuclei principalis and spi­
Medulla oblongata, the IVth ventricle narrows caudally to the cen- nalis nervi trigemini [V]. Dorsal of the Nucleus spinalis nervi tri-
tral canal – in this way a rostral section (open part of the Medulla gemini, in the rostral Medulla oblongata, are the caudal parts of the
oblongata = caudal half of the Fossa rhomboidea) can be distin- Nuclei vestibulares, as well as the Nucleus salivatorius inferior
guished from the caudal section (closed part of the Medulla oblon- [IX]. In the ventrolateral medulla is the Nucleus ambiguus, which
gata) (› Fig. 12.25c). The entrance point to the central canal is comprises the motor neurons of the branchiogenic muscles of the
known as the obex. It serves as an important landmark to deter- 3rd–6th pharyngeal arch (IX, X, medullary section of XI), i.e. the
mine the rostrocaudal level of cross-sections through the rhomb- muscles of the larynx and the pharynx. It forms a longitudinal ros-
encephalon. Laterally and caudally, the Fossa rhomboidea is bor- trocaudal Pars compacta, which passes through the entire Medulla
dered by protrusions of the Nuclei gracilis and cuneatus (Tubercu­ oblongata as the actual Nucleus ambiguus, as well as individual pa-
la gracile and cuneatum), which pass to the spinal cord in the ra-ambigualis nucleus groups ventral of this Pars compacta, includ-
corresponding longitudinal bulges of the Funiculi gracilis and cu- ing the external formation which includes parasympathetic neu-
neatus of the posterior column tracts. rons for the innervation of the heart (› Table 12.5, also › Chap.
13.9). In the immediate vicinity and ventrally of the Nucleus am-
Internal structure of the Medulla oblongata biguus are the groups of medullary breathing regulation with the
The Medulla oblongata (› Fig. 12.27), is structured like the pons pre-BÖTZINGER complex as the medullary respiratory centre.
as a median raphe (Nuclei raphes medullae) with lateral parts, Medial to the respiratory centre the nuclei of the medullary cardio-
containing numerous nuclear areas of the brainstem systems and the vascular entre is positioned in the rostral ventrolateral Medulla
Formatio reticularis, as well as the medullar cranial nerve nuclei ­oblongata, which, amongst others, sends adrenergic neurons to the
(IX–XII). Laterally, the area of the cerebellar peduncle is included. sympathetic neurons of the spinal cord.

Nucleus solitarius
Nucleus dorsalis nervi vagi [X] Nucleus nervi hypoglossi [XII]

Tractus nuclei solitarii Nucleus vestibularis medialis

Nucleus ambiguus,
N. vagus [X] Pars compacta
Nucleus spinalis Pedunculus cerebellaris
nervi trigemini [V] inferior
Nucleus para-ambigualis
Tractus spinalis
(external formation)
nervi trigemini [V]
Ventral respiratory group,
N. hypoglossus [XII] pre-BÖTZINGER complex,
respiratory centre
Nuclei raphe medullae
Rostroventrolateral medulla,
Tractus corticospinalis, cardiovascular centre
pyramis
a Oliva inferior b

Fig. 12.27 Cross-section through the rostral Medulla oblongata at the level of the exit point of the N. vagus. a Diagram [L126]. b Anatomical
dissection [R247].

671
12 Special neuroanatomy

Caudal half Brainstem reflexes

In the caudal half (closed part of the Medulla oblongata = transi- Learning about brainstem function, and particularly about basic
tion to the spinal cord) the lower olive is no longer visible and the configurations, helps with the orientation of brainstem reflexes and
cross-section is significantly reduced. The tapered caudal offshoots their afferent and efferent reflex limbs into the corresponding cranial
of the nuclear areas of the rostral Medulla oblongata are truncated nerves (› Table 12.5). Additionally, the testing of brainstem reflexes
(Nucleus ambiguus, Nucleus dorsalis nervi vagi, Nucleus tractus or cranial nerve reflexes is of central, vital importance when taking
solitarii, Nucleus nervi hypoglossi), which partially extend to the any medical history (e.g., first aid for unconscious people). Also ap-
spinal cord or continue in tracts to/from the spinal cord. The tran- plying to the brainstem as for the entire CNS is the distinction be-
sition from the caudal Medulla oblongata to the spinal cord is fluid tween
and is called a transitional zone. However, the anterior and dorsal • a somatosensory nervous system, the response to environmental
horn of the spinal cord are clearly delimited by the rostrally enter- stimuli via the afferent senses and efferent skeletal muscle move-
ing and/or exiting spinal roots of the C1. ments
The following tract systems go to or pass through the Medulla ob- • an autonomic nervous system, the control and maintenance of
longata: Lemniscus medialis, Tractus tegmentalis centralis, Fas- body functions by autonomic primary afferents and efferents
ciculi longitudinales medialis and posterior, Tractus spinalis nervi For both systems, there are essential rules for their organisation:
trigemini, Tractus corticonuclearis and corticospinalis, Tractus spi- the principle of rostrocaudal hierarchy or the overall impact of
nothalamicus, Tractus spinocerebellaris. Axons from the posterior higher centres is opposed by the principle of local control or the
column nuclei pass ventrally and medially and cross in the midline, shortest possible oligosynaptic interconnection between primary
ventrally of the Nucleus nervi hypoglossi, in the Decussatio lemnis­ afferents and efferents, i.e. of the rapid reflex arches. This results in
corum, and finally ascend. the model of the ‘rope ladder’ nervous system, with ascending and
descending systems side by side, which are configured with each
other on all rostrocaudal levels (from the spinal cord to the cere-
Clinical remarks bral cortex) while at the same time being subject to rostrocaudal
Bilateral damage to the motor cranial nerve nuclei in the Me- hierarchical control. It also derives from the principle that the first
dulla oblongata causes bulbar paralysis. The tongue and central nervous configuration always takes place at the entry point
throat muscles are paralysed by atrophy, so that those affect- level of the afferents, such as controlling the respiratory move-
ed clinically display slurred speech and difficulty swallowing. ments at the level of the Medulla oblongata (breathing reflex).
A possible cause is a neurodegenerative motor neuron dis-
An overview of the brainstem functions or brainstem reflexes and
ease, such as Amyotrophic Lateral Sclerosis (ALS).
their configuration is shown in › Table 12.5.

Formatio reticularis
NOTE The parts of the brainstem referred to as the Formatio reticularis are
In order to inspect the Fossa rhomboidea, the cerebellum is de- those which histologically do not have clearly defined fibre tracts or
tached at the 3 cerebellar peduncles and the rear side of the pons nuclear areas. The area of the Formatio reticularis lies in the inner
and Medulla oblongata (› Fig. 12.25c) can be seen. You can see
the diamond-shaped, identically named ‘floor’ or the front panel of
part of the brainstem (Tegmentum mesencephali, Pars dorsalis pon-
the IVth ventricle. The rostral arms of the Fossa rhomboidea are tis, Medulla oblongata) between the median raphe and the outer ad-
bordered by the cerebellar peduncles; the caudal arms are bor- jacent nuclear areas and tracts. Characteristically, there are varying
dered by the adhesion site of the Tela choroidea of the IVth ventri- numbers of loosely-bundled groups of nerve cells of different sizes,
cle at the Medulla oblongata. In between, where the IVth ventricle as well as fibre bundles, which pass through the area of the Formatio
has its largest lateral expansion, the Recessus laterales are on the reticularis in all directions. From this it has been concluded that the
left and right with the Aperturae laterales. This lateral expansion Formatio reticularis is a diffuse network of multiple relay neurons,
marks the dorsal border between the pons and the Medulla oblon-
gata. Additionally, this limit is indicated by the Striae medullares
which passes through the entire brainstem, and according to some
ventriculi quarti which crosses the floor of the Fossa rhomboidea authors, also through the diencephalon and the cervical spinal cord.
and belongs to the auditory system. Rostrally, the surface of the To this quasi-intrinsic network of the brainstem, certain functions
Fossa rhomboidea provides reference points for the position of the have also been assigned, such as the ascending reticular activating
pontine cranial nerve nuclei (V–VIII), and caudally for the position system (ARAS). Under the influence of serotonergic Raphe nuclei,
of the medullary cranial nerve nuclei (IX, X, XII). this causes an activation of the motor system ascending from the
spinal cord, as well as the central autonomous nuclear areas up to
the hypothalamus and limbic system. As a result, the body is in a
12.3.3 Functional systems of the brainstem state of increased alertness and awareness.
With such a diffuse definition, the Formatio reticularis by its very
The anatomical configuration of the functional system of the brain- nature resists this kind of clear distinction. The more that is known
stem is as complex as the range of functions it performs. The brain- about individual nuclear groups and their functions (for example,
stem contains relay nuclei which process information to and from due to evidence from specific transmitters and receptors), the more
the nuclei of cranial nerves III–XII (e.g., the nuclei for eye movement this perception is replaced by a detailed description of individual
coordination, the auditory system, the vestibular system, but also areas and systems. However, the apparently disorganised diversity
important autonomic centres such as the respiratory and circulatory of the systems in the brainstem is an expression of the phylogeneti-
centres, which amongst others relay autonomous afferents and effer- cally old, ‘matured’ and complex regulation of vital autonomous
ents of the N. vagus). In addition, there are relay nuclei for cerebellar bodily functions.
afferents and nuclei of the monoaminergic neurotransmitter systems
(serotonin, noradrenaline, dopamine). The functional relationships Raphe and Raphe nuclei, serotonin system
are presented in the respective chapters (sensory systems, cranial In all sections of the brainstem, numerous commissure fibres cross
nerves, cerebellum, autonomic nervous system). the midline, which do not only belong to the long ascending and

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 12.4 Cerebellum

Table 12.6 Monoaminergic neurotransmitter systems of the brain- our society, this is a very common psychiatric illness, and is
stem. assumed to be due to a lack of noradrenaline and/or serotonin
in the synaptic gap. This deficiency can be antagonised by the
Name of the Position in the Neuro­ Projection goals continuous use of selective noradrenaline re-uptake inhibitors
nuclear area brainstem transmit-
and/or selective serotonin re-uptake inhibitors, leading to a
ters used
significant improvement in many patients’ symptoms.
Substantia nigra, Borders between Dopamine Striatum
Pars compacta Basis and Tegmen-
tum mesencephali
Area tegmentalis Tegmentum mesen- Dopamine Cerebral cortex, lim-
ventralis (VTA) cephali bic system, Nucleus 12.3.4 Blood supply to the brainstem
accumbens
Nucleus or Locus Part of the Formatio Noradrena- Cerebral cortex, lim- All parts of the brainstem get their arterial blood from the posteri-
caeruleus reticularis in the Teg- line bic system, thala- or vertebrobasilar basin. The individual arterial vessels originate
mentum pontis mus, hypothalamus, either directly from the Aa. vertebrales or the A. basilaris (e.g., Rr.
cerebellum ad pontem) or from their respective branches, e.g., the cerebellar
Raphe nuclei Nuclear groups in the Serotonin Total CNS arteries (› Chap. 12.4.6). Although the arterial vascular network
area of the Mesen- of the brainstem may be superficially highly variable, in the hori-
cephalon up to the zontal section we can distinguish 3 relatively consistent, pro-
Medulla oblongata
nounced supply areas: a posterior, a lateral and an anterior vascular
territory. The following parts of the brainstem are supplied by the
descending tracts, but are also mostly axons of local nuclear groups respective vascular territory:
that are coordinated bilaterally. All of the fibres crossing in all di- • anterior: paramedially located tract systems such as the pyrami-
rections over the midline are referred to as raphes. Depending on dal tract and the medial part of the Lemniscus medialis, cranial
the segment of the brainstem, a distinction is made between the nerve nuclei III, IV, VI, XII
mesencephalic, pontine and medullar raphes. In all raphe seg- • lateral: laterally-located tract systems and cranial nerve nuclei V,
ments, there are serotonergic neurons embedded in different VII, IX, X, XI
groups of nuclei, referred to as mesencephalic, pontine and medul- • posterior: posterior column nuclei, Nuclei vestibulares, Pedun-
lar raphe nuclei. Typical of the serotonergic system (but also of culi cerebellares, Tectum mesencephali
other monoaminergic systems, such as the dopamine, histaminer-
gic or noradrenergic systems, › Table 12.6) is the concentration of
serotonergic somata on a few, relatively small nuclear areas in the
Clinical remarks
brainstem, from where large parts of the brain and spinal cord are Disorders of the arterial supply of the brainstem, due to the
reached by deep axonal fibres. In the case of the serotonergic sys- close proximity of the most varied vital nuclear areas and tracts,
tem, all areas of the CNS without exception and microscopically often lead to wide-ranging symptoms of deficit and are fre-
almost all neurons are reached directly by a dense network of axo- quently life-threatening. One example is the WALLENBERG's
syndrome. This is a unilateral infarction of the dorsolateral Me-
nal terminals. These terminals are often enlarged presynaptic bou-
dulla oblongata due to a circulatory disorder in the A. inferior
tons and are therefore referred to as varicose terminals. They re- posterior cerebelli (PICA = ‘posterior inferior cerebellar artery’).
lease serotonin into the extracellular spaces, from where it can act The symptoms are wide-ranging and highly variable: vertigo
on postsynaptic serotonin receptors of the target neurons. This and postural instability to the damaged side (Nuclei vestibu-
brings to mind a scattergun approach, i.e. the seemingly random lares, lower olive), ipsilateral hemiataxia (Pedunculus cerebel-
distribution of serotonin to all nerve cells of the central nervous laris inferior, cerebellum), contralateral dissociated sensory dis-
system. However, the effect is completely different: turbances (Nuclei gracilis and cuneatus, Tractus spinothalamic-
us), dysphagia and hoarse voice (Nucleus ambiguus),
• Postsynaptic stimulation is also achieved very specifically at in-
HORNER'S syndrome and rapid pulse (central sympathicus and
dividual target cells by numerous, highly-varied and partly cardiovascular centre of the rostroventrolateral Medulla oblon-
counteracting serotonin receptors. gata), as well as respiratory disorders (respiratory centre of the
• Raphe nuclei neurons have different target areas: the dorsal and ventrolateral Medulla oblongata with pre-BÖTZINGER complex).
medial mesencephalic Raphe nuclei send axons in 2 concurrent
systems to the mesencephalon, diencephalon and telencephalon;
the pontine and medullary Raphe nuclei supply the rhomben-
cephalon and spinal cord.
• Even more striking is a particularly strong innervation of the 12.4 Cerebellum
primary somatic afferent nuclei in the brainstem and the spinal Michael J. Schmeißer
cord, especially the pain pathway, as well as the primary soma-
toefferent nuclei, i.e. the motor neurons. This increases aware-
ness of incoming (afferent) environmental stimuli and reinforces SKILLS
the somatic response, i.e. the activation of the skeletal muscle. After working through this chapter, you should be able to:
• use a macroscopic dissection or an anatomical model to describe
the surface anatomy of the cerebellum and explain its functional
Clinical remarks organization
• name the corresponding anatomic sections through the cerebel-
According to current understanding, both the noradrenergic lum, cerebellar nuclei and cerebellar peduncles, and explain their
projections of the Nucleus caeruleus and the serotonergic pro- respective involvement in relay circuits or fibre systems
jections of the Raphe nuclei are clinically highly significant in • explain which clinical neurological tests can be used to test parts
the pathogenesis of mood disorders, such as depression. In of the cerebellum which have a functional-anatomical meaning

673
12 Special neuroanatomy

12.4.1 Overview flocculonodularis (phylogenetically: archicerebellum). In the

14th week, due to the formation of another horizontal furrow in the
The cerebellum, in a similar way to the pons, is part of the rhomb- cranial part, the Fissura prima, Lobus anterior arises (phyloge-
encephalon, forming with it the hindbrain (metencephalon). It is netically: paleocerebellum; in which the Vermis cerebelli is in-
located in the posterior cranial fossa (Fossa cranii posterior), is cluded) and the Lobus posterior (phylogenetically: neocerebel­
positioned dorsally on the brainstem and is connected with it on lum). After the 16th week, as a result of the development of further
each side by 3 stems (Pedunculi cerebellares). The pedunculi con- horizontally-aligned fissures, there is segmentation into lobes, lobu­li,
tain afferent and efferent tracts by which the cerebellum is connect- and leaf-shaped coils or folia.
ed directly or indirectly with other areas of the brain. Macroscopi-
cally the strikingly furrowed cerebellum is divided into 3 sections:
• the cerebellar vermis (Vermis cerebelli) in the middle, 12.4.3 Position and external appearance
• which is flanked by a cerebellar hemisphere (Hemispherium
cerebelli) to the right and left. Topographical relationships
Grey matter is predominantly found in the triple-layered cerebel- The cerebellum lies in the Fossa cranii posterior and borders the
lar cortex (Cortex cerebelli) as well as in the cerebellar nuclei (Nu­ pons, Medulla oblongata and the IVth ventricle ventrally. Cranially,
clei cerebelli); white matter fills the Pedunculi cerebellares, sur- it borders the Lobus occipitalis and the posterior part of the Lobus
rounds the cerebellar nuclei (Corpus medullare cerebelli) and temporalis of the cerebrum – separated by the cerebellar tentorium
penetrates into the winding coils of the cortex. (Tentorium cerebelli) consisting of Dura mater; dorsocaudally, the
Functionally, the cerebellum is primarily responsible for the sub- Os occipitale or the Cisterna cerebellomedullaris. It also encom-
conscious fine-tuning and coordination of movement, and the passes the Medulla oblongata dorsally and laterally, and ranges
maintenance of muscle tone and balance. from laterally thereof up to the pons, so that it completely covers
A midsagittal section through the vermis (› Fig. 12.28) shows the the IVth ventricle.
image of the Arbor vitae. This nomenclature is based on the char-
acteristic arrangement of grey and white matter, which is visible in
this section. Starting from the ‘trunk-shaped' Corpus medullare,
Clinical remarks
increasingly fine lamellae of marrow ‘branch off ’ from it, with dis- An anatomical knowledge of the positional relationships of
tinct ‘leaf-shaped’ coils in the cerebellar cortex (Folia cerebelli). the cerebellum plays a crucial role in the surgical treatment of
tumours of the posterior cranial fossa. Surgical access to in-
fratentorial tumours (e.g., to a schwannoma of the N. vestibu-
laris = ‘acoustic neuroma’ in the cerebellopontine angle) is
12.4.2 Embryology usually undertaken by opening the Fossa cranii posterior after
the temporary removal of parts of the Os occipitale. Depend-
The development of the cerebellum starts in the 2nd half of the em- ing on the entity and position of the tumour (cerebellar vs. ex-
bryonic period between the 5th and 6th weeks. It consists mainly of tra-cerebellar), non-affected parts of the cerebellum are
the metencephalic section of the rhombencephalon and also part- moved aside using a spatula, as are any parts in the way of
ly of caudal parts of the mesencephalon. In this context, the dorso- the surgical field, and thus are spared.
lateral parts of both alar plates are critical; from these the so-called
rhombic lips are formed. These superior sections provide the ma-
jority of the original neuroepithelial tissue of the two cerebellum
systems (Primordia cerebellares), which merge with each other in Surface area anatomy
the course of their growth in the median plane and finally form a The slender, leaf-shaped coils of the cerebellum (Folia cerebelli)
transversal dorsally-curved bulge, the cerebellum plate. Its lateral are separated from each other by a variety of deeply indented, vir-
parts show the strongest growth and develop later into the Hemi- tually parallel furrows (Fissurae cerebelli). The Fissura postero­
spheria cerebelli; the mid-section becomes the Vermis cerebelli. lateralis divides the cerebellum into two main parts: the Lobus
Due to the formation of the first horizontal furrow of the cerebel- flocculonodularis and the Corpus cerebelli. The latter is further
lum, the Fissura posterolateralis, the caudal portions of the cere- divided by the Fissura prima into the Lobus anterior and the Lo­
bellum plate can be distinguished in the 12th week as the Lobus bus posterior. Additional furrows subdivide these lobes into lob-
ules (lobuli). On the cerebellum surface, a distinction is made be-
tween 3 sections.

Folia cerebelli Superior surface anatomy

This area (› Fig. 12.29) is directed towards the Tentorium cerebel-
li or the cerebrum. The boundaries between the vermis and cere-
bellar hemispheres are difficult to recognise on the surface. How­
Corpus medullare ever, the Fissura prima and the Fissura horizontalis are clearly
visible. The latter furrow is not a functional border; instead it forms
a dividing line between the superior and inferior surface areas.

Inferior surface anatomy

The inferior surface anatomy (› Fig. 12.30) is directed towards the
Os occipitale or Cisterna cerebellomedullaris. On it can be seen in
particular the two cerebellar tonsils (Tonsillae cerebelli), adjacent
to the clearly defined vermis and the two cerebellar hemispheres.
Fig. 12.28 Midsagittal section through the cerebellum. As the most caudal components of the hemispheres, they include

674
 12.4 Cerebellum

Lobulus quadrangularis anterior,

Pars anterior

Lobus cerebelli anterior Fissura prima

Lobulus simplex,
Lobulus quadrangularis
posterior
Lobus cerebelli posterior
Lobulus semilunaris
superior

Fissura horizontalis
Fig. 12.29 Superior surface
Lobulus semilunaris inferior
anatomy of the cerebellum.

Tonsillae cerebelli Vermis cerebelli

Lobulus semilunaris superior

Fissura horizontalis

Lobulus semilunaris
inferior

Lobulus biventer

Hemispheria cerebelli Fig. 12.30 Inferior surface

­anatomy of the cerebellum.

the dorsolateral section of the Medulla oblongata and are thus lo- Anterior surface anatomy
cated directly on the edge of the Foramen magnum. The anterior surface of the cerebellum (› Fig. 12.31) is directed to
the IVth ventricles and to the brainstem. On this surface area, it is
primarily the cerebellar peduncles (Pedunculi cerebellares superi­
Clinical remarks or, medius and inferior) which serve to identify where the cere-
In the case of increased intracranial pressure (e.g., due to oe- bellum is separated from the brainstem. The Pedunculi cerebellares
dema, hemorrhages or tumours) the cerebellum can be moved superiores border the unpaired superior medullary velum (Velum
caudally. Its caudal structures, such as the cerebellar tonsils, medullare superius) medially on both sides, a thin fibre plate
are then pressed into the greater Foramen magnum and made of white matter, representing the connection between the
trapped between the Medulla oblongata and the bony struc-
cerebellum and quadrigeminal plate and forming the upper roof of
tures (tonsillar entrapment). A possible consequence is the
compression of the Medulla oblongata with bulbar paralysis the IVth ventricle. A second pair of lamellae, the lower medullary
(failure of the brainstem reflexes, › Chap. 12.3.3). If brain velum (Velum medullare inferius), connects the cerebellum with
pressure is not relieved, this may result in damage to the re- the Medulla oblongata, making it the lower roof of the IVth ventri-
spiratory and circulatory centre in the brainstem, and in cle. Additionally, we can see the flocculus (‘little flake’, positioned
death. below the medial cerebellar peduncle) and the nodulus (‘little nod-
ule,’ section of the vermis below the Velum medullare superius),
which, together as the Lobus flocculonodularis, are separated from
the rest of the cerebellum by the Fissura posterolateralis. The floc-

Velum medullare superius

Lobulus centralis
Nodulus
Pedunculus cerebellaris superior
Velum medullare inferius Pedunculus cerebellaris medius
Pedunculus cerebellaris inferior
Flocculus

Fissura posterolateralis
Pedunculus flocculi
Fig. 12.31 Inferior surface of
the cerebellum.

675
12 Special neuroanatomy

Hemispherium Vermis Clinical remarks

cerebelli cerebelli
Paravermal zone Chronic alcohol abuse may cause permanent damage to the
cerebellum, in particular atrophy of the Vermis cerebelli. In
Fissura prima this process, parts of the vestibulocerebellum (nodulus) and
the spinocerebellum (vermis and the paravermal zone) perish.
Affected patients can no longer coordinate their eye move-
ments and can no longer maintain their balance (due to the
malfunction of the vestibulocerebellum and spinocerebel-
lum). This can lead to the development of poor gaze stabiliza-
tion (e.g., jerky eye movements and/or multiple corrections of
the eye position when trying to fix a new object in the field of
Fissura vision) or cerebellar ataxia (wobbly and swaying when stand-
posterolateralis ing still and walking, tendency to fall).

Pontocerebellum
Spinocerebellum 12.4.4 Internal structure
Vestibulocerebellum
The fundamental micro-cellular structure of the cerebellar cortex is
Fig. 12.32 Functional-anatomical classification of extended small crucial to understanding the configurations and tracts of the cere-
cortex. [R247] bellum. The grey matter, i.e. the accumulation of nerve cell bodies,
is predominantly found within the cerebellum in the cerebellar
cortex (Cortex cerebelli) and in the cerebellum nuclei (Nuclei cere-
culus and nodulus are connected via nerve fibres in the Pedunculi bellares).
flocculi.
Cerebellar cortex
Functional classification The Cortex cerebelli, in contrast to the Cortex cerebri, reveals a
Functionally, we divide the cerebellum into 3 sections (› Fig. 12.32). three-layered structure. From the outside in, these are:
• The molecular layer (Stratum moleculare, outermost layer): low
Vestibulocerebellum density of neurons, high levels of nerve cell appendages (espe-
This part consists of the Lobus flocculonodularis, and it is both af- cially PURKINJE cell dendrites and axons of granular cells) and
ferently and efferently closely connected with the vestibular appa- synapses
ratus of the inner ear. In addition, there are efferent connections to • The PURKINJE cell layer (Stratum purkinjense or ganglionic
the oculomotor centres of the Formatio reticularis and the eye middle layer): predominantly nerve cell bodies of the PURKIN-
muscle nuclei. The vestibulocerebellum serves primarily for the JE cells and BERGMANN glial cells (specialised astrocytes)
controlling of supporting motor skills (stabilisation of standing • The granular cell layer (Stratum granulosum, innermost layer):
and walking), fine-tuning of eye movement as well as the coordi- predominantly nerve cell bodies of the granular cells
nation of both functions with the vestibular system (maintenance
of balance). NOTE
The cerebellum contains more than 50% of the neurons in the
Spinocerebellum brain and hence more neurons than the cerebrum. In percentage
This part consists of the vermis (without the nodulus), the paraver- terms, the granular cells in the granular layer of the cerebellar cor-
mal zone of both hemispheres (Partes intermediae) as well as the tex form the majority (approximately 99% of all the neurons in the
cerebellar cortex).
largest part of the Lobus cerebelli anterior. The spinocerebellum
receives direct afferents from the spinal cord and is indirectly effer-
ently connected via the Nucleus ruber and Formatio reticularis The cerebellum receives afferent inputs, either via the so-called
with the spinal cord. It is largely responsible for the regulation of mossy fibers (axonal appendages of neurons from the Pons nuclei,
muscle tone and, together with the vestibulocerebellum, controls the spinal cord, the Formatio reticularis or the vestibular nuclei) or
supporting motor functions. via climbing fibres (axonal appendages from the lower olive nucle-
us complex of the Medulla oblongata). This input in both cases is
Pontocerebellum excitatory/glutamatergic:
This part contains the largest area of the cerebellum, the parts of • Mossy fibre axons end in the Stratum granulosum and stimulate
the cerebellar hemispheres which lie lateral to the paravermal zone. mainly granular cells. These granular cells, in turn, send their
It is mainly afferently connected with the pons (and thus indirectly axonal appendages, known as parallel fibres, into the Stratum
with the cerebrum) and partly efferently connected with the olive moleculare and form, amongst others, excitatory/glutamatergic
and with the Nucleus ruber and thalamus. The primary role of the synapses at the distal dendritic tree of the PURKINJE cells.
pontocerebellum is the coordination of fine motor activities and • Climbing fibre axons pass directly into the Stratum moleculare
the speech muscles. and form, as in the case of the parallel fibres, excitatory/glutama-
tergic synapses on PURKINJE cell dendrites.
The function of the PURKINJE cells is significant. They are the only
neurons of the cerebral cortex which send an axon which then leaves
the Cortex cerebelli again. Thus, PURKINJE cells are a central inte­

676
 12.4 Cerebellum

gration element of all the neuronal circuits; this includes the cere- In the cerebellar nuclei, multipolar nerve cells are particularly
bellum cortex as a ‘relay station’. Interestingly, PURKINJE cells are found, projecting efferently into other areas of the brain. These
inhibitory and end with their axons at the neurons of the cerebellar projection fibres form primarily excitatory/antiglutamatergic syn-
nuclei, where they form inhibiting, GABAergic synapses. apses in their target area.

Cerebellar peduncles
Clinical remarks The cerebellum is connected with the brainstem on each side by 3
Contrary to previous assumptions, malfunctions of the cere- cerebellar peduncles (Pedunculi cerebellares); this is where all the
bellum and its circuits also appear to be accompanied by a afferent and efferent tracts of the cerebellum pass. The volumes of
decline in higher brain activities, such as social interaction the individual cerebellar peduncles and thereby also their fibre
and communication. In this context, the integrity of the PUR- contents, are visible from the front, especially after dissection when
KINJE cells play a highly crucial role. So for example we often
viewing the Facies anterior (› Fig. 12.31).
find a lower number of PURKINJE cells in certain cortical sec-
tions of the cerebellum in cross-sections of patients with autism. • Pedunculus cerebellaris superior: The superior cerebellar pe-
duncle contains mainly efferent fibres from all 4 cerebellar nuclei,
which primarily pass to the Nucleus posterior ventrolateralis of
the thalamus (Tractus cerebellothalamicus) and to the Nucleus
Cerebellar nuclei ruber into the mesencephalon (Tractus cerebellorubralis). In ad-
Embedded in the Corpus medullare cerebelli of the pontocerebel- dition, afferent fibres from the spinal cord (Tractus spinocerebel-
lum, there is a total of 4 cerebellar nuclei (Nuclei cerebelli) on each laris anterior, superior, cervicospinocerebellaris) run into it.
side, which can be particularly recognised in oblique or flat sec- • Pedunculus cerebellaris medius: The middle cerebellar pedun-
tions through the upper cerebellar peduncles on the basis of their cle is the most pronounced and lies furthest laterally, containing
macroscopically characteristic shapes. Listed below from lateral to only afferent fibres (Fibrae pontocerebellares), which arise from
medial, they are (› Fig. 12.33): the Nuclei pontis.
• Nucleus dentatus (dentate nucleus): positioned furthest lateral- • Pedunculus cerebellaris inferior: the lower cerebellar peduncle
ly, looks like a U-shaped, serrated, pleated tape; its anteromedial lies medial of the middle peduncle and is divided into 2 sections:
aperture is referred to as the Hilum nuclei dentati an external fibre tract, the so-called Corpus restiforme, contain-
• Nucleus emboliformis (emboliform nucleus): elongated, lying ing only afferent fibres (Tractus spinocerebellaris posterior, Fi-
medial of the Hilum nuclei dentati brae cuneocerebellares, Tractus trigeminocerebellaris, Tractus
• Nucleus globosus (globose nucleus): round, lying medial of the olivocerebellaris, Tractus reticulocerebellaris), and a medially
Nucleus emboliformis; often divided in two connecting section referred to as the Corpus juxtarestiforme,
• Nucleus fastigii (fastigial nucleus): egg-shaped, lying furthest to with efferent (Tractus cerebellovestibularis) and afferent fibres
medial (Tractus vestibulocerebellaris).
The cerebellar nuclei mainly receive afferent input from the PUR-
KINJE cells of the cerebellar cortex. Due to the fact that each cere- NOTE
bellar nucleus receives afferents from a topographically different Within the cerebellar peduncles, the ratio between afferent and ef-
area of the cerebellar cortex, functional attributions can be made: ferent fibres is approx. 40 : 1. This underlines the central role
• Nucleus dentatus – pontocerebellum played by the cerebellum within the complex integration of afferent
• Nucleus emboliformis – spinocerebellum signals.
• Nucleus globosus – spinocerebellum
• Nucleus fastigii – vestibulocerebellum, spinocerebellum
12.4.5 Neurovascular pathways
NOTE
The Nucleus emboliformis and Nucleus globosus of the cerebellum Afferent neurovascular pathways
are functionally very similar, because both receive their primary af- With the afferent neurovascular pathways of the cerebellum
ferents from the spinocerebellum. They can therefore be combined (› Fig. 12.34), a distinction is made between the climbing fibre
with a nucleus, the so-called Nucleus interpositus cerebelli. system and the mossy fibre system.

Decussatio pedunculorum Velum medullare superius

cerebellarium superiorum
Lingula cerebelli
Ventriculus quartus
Nucleus fastigii
Pedunculus cerebellaris superior
Nucleus globosus
Cortex cerebelli Nuclei cerebelli
Nucleus emboliformis
Stratum moleculare
Nucleus dentatus
Stratum
granulosum

Lamellae
of marrow
Hilum nuclei dentati
Fissurae cerebelli

Corpus medullare cerebelli Nodulus

Fig. 12.33 Cerebellar nuclei.

677
12 Special neuroanatomy

Cerebellar cortex Cerebellar nuclei Tractus

Tractus pontocerebellaris cerebello-
Nuclei pontis thalamicus
Pontocerebellum Nucleus
Thalamus Cortex
(hemispheres) dentatus
Nuclei olivares Tractus olivocerebellaris
inferiores
Brainstem
Spinocerebellum

Medulla Tractus spinocerebellaris anterior/posterior Paravermal Nucleus Tractus

Nucleus ruber
spinalis Tractus cuneocerebellaris Zone interpositus cerebello-
rubralis
Formatio Vermis
reticularis Tractus reticulocerebellaris Tractus Formatio
reticularis
Nucleus cerebello-
fastigii reticularis
Vestibulocerebellum
Vestibular organ
Tractus vestibulocerebellaris
Vestibular organ Nodulus
Tractus
Flocculus cerebello-
Nuclei vestibulares vestibularis Medulla spinalis

Fig. 12.34 Afferent and efferent compounds of the cerebellum. [L141]

Climbing fibres are derived from the lower olive nuclear complex mus via the Tractus cerebellothalamicus or reaching the con-
(Complexus olivaris inferior), run as the Tractus olivocerebellar­ tralateral Nucleus ruber via the Tractus cerebellorubralis.
is through the inferior cerebellar peduncle and cross to the oppo- • Efferents from the spinocerebellum or the vermis as well as
site side, partly to the cerebellar nuclei, but above all to the PUR- from the vestibulocerebellum or the nodulus project onto the
KINJE cell populations of the cerebral cortex in their entirety. Nucleus fastigii, where principally a relay to the vestibular nuclei
Mossy fibres originate from several different areas. Common to all and to the Formatio reticularis takes place on both sides. These
mossy fibres is the characteristic that they end at the granular cells fibre connections are known as the Tractus cerebellovestibu­
of the cerebellar cortex: laris and the Tractus cerebelloreticularis.
• Spinocerebellar mossy fibres derive from the spinal cord and all • Most efferents from the vestibulocerebellum or the Lobus floc­
end ipsilaterally in the spinocerebellum. The first one is the culonodularis, however, go directly to the Nuclei vestibulares
Tractus spinocerebellaris anterior, running through the supe- without being relayed into the cerebellum nuclei.
rior cerebellar peduncle. The Tractus spinocerebellaris poste­ • Nucleo-olivary fibres take all cerebellar nuclei to the lower olive
rior and the Tractus cuneocerebellaris run conversely in the nuclear complex.
lower cerebellar peduncle.
• Trigeminocerebellar mossy fibres arise from the 3 somatoaffer-
ent nuclei of the N. trigeminus [V] and, like the spinocerebellar 12.4.6 Blood supply
mossy fibres, run via the inferior cerebellar area into the ipsilat-
eral areas of the spinocerebellum. The cerebellum receives 3 arteries, all of which originate from the
• Pontocerebellar mossy fibres arise from the Nuclei pontis, then rear, vertebrobasilar basin:
cross to the opposite side as the Tractus pontocerebellaris at the • A. superior cerebelli from the A. basilaris: supplies the upper
middle cerebellar peduncle, thus ending in the contralateral parts of the hemispheres and the Vermis cerebelli, as well as the
pontocerebellum. Nucleus dentatus
• Reticulocerebellar mossy fibres arise from the Formatio reticu- • A. inferior anterior cerebelli from the A. basilaris: supplies the
laris, run as the Tractus reticulocerebellaris through the lower flocculus and peripheral areas of the lower surface of the hemi-
cerebellar peduncle and end in the spinocerebellum bilaterally. spheres
• Vestibulocerebellar mossy fibres run partially directly out of • A. inferior posterior cerebelli from the Pars intracranialis of
the Nuclei vestibulares, partially as the Tractus vestibulocere­ the A. vertebralis: supplies the lower parts of the hemisphere and
bellaris via the Corpus juxtarestiforme of the lower cerebellar the Vermis cerebelli, as well as the Nuclei emboliformis, globo-
peduncle and bilaterally into the vestibulocerebellum. sus and fastigii
The veins of the cerebellum run independently of the arteries and
Efferent pathways can be assigned to the following drainage areas:
With the exception of a few fibres of the homeostatic system, all • Blood from the anteromedial and superomedial surface-drain-
other efferent fibres of the cerebellar cortex (› Fig. 12.34) are re­ age area V. magna cerebri: V. precentralis cerebelli, V. superior
layed in the cerebellum nuclei. Here, the following principles are vermis, Vv. superiores cerebelli mediales
important: • Blood from the superolateral surface-drainage area, Sinus rectus:
• Efferents from the pontocerebellum or the cerebellum hemi­ Vv. superiores cerebelli laterales
spheres project in particular onto the Nucleus dentatus, and ef- • Blood from the inferolateral surface-drainage area Sinus petro-
ferents from the paravermal zone project onto the spinocere­ sus superior: V. petrosa
bellum on the Nucleus interpositus. They are there relayed onto • Blood from the inferomedial surface-drainage area Sinus trans-
projection neurons, primarily reaching the contralateral thala- versus: V. inferior vermis, Vv. inferiores cerebelli

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 12.5 Cranial nerves

The expansion of supply and/or drainage pathways depends on the be seen in the same way as the spinal nerves, which exit the spinal
calibre of their respective vessels and shows strong inter-individual cord in pairs towards the periphery. However, the N. olfactorius [I]
differences. In addition, there are numerous anastomoses, both be- and the N. opticus [II] do not fit into a scheme like this due to their
tween arteries and between veins. ontogenous origins as separate parts of the brain. There are also
other differences between the spinal and cranial nerves (› Ta-
ble 12.7): while the spinal nerves primarily spread out segmentally,
Clinical remarks the cranial nerves do not run segmentally and, in part, run in such
During a clinical neurological examination, damage to the cer- a complex manner between the meninges or through certain crani-
ebellum can be externalised by disorders of the balance regu- al cavities and apertures to their target organs in the head/neck
lation, coordination of movements, gaze stabilisation and area, that a significantly wider topographical understanding is re-
muscle tone. It is important at this point to roughly record all 3 quired in order to understand their pathway. While almost all cra-
functional anatomical entities of the cerebellum in one single
nial nerves have their target organs in the head/neck area, part of
examination.
The first thing to check is the spinocerebellum and vestibulo- the fibres of the N. vagus [X] pass into the abdominal cavity to the
cerebellum using the so-called ROMBERG's test. The patient CANNON’s point on the Flexura coli sinistra.
is asked to stand up straight with their feet next to each other Spinal nerves carry 4 different fibre qualities, whereas in the cranial
and parallel, and the clinician observes the patient to see if nerves a total of 7 fibre qualities can be distinguished, but not all
they sway or start to fall, both with their eyes open and closed. cranial nerves carry 7 fibre qualities. Altogether we can distinguish,
If the patient starts to sway and this is not made worse by in the same way as for the spinal nerves:
closing the eyes, this is referred to as cerebellar ataxia. In
• general somatoefferent fibres for the innervation of the skeletal
most cases, due to the anatomical proximity to each other, it
is caused by a combined lesion of the spinocerebellum and muscles
the vestibulocerebellum (disorders in the regulation of bal- • general somatoafferent fibres, which take impulses from the
ance and of muscle tone). skin (exteroception), the GOLGI tendon organs or the muscle
A further step is to test the pontocerebellum via the so-called spindle (proprioception)
finger nose test. The patient is requested to touch the tip of • general visceroefferent fibres for the parasympathetic innerva-
their nose with the tip of their index finger in a sweeping mo- tion of smooth muscle fibres and glands
tion, first with their eyes open, then closed, without resting
• general visceroafferent fibres which take impulses from the mu-
their weight on the elbow. If the pontocerebellum is damaged,
they display either dysmetria or hypermetria, coupled with an
cous membranes, viscera and the blood vessels to the CNS
intention or cerebellar tremor. They will not be able to bring In addition, the cranial nerves are distinguished as having further
the index finger to the tip of the nose in a fluid manner; in- fibre qualities, or ‘special’ fibres, according to their embryological
stead they will overshoot the target area, trembling erratically. development from the pharynx. Thus, the following can also be
Other possible ‘cerebellum symptoms’ are, for example, scan- found in the cranial nerves:
ning speech (slurred speech, monotonous, sluggish pronunci- • special visceroefferent fibres for the innervation of the striated
ation due to disruption of motor function), saccadic eye move- muscles, pharyngeal arch muscles, e.g., mastication muscles
ments with coarse nystagmus (disruption of the optical motor
function) and what is known as dysdiadochokinesis, an im-
• special visceroafferent fibres, which take impulses from the sen-
pairment of fast interaction between antagonistic muscles, sory epithelial cells of the smell and taste receptors
such as when driving in screws (disruption of movement coor- The fibres of the sensory epithelia of the eye and the ear are excep-
dination). tions, and are therefore not referred to as being specially viscero­
afferent, but as being specially somatoafferent. However, in aca-
demic literature, the fibre qualities are often inconsistently as-
signed. Correspondingly, the fibres of the N. olfactorius are also in
part referred to as specially visceroafferent.
12.5 Cranial nerves The autonomic nerve fibres exiting the Medulla spinalis leave the
Anja Böckers, Michael J. Schmeißer spinal cord through the ventral root and are relayed onto a second
postganglionic neuron in the sympathetic system as they continue
into the paravertebral or prevertebral ganglia. This relay onto the
SKILLS second neuron occurs in the parasympathetic system, mostly in the
After working through this chapter, you should be able to: intramural ganglia, e.g., in the intestinal wall. The same principle of
• name the 12 cranial nerves correctly
configuration applies to the autonomic fibres of the cranial nerves.
• point out the exit points of the 12 cranial nerves on a dissection
or on a model of the brain
• independently sketch out the 2-D structure of the cranial nerve Table 12.7 Characteristics of the cranial nerves in comparison with
nuclei in the brainstem (› Fig. 12.39a), and give the name and the spinal nerves.
describe the quality and/or function of the cranial nerve nuclei
• present an overview of the arterial blood supply of the cranial Spinal nerve Cranial nerve
nerve nuclei Segmental arrangement Non-segmental arrangement
(Mostly) 31 paired spinal nerves 12 paired cranial nerves
Note: the cranial nerves are also presented in › Chap. 9.3.
Exit from the Medulla spinalis Exit from the Truncus encephali
Passes through segmentally arranged Passes through non-segmentally
Foramina intervertebralia arranged openings of the internal sur-
12.5.1 Overview face of the cranial base
4 functional fibre qualities 7 functional fibre qualities
Cranial nerves (Nn. craniales) are 12 nerves arranged in pairs,
which exit the central nervous system at the base of the brain or at Primary target organs below the upper Primary target organs above the upper
thoracic aperture thoracic aperture
the brainstem. To make it easier to understand, they can primarily

679
12 Special neuroanatomy

From a topographical point of view, the relay to the sympathetic Table 12.8 Fibre qualities, distinguished by efferents and afferents.
ganglia occurs remotely from organs, so that the postganglionic
fibres show a divergent course and travel as fine nerve plexus with Fibre quality Innervation
the arterial vessels to their target organs in the head and throat Efferents
area. General somatoefferent Motor: skeletal muscles
General visceroefferent Parasympathic: glands, smooth muscles
NOTE
Special visceroefferent Branchiomotoric: pharyngeal arch muscles
In the cranial nerves, 7 different fibre qualities (› Table 12.8) can
be distinguished; however, not every cranial nerve carries fibre Afferents
qualities. General somatoafferent Proprioceptive (joints, muscles) and
exteroceptive (sensitivity – skin)
A total of 12 pairs of Nn. craniales can be distinguished, the struc- General visceroafferent Enteroceptive (sensitivity – mucosal, blood vessels)
ture of which is laid out in the following chapter (› Fig. 12.35).
Special visceroafferent Odour and taste organ
The cranial nerves are numbered from rostral to caudal using Ro-
Special somatoafferent Sensory: vision, hearing and balance organ
man numerals. This means that the first 4 cranial nerves (I-IV)
have their exit point in the mesencephalon or further rostral from
there, the medial 4 cranial nerves (V–VIII) exit in the pons and the torius [III], the N. abducens [VI] and the N. hypoglossus [XII]
caudal 4 cranial nerves (IX–XII) exit in the Medulla oblongata (4th all leave the CNS.
rule). • The lateral series forms the extension of the Sulcus posterolater-
The exit points of the cranial nerves are arranged on the ventral alis, the recess through which the Radix posterior leaves the spi-
side in a medial and in a lateral row in the brainstem: nal cord. Thus, in the Medulla oblongata, the lateral exit points
• The medial range extends the exit points of the ventral roots of of the N. glossopharyngeus [IX], the N. vagus [X] and the N. ac-
the spinal nerves cranially. Following this line, the N. oculomo- cessorius [XI] are located in the Sulcus retroolivaris. Further

N. oculo-
motorius
N. olfactorius [I] [III]
N. opticus N. troch-
[II] learis [IV]
N. abducens
[VI]
N. trigeminus [V]

N. intermedius [VII]
N. facialis [VII]

N. vestibulocochlearis [VIII]

N. glossopharyngeus [IX]

N. vagus [X]
Fig. 12.35 Cerebrum, brainstem
N. accessorius [XI] and cerebellum with the exit
N. hypoglossus [XII] points of the 12 pairs of cranial
nerves, which are numbered in
the order of their exit from ros-
tral to caudal, using Roman
numerals (I–XII). View from bas-
al. The Ist cranial nerve is a part
of the cerebrum which was dis-
placed during development, cor-
responding to the N. opticus [II],
Efferent (motor) fibres Afferent (sensitive) fibres Spinal nerve fibres which is a prolapsed protrusion
of the diencephalon.

680
 12.5 Cranial nerves

cranially the exit points of the N. trigeminus [V] and the N. fa- 12.5.2 Embryology
cialis [VII] join.
The N. trochlearis [IV] is an exception in this regard, as it is the For a topographical situational awareness of the cranial nerve nu-
only cranial nerve on the dorsal side of the mesencephalon which clei in the brainstem, it is essential to be able to report their longi-
leaves the CNS and has the longest intratradural course (› Fig. tudinal arrangement. It must be borne in mind that cranial nerve
12.36). nuclei should not be thought of as being round or spherical accu-
The names of the 12 cranial nerves can easily be remembered or mulations of neurons, but – in the same way as the spinal cord –
repeated in the correct order based on a mnemonic such as ‘On old they are arranged in intermittent columns of nuclei that can also
Olympus's towering top a Finn and German viewed some hops,’ expand over a distance, e.g., from the pons to the Medulla oblonga-
meaning that their exit points are localised on the brainstem ac- ta. For a three-dimensional understanding of their position, this
cording to the 4th rule described above. Furthermore, the 4th rule image must then be expanded to include the mediolateral arrange-
also includes the following: ment of the individual cranial nerve nuclei. This mediolateral ar-
• 4 cranial nerves generally carry visceroefferent fibres (III, VII, IX rangement is derived from the embryological development of the
and X) rhombencephalon.
• 4 cranial nerves, of which the numbers are factors of 12, possess From early on in development, we can already distinguish in the
somatoefferent nuclear areas within the brainstem (III, IV, VI neural tube a base plate pointing ventromedially to the Chorda
and XII) dorsalis and a roof plate for the neural tube pointing dorso-medi-
The 12 cranial nerves are uniformly covered, from › Chap. 12.5.4 ally. Between these two plates, in the dorsal half of the neural tube,
to Chap. 12.5.16: are the alar plates, which are separated by the Sulcus limitans
• The 1st section describes the respective cranial nerve exit point from the ventral half of the neural tube, known as the base plates
from the basal side of the brain or brainstem. (› Fig. 12.38a). The ongoing differentiation of the neurons in the
• The 2nd section largely consists of a summarised graphic pre- alar and base plates is controlled by the chordal process which sup-
sentation of the cranial nerves with its target organs (› Fig. presses dorsalising genes with specific substances. Subsequently,
12.37) – the corresponding peripheral nerve pathway is de- motor neurons form from the neuroblasts near the chord of the
scribed in › Chap. 9.3. neural tube (in the base plates), while with an increasing concen-
• In the 3rd section, the respective cranial nerve nuclei, their posi- tration gradient of these substances, from ventral to dorsal, vis-
tions, qualities and features are described as well as their afferent ceroefferent, visceroafferent and somatoafferent neurons are differ-
and efferent links to other central brain sections or systems. entiated. Finally, the development of the pontine flexure brings
• Finally, for each of the 12 cranial nerves, we will describe how about the expansion of the central canal to the IVth ventricle, so
their function can be checked in the context of a clinical neuro- that the roof plate for the ependymal ventricle roof thins out and
logical examination. the alar and base plates open like the pages of a book, with the
spine of the book being formed by the former base plate (› Fig.
12.38b). Dorsal parts of the neural tube wall thus go to lateral and

A. cerebri anterior
Bulbus olfactorius Chiasma opticum

N. opticus [II]

Tractus olfactorius

Tractus opticus

N. oculomotorius [III]

N. trochlearis [IV]

N. abducens [VI]

N. trigeminus [V]

Tentorium cerebelli

N. facialis [VII]

N. vestibulocochlearis [VIII]
Colliculus superior sinister
N. glossopharyngeus [IX]

N. vagus [X] Colliculi inferiores

N. accessorius [XI] Pedunculi cerebellares

N. hypoglossus [XII] Ventriculus quartus

N. accessorius [XI], Radices spinales Medulla spinalis

Fig. 12.36 Exit points of the Nn. craniales on the brainstem and their course in the subarachnoid space. View from the top left after removal of
the left halves of the cerebrum and cerebellum as well as of the Tentorium cerebelli. The N. abducens has the longest intracranial extradural
pathway up to the point where it passes through the cranial base.

681
12 Special neuroanatomy

Target organs Reorganisation Cranial nerve Nuclear areas

Striated General
Muscles somatoefferent

Smooth muscles, 2nd neuron General

glands (para- visceroefferent
sympathetic)

Striated Specifically
pharyngeal arch visceroefferent
muscles

Sensory receptors 1st neuron General

of the skin and the (cranial nerve vein) somatoafferent
proprioception

Sensory receptors of 1st neuron General

the mucous membranes (sensory) visceroafferent

Receptors of the 1st neuron Special

olfactory and (1st, 7th, 9th, 10th visceroafferent
taste sense cranial nerve)
Fig. 12.37 Fibre qualities of the
Receptors in the 1st neuron Special cranial nerves (nuclei) with pos-
equilibrioception (8th cranial nerve) somatoafferent sible configurations or reorgani-
sation points and the respective
effectors. [L127]

Roofplate Ventriculus quartus Ependymal roof Sulcus medianus

Sulcus limitans VIII

Sulcus limitans
V, VII, IX, X
Alar plate

Sulcus Alar plate

limitans VII, IX, X
Basal plate III, VII, IX, X
Oliva
V, VII, IX, X, XI
5th SSA 7th SSA
III, IV, VI, XII
a Floorplate b Basal plate c

General somatoefferent nuclei (GSE) Special visceroefferent nuclei (SVE) General somatoafferent nuclei (GSA)
General visceroefferent nuclei (GVE) General and special visceroafferent nuclei (G/SVA) Special somatoafferent nuclei (SSA)

Fig. 12.38 Development of the rhombencephalon and of the mediolateral arrangement of the cranial nerve nuclei, according to their function.
a Originally there is a dorsoventral arrangement in the neural tube (5th week of development. b This arrangement is changed by the expansion
of the Canalis centralis to the IVth ventricle (7th week of development) into a mediolateral arrangement. c The individual fibre qualities are
attributable to the respective cranial nerve nuclei. a,b [L126]

to ventral followed by visceroafferent, then visceroefferent and, fi- ris, Nucleus nervi abducentis and the Nucleus nervi hypoglossi
nally, furthest medial by somatoefferent neurons. (see above, 4th rule).
The respective column nuclei are in the immediate proximity of the The general somatoafferent nucleus column also lies lateral, but
floor of the IVth ventricle. Specifically, this means that the special does not reach the floor of the IVth ventricle, but instead runs in-
somatoafferent columnar nuclei of the VIIIth cranial nerves (Nu­ side of the brainstem. Also included are neurons of the Vth, VIIth,
clei vestibulares and cochleares) lies furthest to lateral, followed IXth and Xth cranial nerves, which are arranged longitudinally in
medioventrally by the general and special visceroafferent nuclei the Nuclei mesencephalicus, pontinus and spinalis nervi trigem­
(Nucleus tractus solitarii) of the VIIth, IXth and Xth cranial nerve ini longitudinal alignment. The same applies to the specially vis-
(› Fig. 12.38c). Medial to the Sulcus limitans, the general viscero­ ceroefferent nucleus columns of the Vth, VIIth, IXth, Xth and XIth
efferent columnar nuclei of the IIIrd, VIIth, IXth and Xth cranial cranial nerves, the neurons of which innervate branchiogenic mus-
nerve joins with the Nuclei accessorii nervi oculomotorii, Nuclei cles of the head and throat area and include those of the ­Nucleus
salivatorii superior and inferior and the Nucleus dorsalis nervi motorius nervi trigemini, Nucleus nervi facialis, Nucleus am­
vagi, (see above, 4th rule). However, the general visceroefferent biguus and the Nucleus nervi accessorii (› Fig. 12.39).
nucleus of the IIIrd cranial nerve has no direct contact with the The last nuclear group (V, VII, IX, X and XI) is closely developmen-
IVth ventricle; it has a rather more cranial position in the mesen- tally linked with the development of the oropharyngeal arches. This
cephalon. Finally located between this nucleus column and the means that the entire musculature of a pharyngeal arch is innervat-
Sulcus medianus is the general somatoefferent nucleus column ed by one of these cranial nerves, the ‘pharyngeal arch nerve’. Ac-
formed by the nuclei of the IIIrd, IVth, VIth and XIIth cranial cordingly, each of the above-mentioned cranial nerves can be as-
nerve, the Nucleus nervi oculomotorii, Nucleus nervi trochlea­ signed to a pharyngeal arch (› Table 12.9). With its N. accessorius

682
 12.5 Cranial nerves

Nucleus accessorius
nervi oculomotorii

Nucleus nervi
oculomotorii

Nucleus nervi trochlearis

Nucleus mesencephalicus
nervi trigemini
Nucleus motorius
nervi trigemini

Nucleus nervi abducentis (Nucleus pontinus

nervi trigemini*)
Nucleus nervi facialis

Nucleus salivatorius Nucleus principalis

superior posterior

Nucleus salivatorius inferior

Nucleus vestibularis superior
Nucleus ambiguus Nucleus vestibularis lateralis Nuclei
Nucleus vestibularis inferior vestibulares
Nucleus dorsalis nervi vagi Nucleus vestibularis medialis
Nucleus nervi hypoglossi Nucleus spinalis
nervi trigemini

Nucleus nervi accessorii Nucleus tractus solitarii

Nucleus ruber
Glandula pinealis
Pedunculus cerebri,
Crus cerebri Nucleus accessorius nervi oculomotorii

N. oculomotorius [III] Nucleus nervi oculomotorii

N. trochlearis [IV]
Nucleus nervi trochlearis
Nucleus mesencephalicus nervi
N. trigeminus [V] trigemini

Nucleus motorius nervi (Nucleus pontinus nervi trigemini*)

trigemini
Nucleus nervi abducentis
Pons
Nuclei vestibulares
Nucleus nervi facialis
Nucleus salivatorius superior
N. abducens [VI]
N. facialis [VII] Nuclei cochleares
N. vestibulocochlearis [VIII] Nucleus salivatorius inferior
N. glossopharyngeus [IX]
N. vagus [X] Nucleus dorsalis nervi vagi

Nucleus nervi hypoglossi

N. hypoglossus [XII]
Nucleus ambiguus

N. accessorius [XI] Nucleus tractus solitarii

Nucleus spinalis nervi trigemini

b Nucleus nervi accessorii

N. accessorius [XI], Radices spinales

General somatoefferent nuclei (GSE) General and special visceroafferent nuclei (G/SVA)
General visceroefferent nuclei (GVE) General somatoafferent nuclei (GSA)
Special visceroefferent nuclei (SVE) Special somatoafferent nuclei (SSA)

Fig. 12.39 Longitudinal arrangement of the cranial nerve nuclear areas III–XII). a Nuclear areas of the cranial nerves III–XII with a dorsal view
of the brainstem or the rhombus pit. The right side of the image shows the Nuclei terminationes (end nuclei) of the afferent tracts, the left side
of the image half the Nuclei originis (nuclei of origin) of the efferent tracts. b Spatial overview of efferent and afferent nuclear areas of cranial
nerves III–XII and their pathway in the brainstem viewed from the median plane; ∗ clinically: Nucleus sensorius principalis nervi trigemini.

683
12 Special neuroanatomy

Table 12.9 Assignment of the most important cranial nerves for the • The posterior supply area is ultimately fed by the A. spinalis pos-
respective pharyngeal arches and the corresponding branchiogenic terior of the A. vertebralis or by branches of the A. inferior pos-
muscles. terior cerebelli and reaches, among others, the Nuclei vestibu-
Pharyngeal arch Pharyngeal arch nerve Muscles lares.
The close topographical proximity of the cranial nerves with the
1st pharyngeal arch N. trigeminus [V]; N. man- • Chewing muscles
basal brain arteries along their intracranial pathway up to the point
(mandibular arch) dibularis [V/3] • M. mylohyoideus
• Venter anterior musculi when it breaks through the bone is often the cause of clinical symp-
digastrici toms or malfunctions of the cranial nerves. For example, a vessel
• M. tensor tympani may compress a directly neighbouring cranial nerve due to an an-
• M. tensor veli palatini eurysmal enlargement.
2nd pharyngeal N. facialis [VII] • Mimic muscles
arch (hyoid arch) • M. stylohyoideus NOTE
• Venter posterior musculi • The N. oculomotorius [III] passes through the Fossa interpedun-
digastrici cularis and here lies in the immediate proximity to the A. cerebri
• M. stapedius posterior or, further along its pathway, to the A. communicans
3rd pharyngeal arch N. glossopharyngeus [IX] • Pharyngeal muscles posterior.
• M. stylopharyngeus • At the Meatus acusticus internus, the A. inferior anterior cerebelli
• M. levator veli palatini leaves the A. labyrinthi and at the cerebellopontine angle is
found in the immediate vicinity of the N. facialis [VII] and N. ves-
4th pharyngeal arch N. vagus [X] with N. laryn- • Laryngeal muscles
(laryngeal arch) geus superior • Pharyngeal muscles:
tibulocochlearis [VIII].
• The strongest branch of the A. vertebralis, the A. inferior posterior
M. cricothyroideus
cerebelli, runs initially near the olive in the immediate vicinity of
5th pharyngeal arch – Regresses – – Regresses – the N. hypoglossus or to the cranial nerve roots along the Fora-
6th pharyngeal arch N. vagus [X] with N. laryn- • Inner laryngeal muscles men jugulare.
geus inferior (N. recurrens) • Upper oesophageal muscles

Clinical remarks
having a cranially-oriented course, the Radix spinalis is referred to In the case of the functional failure of a cranial nerve, it is ini-
partially inconsistently as being specially visceroefferent or as so- tially important for the purposes of ongoing diagnosis to dis-
matoefferent. tinguish whether it is a central (supranuclear) lesion or a le-
sion of the cranial nerve nucleus, or whether the cranial nerve
is damaged in its peripheral pathway. To do so, it is crucial to
know the exact position of the cranial nerve nuclei, its exit
12.5.3 Arterial blood supply point and its adjacent structures, in order to be able to local-
ise the lesion precisely. Clinically, due to the close topograph-
A disruption in arterial perfusion can result in brainstem infarc- ical relationships of the cranial nerves with each other, dis-
tions, leading to resulting tissue death in the perfusion area of lo- eases involving combined cranial nerve lesions are frequently
calised neuronal structures and thus leading to a corresponding found – for example, if caudal cranial nerves run very closely
loss of function. The symptoms observed enable conclusions to be together as they pass through the openings in the base of the
drawn about the localisation of the affected brainstem area and the internal surface of the cranial base (e.g., through the Foramen
jugulare). Isolated cranial nerve lesions – especially of the
affected vessel. IIIrd to VIIIth cranial nerves – are frequently causally affected
To simplify, the brainstem belongs to the cranial nerve nuclei con- due to hemorrhage or lesions of the brainstem arteries.
tained within it to the supply area of the Aa. vertebrales, which
come together at the level of the transition from the Medulla ob-
longata to the pons to the A. basilaris. Accordingly, nuclear areas of
the Medulla oblongata are supplied to some extent by the A. verte-
bralis or its branches, such as the pons to some extent from the A. 12.5.4 N. olfactorius (1st cranial nerve, N. I)
basilaris and its branches. It is not possible to allocate one single Michael J. Schmeißer
vessel so clearly to the mesencephalon, but here again there is a
constant arterial blood supply of the cross-section of the brainstem
by an anterior, posterior and lateral inflow area: SKILLS
• With its branches, the anterior supply area takes blood parame- After working through this chapter, you should be able to:
• describe the special position of the N. olfactorius in comparison
dially into the brainstem and thus reaches the general somatoef-
to cranial nerves III–XII and explain the difference between a pri-
ferent nuclear areas of the IIIrd, IVth, VIth and XIIth cranial mary and a secondary sensory cell
nerve (› Chap. 12.5.1, 4th rule). Depending on the position of • clinically distinguish a lesion of the N. olfactorius from a lesion of
the level, the inflow takes place from the A. spinalis anterior or the N. trigeminus
the Rr. paramediani of the A. vertebralis, the Rr. mediales of the
Aa. pontes of the A. basilaris and from the A. superior cerebelli
and from the Rr. interpendunculares of the A. cerebri posterior N. olfactorius [I] is the term given to approximately 20 fine nerve
in the area of the mesencephalon. fibres, surrounded by meninges (Fila olfactoria). These contain un-
• The lateral supply area reaches the nuclei of the Vth, VIIth, IXth, myelinated axons of the bipolar olfactory neurons and from the ol-
Xth and XIth cranial nerves via branches of the A. inferior ante- factory mucosa in the upper nasal cavity, they pass through the Lam-
rior cerebelli from the A. basilaris and Rr. laterales (differentiat- ina cribosa of the Os ethmoidale up into the anterior cranial fossa
ed as Rr. circumferentes breves and longi) of the Aa. pontes from and the Bulbus olfactorius (› Fig. 9.32). Thus the N. olfactorius [I]
the A. basilaris. is not a classic cranial nerve fibre with a peripheral fibre pathway and

684
 12.5 Cranial nerves

a central nuclear area; instead it corresponds to the first part of the cus is initially embedded in the retrobulbar fat body of the orbita,
olfactory system of the CNS (› Chap. 13.6.2) and so it is assigned to then passes through the anulus of ZINN (Anulus tendineus com-
the telencephalon. As before, we are still not in agreement about the munis) and is then fed as the only nerve via the Canalis opticus
quality of its fibres: basically, the fibres taking impulses from the sen- into the middle cranial fossa, where it joins with the N. opticus of
sory epithelial cells of the olfactory receptors are referred to as spe- the opposite side in the Chiasma opticum above the pituitary gland
cially visceroafferent fibres. However, in academic literature, the fi- (for Optic Tract see › Chap. 13.3.1). The A. and V. centralis reti-
bres of the N. olfactorius are also partially stated as being specially nae run directly behind the Bulbus oculi, inside the N. opticus [II],
somatoafferent (› Chap. 12.5.1). Olfactory neurons are primary on their way to the retina.
sensory cells, which receive impressions of the sense of smell via its
dendrites and transfer them via their axons to the central nervous
system. Secondary sensory cells also receive impulses; these cannot
Clinical remarks
however be transferred directly to the central nervous system. Examination
The patient is initially questioned about his general vision, as
Clinical remarks detrimental effects on the N. opticus may only be accompa-
nied by a partial loss of vision (‘blurred vision’, ‘dark spots’),
Examination but may sometimes lead to blindness. You should therefore
direct the examination – separately for each eye – towards
When taking a detailed patient medical history, we ask firstly
acuity (using an eye chart) and the field of vision (using finger
about disturbances in smell and taste. An olfactory sensory
perimetry). In addition, it is essential to examine the pupillary
disorder is hard to diagnose in a patient's history because it
reflex because the afferent reflex largely runs via the N. opti-
often presents as a disruption of the sense of taste. To objec-
cus. In case of damage it is not possible to trigger a light reac-
tively carry out a functional test for the sense of smell, the pa-
tion (contraction of the pupil = miosis) either ipsilaterally or
tient closes their eyes and, isolated under each nostril, vari-
contralaterally when shining a light in the affected eye, where-
ous aromatic substances are proffered to test their smell. In
as the reflex response is normal in both eyes when a light is
this context it is very important for the subsequent ‘odour
shone in the healthy eye.
samples’ to be carried out using irritants such as ammonia,
because it is not perceived by the N. olfactorius [I], but via the Damage to the nerve
branches of the N. trigeminus [V] supplying the nasal mucosa.
An acute inflammation of the optic nerve (Neuritis nervi optici
If the affected person fails to perceive either the aromatic or
or retrobulbar neuritis) is primarily identified by a potentially
the irritating substances, the nasal mucosa may be affected. If
reversible one-sided loss of vision. Affected patients report
the affected person reacts to the irritating substance but not
seeing a ‘veil’, but imaging of the ocular fundus, including an
to the aromatic substances, a neurogenic disorder, e.g., a dis-
evaluation of the optic nerve papilla, often reveals no abnor-
order of the N. olfactorius [I], is very likely.
malities (‘the patient cannot see anything and the doctor can-
Damage to the nerve not see anything either’). In about one third of the cases, opti-
cal nerve neuritis in young people is the first symptom of mul-
In the case of a fracture of the base of the skull, the N. olfacto-
tiple sclerosis (MS), a relatively frequent autoimmune disease
rius can be torn off from the nasal cavity in the bony area
of the central nervous system.
where it penetrates into the anterior cranial fossa. This may
Due to increased intracranial pressure (e.g., due to a brain tu-
result in olfactory impairment (hyposmia) or a complete fail-
mour or a cerebral haemorrhage) the optic nerve can be com-
ure of the ability to smell (anosmia).
pressed on both sides. This is accompanied by a venous back-
flow, entailing an ophthalmoscopically-visible oedema of the
optic papilla, which has now protruded into the bulbi. This is
called papilloedema.
12.5.5 N. opticus (2nd cranial nerve, N. II)
Michael J. Schmeißer

12.5.6 N. oculomotorius (3rd cranial nerve, N. III)

SKILLS Michael J. Schmeißer
After working through this chapter you should be able to:
• describe the special position of the optic nerve in comparison
with cranial nerves III–XII SKILLS
• explain what a Stasis papilla is and consider the possible causes
After working through this chapter, you should be able to:
for it • name the target organs of the N. oculomotorius
• enumerate the cranial nerve nuclei of the N. oculomotorius, ex-
plain their topographical position and clarify their respective
In a similar way to the N. olfactorius, the N. opticus [II] is also not functions correctly
a classic cranial nerve; instead it is a CNS structure of the optic • describe the clinical findings in a case of oculomotoric paralysis
tract, assigned to the diencephalon, and is enveloped by meninges and identify possible causes
and oligodendrocytes. Its exclusively special somatoafferent fibres
are the bundled axons of the multi-polar ganglion cells of the reti-
na; initially these axons are unmyelinated and subsequently be- The N. oculomotorius [III] is a classic cranial nerve and, as well as
come myelinated (› Chap. 9.3.2). These transfer visual informa- the N. trochlearis [IV] and the N. abducens [VI], is one of the 3 cra-
tion and predominantly end in the Corpus geniculatum laterale nial nerves that control the movements of the eyeball (‘eye muscle
(CGL) of the thalamus. The optic nerve papilla (Discus nervi opti­ nerve’). Due to its general somatoefferent innervation of almost all
ci) is seen in the ocular fundus reflection as a yellowish disc, and it the striated extra-ocular eye muscles, it is able to move the Bulbus
marks the beginning of the N. opticus at the dorsal pole of the Bul- oculi medially downwards, medially upwards and laterally upwards.
bus oculi. As it continues its slightly S-shaped course, the N. opti- In addition, its general somatoefferent fibres are mainly responsible

685
12 Special neuroanatomy

for lifting the eyelids. It innervates generally visceroefferently the Both nuclei are adjacent to each another in the mesencephalon at
smooth intra-ocular muscles. It ensures the contraction of the pupil the level of the Colliculi superiores (› Fig. 12.41). The Nucleus
(miosis) and intensifies the curvature of the lens (› Fig. 12.41). nervi oculomotorii is located ventrally of the aquaduct and posteri-
or to the Nucleus ruber close to the midline. It consists of several
Course and branches sections; particularly noteworthy here is the unpaired Nucleus cau-
The N. oculomotorius exits from the brainstem medially on the Crus dalis centralis, which contains the somata of the motoneurons for
cerebri in the Fossa interpeduncularis of the mesencephalon (› Fig. the M. levator palpebrae superioris from both sides. The Nucleus
12.40). It initially runs between the A. superior cerebelli and the A. accessorius nervi oculomotorii is located mediodorsally of the Nu-
cerebri posterior, and laterally of the A. communicans posterior and cleus nervi oculomotorii, even closer to the midline.
the Proc. clinoideus posterior it breaks through the Dura mater. Af- The configurations of the ‘eye muscle nuclei’ with each other and
ter that, it enters the Sinus cavernosus and passes through its side their associations with supranuclear, pre-oculomotor centres are
wall as the uppermost nerve (› Fig. 12.46). From here it passes extremely complex (› Chap. 13.3.3). Amongst others, the in­
through the mediocaudal part of the Fissura orbitalis superior into ter-nuclear neurons are important here. These are found in addi-
the orbita, entering through the Anulus tendineus communis (annu- tion to the classic general somatoefferent motoric projection neu-
lus of ZINN), where it divides into further branches: rons in the ‘eye muscle nuclei’. The individual ‘eye muscle nuclei’ in
• R. superior: This smaller branch supplies the M. rectus superior the brainstem are relayed via them. The most studied internuclear
(elevation of the Bulbus oculi, combined with mild adduction projection runs in the Fasciculus longitudinalis medialis (FLM)
and internal rotation) and the M. levator palpebrae superioris and connect internuclear neurons of the Nucleus nervi abducentis
(lifting of the upper lids) general somatoefferent. with inter-nuclear neurons of a contralateral subnucleus of the Nu-
• R. inferior: This larger branch supplies the M. rectus medialis cleus nervi oculomotorii. In addition, the Nucleus accessorius ner-
(adduction of the Bulbus oculi), the M. rectus inferior (depression vi oculomotorii plays a crucial role in the pupillary and accommo-
of the Bulbus oculi, combined with mild adduction and external dation reflex as well as in the convergence reaction (› Chap. 13.3.2).
rotation) and the M. obliquus inferior (elevation of the Bulbus oc-
uli, combined with mild abduction), generally somatoefferent.
• R. ad ganglion ciliare: This general visceroefferent branch pass-
Clinical remarks
es to the Ganglion ciliare (› Chap. 9.3.3). Its parasympathetic Examination
fibres are relayed from pre- to postganglion and continue to the In a general inspection, the position of the eyelids is noted
M. sphinchter pupillae (contraction of the pupil = miosis) and first, then on closer inspection the position of the bulbi and
the M. ciliaris (relaxation of the zonular fibres and resulting the pupil – always comparing both sides. Additionally, the pa-
strengthening of the lens curvature in short-distance visual ac- tient should be asked about double vision. In the event of fail-
commodation). ure of the N. oculomotorius, this would lessen on the dam-
aged side looking downwards and outwards, but it would nev-
er quite disappear. For a general and combined examination
Cranial nerve nuclei and central links of the oculomotor system, including the ‘eye muscle nerve’,
Corresponding to its 2 fibre qualities, the N. oculomotorius has 2 N. oculomotorius [III], N. trochlearis [IV] and the N. abducens
specific cranial nerve nuclei: the general somatoefferent Nucleus [VI], the patient is asked to focus their eyes on an index finger
nervi oculomotorii and the general visceroefferent Nucleus acces­ held approximately 20–30 cm away at eye level and to follow
sorius nervi oculomotorii (Nucleus EDINGER-WESTPHAL ). its course. The eye movement is then tracked while moving the
index finger to all lines of sight (cranial-caudal, medial-lateral
and combinations of these). If there is damage to the N. oculo-
motorius, the Bulbus oculi on the affected side deviates
downwards and outwards from the start of the examination
and is usually unable to follow the index finger. The conver-
gence reaction is checked by moving the index finger towards
the patient's nose at eye level. Here, it is important to check
whether both eyeballs move towards the centre, and that re-
flexive miosis occurs simultaneously in both eyes. Lastly, the
pupillary reflex is checked. In the event of a failure of the
N. oculomotorius, the efferent reflex fails, so that there is nei-
ther a direct or indirect light reaction in the affected eye.

Damage to the nerve

The complete picture of oculomotoric paralysis is character-
ised by the following 3 key symptoms:
• Ptosis (drooping eyelid) due to the paralysis of the M. leva-
tor palpebrae superioris
• Incorrect outwards positioning of the bottom of the Bulbus
oculi due to the loss of the Mm. rectus superior, rectus me-
dialis, rectus inferior and obliquus inferior
• Mydriasis (widening of the pupil) due to the failure of the
M. sphincter pupillae
On closer examination, it also emerges that near-point accom-
modation (due to the failure of the M. ciliaris) and the conver-
gence reaction (due to the failure of one of the two Mm. recti me-
diales) are no longer possible. Affected patients also report dou-
ble vision. The following should be taken into account in cases
Fig. 12.40 Exit point of the N. oculomotorius. The IIIrd cranial nerve of oculomotor paralysis or excluded by imaging techniques:
exits directly above the pons; Ventral view.

686
 12.5 Cranial nerves

Target organs Reorganisation Cranial nerve Nuclear areas

M. levator palpe- Nucleus nervi

brae superioris oculomotorii
M. rectus superior
Fissura orbitalis superior
M. rectus medialis
M. rectus inferior
N. oculomotorius [III]
M. obliquus inferior

M. sphincter pupillae Nucleus accessorius

Ganglion ciliare nervi oculomotorii
M. ciliaris

Fig. 12.41 Pathway, branches and fibre qualities of the N. oculomotorius, left. Lateral view. [L127]

• bulges or aneurysms of the intracranial vessels that run

Pathway
close to the nerve, such as the Aa. cerebri posterior or com- The N. trochlearis exits dorsally as a single cranial nerve from the
municans posterior brainstem directly below the Colliculi inferiores (› Fig. 12.42). It
• a thrombosis of the Sinus cavernosus runs within the Cisterna ambiens between the A. superior cerebelli
• Tumours of the internal surface of the cranial base and/or and the A. cerebri posterior around the cerebral crus and basally
the orbita forwards and finally penetrates the Dura mater in order to enter
• Skull fractures into the side wall of the Sinus cavernosus. Here, it runs directly be-
• Inflammation of the meninges that cover the brain in the
low the N. oculomotorius (› Fig. 12.46). Finally, it runs through
area of the cranial base
Furthermore, intracranial pressure and the subsequent dis- the laterocranial part of the Fissura orbitalis superior furthest later-
placement of the brain mass into the tentorium slot (‘upper ally and arrives outside of the Anulus tendineus communis (annu-
entrapment’) can lead to what is called clival syndrome. Here, lus of ZINN) under the roof of the orbit to the M. obliquus superior.
the N. oculomotorius is compressed against the bony edge of
the clivus due to the brain mass displacement, gets into a Cranial nerve nuclei and central links
state of irritation (small pupils ipsilaterally initially) and finally Since the N. trochlearis only has one fibre quality, there is also only
fails (open, non-responsive pupils ipsilaterally).
one nuclear area, the general somatoefferent Nucleus nervi trochle­
aris. This is located in the mesencephalon at the level of the Colliculi
inferiores ventrally of the aquaduct (› Fig. 12.43). Its efferent fibres
cross over to the opposite side before exiting the brainstem dorsally.
12.5.7 N. trochlearis (4th cranial nerve, N. IV) In the same way as has already been mentioned for the N. oculomo-
Michael J. Schmeißer torius, the configurations of the ‘eye muscle nuclei’ with each other,
and their connection with supranuclear, pre-oculomotor centres, are
extremely complex (› Chap. 13.3). A tract that is solely or princi-
SKILLS pally assigned to the N. trochlearis has not been described here.
After working through this chapter, you should be able to:
• name the target organ and cranial nerve nuclei of the N. trochlear-
is
• precisely explain the topographical pathway of the N. trochlearis
• describe the clinical findings of a trochlear paralysis and give the
possible causes

The N. trochlearis [IV] is a purely general somatoefferent cranial

nerve. It is the thinnest of all the cranial nerves and is responsible
for the motor innervation of the M. obliquus superior (› Fig.
12.43). In its primary position (looking straight ahead), this muscle
can roll the Bulbus oculi inwards and move it laterally downwards.
However, when the eye is positioned in the adduction position, the
M. obliquus superior is mainly responsible for the lowering of the
eyeball laterally downwards. Fig. 12.42 Exit point of the N. trochlearis. The IVth cranial nerve
exits below the Colliculi inferiores; dorsal view.

687
12 Special neuroanatomy

Target organs Cranial nerve Nuclear areas

Fissura orbitalis superior

M. obliquus superior N. trochlearis [IV] Nucleus nervi

trochlearis

Fig. 12.43 Pathway, branches and fibre qualities of the N. trochlearis, left. Lateral view. [L127]

Clinical remarks muscles of the Tuba auditiva or in the Cavitas tympani (M. tensor
Examination veli palatini, M. tensor tympani). General somatoafferent fibres car-
When examined, the patient may already present with a tilted ry, in particular, the sensitivity as well as the temperature and pain
head position. Similarly to the examination of the other two sensations of the facial skin. However, the mimic muscles radia­ting
‘eye muscle nerves’, the position of the bulbi is noted, the into the facial skin are innervated by the N. facialis [VII].
clinical examination for eye-tracking movements, as already
described for the N. oculomotorius, is carried out and the pa- Pathway and branches
tient is asked about double vision. Where there is isolated
The division of the N. trigeminus into both of its fibre qualities can
damage to the N. trochlearis, the eye can still be moved in all
the main directions. Therefore, the clinical diagnosis of an iso-
already be macroscopically visualised when it exits the brainstem
lated lesion of the N. trochlearis where there is no tilted head in the area of the lateral pons (› Fig. 12.44). This can be distin-
position is singularly difficult to make. guished as a larger Radix sensoria nervi trigemini (syn.: Por­tio
major) and a Radix motoria nervi trigemini (syn.: Portio
Damage to the nerve ­minor). Both cranial nerve parts pass via the Margo superior of the
In case of a trochlear paralysis, the affected bulb is turned temporal bone, to form the Ganglion trigeminale (GASSER’s gan­
medially upwards and slightly outwards. The resulting glion), in a pouch-shaped dural duplicature called the Cavum tri­
obliquely distorted double images lie over each other and are geminale. The Ganglion trigeminale is located at the Facies anteri-
primarily perceived when looking medially downwards. Occa-
sionally the affected patient develops a posture where the
or at the tip of the Pars petrosa ossis temporale in the Impressio tri-
head is permanently tipped to the healthy side. This position geminalis. This ganglion contains most of the perikarya of
is adopted to compensate for the fact that the Bulbus oculi pseudo-unipolar sensory neurons, which are somatotopically ar-
can no longer turn inwards. The causes of trochlear paralysis
is the same as for oculomotoric paralysis, because both
nerves run adjacent to each another. Therefore, whatever the
cause, nerve damage to both nerves is identified.

12.5.8 N. trigeminus (5th cranial nerve, N. V)

Anja Böckers

SKILLS
After working through this chapter, you should be able to:
• name the target organs of the three trigeminal branches
• correctly describe the neuronal stations of the trigeminoafferent
system
• clinically differentiate between peripheral and central trigeminal
lesions

The name of the N. trigeminus [V] results from its splitting into 3
main branches to innervate the head: the N. ophthalmicus [V/1],
the N. maxillaris [V/2] and the N. mandibularis [V/3]. The N. tri-
geminus is a mixed cranial nerve made from general somatoafferent
and specially visceroefferent fibres, since it is supplied by the mus-
cles developing from the first pharyngeal arch. These include the
masticatory muscles, parts of the muscle of the floor of the mouth Fig. 12.44 Exit point of the N. trigeminus. The cranial nerve vein
(M. mylohoideus, Venter anterior musculi digastrici) and smaller exits at the lateral side of the pons; Ventral view.

688
 12.5 Cranial nerves

Fig. 12.45 Inside view of the

Chiasma opticum A. cerebri anterior dextra,
Pars postcommunicalis right Fossa cranii media. The
Cavum trigeminale (MECKEL’s
Pedunculus cerebri,
Crus cerebri Infundibulum cavity) is opened after removing
the Dura mater and the arach-
N. oculomotorius [III] N. opticus [II] noidea. You can see the Gangli-
on trigeminale with its crescent
N. trochlearis [IV] A. carotis interna, shape and its split into the three
(Plica petroclinoidea Pars cerebralis branches of the trigeminal
anterior) nerve: the N. ophthalmicus with
N. trigeminus [V], its passage through the Fissura
Radix motoria N. ophthalmicus [V/1] orbitalis superior into the orbit,
N. trigeminus [V], the N. maxillaris nerve and its
Radix sensoria Ganglion trigeminale passage through the Foramen
N. facialis [VII]
rotundum into the Fossa ptery-
N. maxillaris [V/2] gopalatina, as well as the N.
N. abducens [VI] mandibularis with its passage
N. vestibulocochlearis [VIII] N. mandibularis [V/3] through the Foramen ovale in
the Fossa infratemporalis.

ranged according to their supply areas in a dorsoventral direction.

Clinical remarks
Immediately after the ganglion, the N. trigeminus divides into its Sharp, shooting, stabbing pain is mostly limited to the face,
three main branches which exit the mid cranial fossa via various and is referred to as trigeminal neuralgia. These fits typically
openings in the internal surface of the cranial base (› Fig. 12.45). only last for a few seconds, rarely for more than 2 minutes. Be-
tween the bouts, the patient is usually pain-free, although the
overall trend is progressive. The cause is frequently pathologi-
NOTE cal neurovascular contact between the A. superior cerebelli and
For a simplified functional understanding, you should note the fol- the N. trigeminus (where it leaves the brainstem). Trigeminal
lowing rough division of the innervation areas of the head for the neuralgia is initially treated with drugs, but if this is unsuccess-
three trigeminal branches: ful, invasive procedures can be considered. These include per-
• N. ophthalmicus [V/1]: Area above the lower eyelid, which is the
cutaneous puncture through the cheek and/or through the Fo-
forehead up to the lambdoid suture, including the skin area as ramen ovale to perform a thermocoagulation of the Ganglion
well as the head cavities, i.e. the orbita and the eye trigeminale. This procedure is destructive and therefore also
• N. maxillaris [V/2]: Area between lower eyelid and upper lip,
reduces touch sensations in the area of one or more branches
which is the skin area including the body openings, i.e. nasal cav- of the trigeminal nerve (hypoaesthesia). Another therapeutic
ity and adjacent upper jaw area method is microvascular decompression. Here, the above-men-
• N. mandibularis [V/3]: Area between the bottom lip and chin line,
tioned pathological neurovascular contact is resolved by the
which is the skin area including the adjacent body opening, i.e. use of an interponate, such as a small Teflon sponge.
oral cavity and adjacent lower jaw area; the N. mandibularis is the
only trigeminal branch which carries special visceroefferent fibres
to the muscles of the 1st pharyngeal arch.
A ganglion adheres to each of the three branches of the trigeminal
nerve. Here, however, the sensory fibres are not switched, but the N. ophthalmicus
general visceroefferent fibres of the other cranial nerves are. They The N. ophthalmicus [V/1] is a purely afferent nerve, carrying im-
include: pulses from the area of the orbita, the Bulbus oculi, including the
• N. ophthalmicus [V/1]: the Ganglion ciliare adheres in the orbita cornea, the skin of the face up to the lambdoid suture and the back
with the switching over of the general visceroefferent fibres of the of the nose (› Fig. 12.49, but also of the mucosa of the ethmoidal
N. oculomotorius [III].
• N. maxillaris [V/2]: the Ganglion pterygopalatinum adheres in the
sinuses, the sphenoidal sinus, of the nasal septum and the dura of
Fossa pterygopalatina with the switching over of the general vis- the anterior cranial cavity. It forms the basis of the corneal reflex.
ceroefferent fibres of the N. facialis [VII]
• N. mandibularis [V/3]: the Ganglion oticum adheres at the Fora-
men ovale with the switching over of the general visceroefferent
Clinical remarks
fibres of the N. glossopharyngeus [IX] The corneal reflex is a reflexive protective mechanism of the
Each of the three branches of the trigeminal nerve supplies one eye, with stimulation of the cornea leading to closure of the
section of the Dura mater in sensory terms. To simplify matters, the opening between the eyelids (palpebral fissure). The corneal
innervation of the Dura mater can be described as follows: reflex is a polysynaptic reflex, which should be particularly
• N. ophthalmicus [V/1]: Dura mater of the anterior cranial cavity noted when checking the neurological status of an uncon-
• N. maxillaris [V/2] and N. mandibularis [V/3]: Dura mater of the scious patient (see below). It can be absent in peripheral
middle cranial cavity; the Dura mater of the posterior cranial cavi- nerve lesions, as well as in cases of severe brainstem lesions.
ty is not innervated by the N. trigeminus [V], but by the Rr. The reflex is usually triggered by touching the cornea with a
meningei of the N. vagus [X] and the N. glossopharyngeus [IX]. cotton swab, but it is also possible to trigger the reflex here
using glaring lights or acoustic stimuli. The stimulatory im-
The special visceroefferent fibres arise from the Nucleus motorius pulses are routed through fibres of the N. ophthalmicus. After
nervi trigemini located in the pons, and the general somatoafferent central configuration in the trigeminal nucleus complex, the
reflex arch runs polysynaptically via the Colliculi superiores,
fibres end in an elongated nuclear pillar which begins in the mesen­
the Formatio reticularis, and finally to the nuclear complex of
cephalon as the Nucleus mesencephalicus nervi trigemini and the N. facialis. From here, the efferent pulses travel via the
reaches up to the Nucleus principalis (syn.: Nucleus pontinus) in N. facialis to the facial muscles (M. orbicularis oculi), which
the pons, continuing via the entire Medulla oblongata into the Nu- generate eyelid movement.
cleus spinalis nervi trigemini.

689
12 Special neuroanatomy

After the Ganglion trigeminale, the N. ophthalmicus [V/1] continues Clinical remarks
on its way to the Fissura orbitalis superior through the Sinus cav­
It is estimated that approximately 90% of the population, hav-
ernosus or in its lateral limit, through the Dura mater. The Sinus cav-
ing had a previous infection of chickenpox, are carriers of the
ernosus nestles laterally on both sides of the Corpus ossis sphenoida- varicella zoster virus infection. The viruses remain in the spi-
lis with the Sinus sphenoidalis located within it (› Fig. 12.46). Still in nal nerves of the spinal cord, and can be reactivated when
the Sinus cavernosus, the N. ophthalmicus emits an R. meningeus triggered by stress, UV light or as the result of a weakened im-
recurrens (syn.: R. tentorius) for the dura of the anterior cranial mune system (e.g., in cases of HIV-related disease or chemo-
cavity and the Tentorium cerebelli. Before its passage through the Fis- therapy). Typical skin eruptions with weeping blisters are dis-
sura orbitalis superior, the N. ophthalmicus splits into its three main tributed in the dermatome of the affected spinal ganglion.
Mostly the thoracic, belt-like dermatomes of the intercostal
branches (› Fig. 12.47, light green-coloured nerve branches):
nerves are affected, and this is also known as shingles (her-
• N. nasociliaris (1st main branch): It passes through the Anulus pes zoster). However, the virus may also remain in the head
tendineus to the medial orbital wall. Here it divides into both the ganglia of the cranial nerves, frequently in the ganglia of the
Nn. ethmoidales anterior and posterior: N. trigeminus, so that typically the blisters spread into the cu-
The N. ethmoidalis anterior reaches the anterior cranial cavity taneous innervation areas of the N. ophthalmicus, N. maxillar-
with its R. meningeus via the identically named foramen of the is or N. mandibularis – like the common cold sore. If the 1st
orbita, then passes through the Lamina cribrosa in order to enter trigeminal branch is affected (› Fig. 12.48), we also refer to it
as Zoster ophthalmicus, which due to the involvement of the
the nasal cavity. Its Rr. nasales anteriores laterales and septi in-
surface epithelium of the eye, the cornea and the conjunctiva
nervate the anterior part of the nasal cavity and of the nasal sep- is very painful. If it heals leaving scars, this may lead to blind-
tum and the anterior ethmoidal sinuses. Its terminal branches ness in the affected eye.
leave the nasal cavity again as Rr. nasales externi for the area of
the dorsum of the nose to the tip of the nose.
The N. ethmoidalis posterior also passes through the identically
named foramen of the orbita, reaching the posterior ethmoidal N. maxillaris
sinuses. The N. maxillaris [V/2] is a purely afferent nerve, carrying impulses
The pathway of the N. nasociliaris is eventually continued by the from the area of the lower eyelid, the cheek skin and the upper lip.
N. infratrochlearis, with its branches innervating the medial Its cutaneous innervation area also includes the skin above the zy-
eye angle. Sensory branches of the Ganglion ciliare run along gomatic bone and the temporal area (› Fig. 12.49). In addition, it
with the Nn. ciliares breves and longi to the Bulbus oculi and also carries afferents from the mucous membranes of the rear and
supply the cornea and the conjunctiva. lower nasal cavity, the maxillary sinus, the palate and the maxilla,
• N. frontalis (2nd main branch): It runs around the roof of the including the associated upper teeth and the meninges of the mid-
orbit in order to innervate the N. supraorbitalis and the N. su­ dle cranial fossa. After passing through the Ganglion trigeminale, it
pratrochlearis, of the forehead, sinus and upper eyelid via its runs together with the N. ophthalmicus through the Sinus caverno-
two end branches. sus, but further basolaterally it is located in the lateral boundaries of
• N. lacrimalis (3rd main branch): It runs along the lateral orbita the sinus (› Fig. 12.46) before it goes through the Foramen rotun-
above the M. rectus lateralis to the lacrimal gland. Postgangli­ dum into the Fossa pterygopalatina. The ramifications of the
onic general visceroefferent fibres of the N. facialis [VII] from N. maxillaris [V/2] are presented in › Fig. 12.47in orange:
the Ganglion pterygopalatinum accumulate here via the R. com­ • An R. meningeus leaves the N. maxillaris intracranially for the
municans cum nervo zygomatico. Sensory fibres also accumu- dura of the middle cranial fossa. In the Fossa pterygopalatina,
late at the lateral eye angle, upper eyelid and conjunctiva. the following branch off from the N. maxillaris:

Diaphragma sellae Infundibulum

Chiasma opticum
Sinus intercavernosi
N. opticus [II]
Sinus cavernosus
A. ophthalmica
N. oculomotorius [III]
A. carotis interna, Pars cerebralis
A. carotis interna, Pars cavernosa

N. trochlearis [IV]
Neurohypophysis Hypophysis
N. abducens [VI] Adenohypophysis [Glandula pituitaria]

N. ophthalmicus [V/1]

Sella turcica, Fossa hypophysialis

N. maxillaris [V/2]

Dura mater cranialis Sinus sphenoidalis

Fig. 12.46 Frontal section through the Sinus cavernosus at the level of the Glandula pituitaria (pituitary gland, hypophysis). View from pos-
terior. The Sinus cavernosi surrounds both sides of the Corpus ossis sphenoidalis with the Sella turcica and the Fossa hypophysialis. The N.
oculomotorius [III], the N. trochlearis [IV], the N. ophthalmicus [V/1] and the N. maxillaris [V/2] run within the lateral wall of the Sinus caverno-
sus. The N. abducens [VI] and the A. carotis interna are centrally located in the Sinus cavernosus.

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 12.5 Cranial nerves

N. nasociliaris R. meningeus recurrens [R. tentorius]

N. lacrimalis
R. meningeus
Radix sensoria [nasociliaris] ganglii ciliaris
N. ophthalmicus [V/1]
N. frontalis

Ganglion ciliare Rr. temporales superficiales

N. ethmoidalis posterior
Ganglion trigeminale
N. ethmoidalis anterior

N. supraorbitalis N. mandibularis [V/3]

N. supratrochlearis
R. meningeus
N. infratrochlearis

Rr. nasales interni N. trigeminus [V]

R. nasalis externus
N. petrosus minor
N. maxillaris [V/2] (N. glossopharyngeus [IX])

R. zygomaticotemporalis
N. meatus acustici externi,
N. zygomaticus Nn. auriculares anteriores

R. zygomaticofacialis
N. facialis [VII]
N. canalis pterygoidei
Chorda tympani
N. infraorbitalis

Ganglion N. auriculotemporalis
pterygopalatinum

Rr. nasales N. musculi tensoris tympani

posteriores superiores;
N. nasopalatinus
Rr. parotidei;
Rr. alveolares superiores Rr. communicantes cum nervi faciali

N. pharyngeus
Ganglion oticum
Nn. palatini major et minores
N. musculi tensoris veli palatini;
Nn. temporales profundi
N. pterygoideus medialis
N. pterygoideus lateralis;
N. massetericus N. alveolaris inferior
N. buccalis
N. lingualis
N. mentalis

Ganglion submandibulare N. mylohyoideus

Fig. 12.47 N. trigeminus left with a split into the main branches N. ophthalmicus [V/1] (bright green), N. maxillaris [V/2] (orange) and N. man-
dibularis [V/3] (turquoise). Lateral view.

• The N. zygomaticus incorporates postganglionic general vis-

ceroefferent fibres of the N. facialis [VII], passes through the Fis-
sura orbitalis inferior in the orbita and releases these fibres here
via the R. communicans cum nervo zygomatico in the direc-
tion of the Glandula lacrimalis. The trigeminal general soma-
toafferent fibres run along the lateral orbital wall and, with the
Rr. zygomaticotemporalis and zygomaticofacialis, pass
through canals of the same name via the cheekbone to the sur-
face of the face, in order to innervate the skin of the temple
above the cheekbone and of the lateral eye angle.
• Rr. alveolares superiores posteriores supply the molars of the
upper jaw with adjacent areas of the Sinus maxillaris and the
gingiva. The Rr. alveolares superiores medii and anteriores
from the N. infraorbitalis (see below) accordingly innervate the
premolars, canines and incisors. The Rr. alveolares superiores are
Fig. 12.48 Zoster ophthalmicus. The skin is affected in the innerva- collectively referred to as the Plexus dentalis superior.
tion area of the 1st trigeminal branch, as well as the epithelium of the • The N. infraorbitalis is the terminal branch of the N. maxillaris
surface of the eye such as the cornea and the conjunctivae. The con- [V/2]. Unlike the previous branches, it initially runs via the Fissura
junctiva becomes clearly reddened and the eyelids narrowed. [E943] orbitalis inferior into the orbita, but leaves again immediately via

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12 Special neuroanatomy

• The anterior nerve trunk is also known as the N. masticatorius

(chewing nerve), as mostly special visceroefferent fibres for
mastication muscles originate from it:
– The Nn. pterygoidei lateralis and medialis are fine branches
N. ophthalmicus [V/1] that run directly to the masticatory muscles. The N. pterygoi-
deus medialis usually releases the special visceroefferent fibres
for the M. tensor veli palatini and M. tensor tympani.
N. maxillaris [V/2] – The Nn. temporales profundi for the M. temporalis and the
N. massetericus for the M. masseter, the special visceroeffer-
SOELDER lines ent supply of the maxillary-closing muscle.
N. mandibularis [V/3]
– The only afferent nerve of the N. masticatorius is the N. buc­
calis: it penetrates the M. buccinator and innervates the buc-
cal mucosa with adjoining buccal sections of the gingiva.
• The posterior main trunk of the N. mandibularis contains mixed
fibre qualities:
– N. auriculotemporalis: On its lateral pathway, it forms a loop
Fig. 12.49 Innervation areas of the facial skin by the N. trigeminus, around the A. meningea media. Its general somatoafferent fibres
exit points and protopathic sensitivity. On the left side of the face
ultimately go to the skin of the ear and, with a small branch, the
(right side on the illustration) the somatotopic structure of the proto-
pathic sensibility is shown, on the right side of the face are the inner-
N. meatus acustici externi, to the external ear canal and the ear-
vation areas and nerve exit points for the 3 peripheral trigeminal drum. Together with branches of the A. temporalis superficialis,
branches. [K340] its branches reach the temple cranially. In addition, postgangli-
onic general visceroefferent fibres of the N. glossopharyngeus
[IX] accumulate onto the N. auriculotemporalis from the Gan-
the Canalis infraorbitalis, in order to move forward in the roof of glion oticum for the innervation of the Glandula parotidea.
the Sinus maxillaris and to exit below the eye at the Foramen infra- – N. alveolaris inferior: It runs between both the Mm. ptery-
orbitale (trigeminal pressure point V/2, › Fig. 12.49, left side). goidei to caudal. At the Foramen mandibulae it enters the
• The Rr. nasales posteriores superiores laterales and mediales bony Canalis alveolaris inferior of the mandibula and with the
pass through the sphenopalatine foramen medially into the na- fine branches of the Plexus dentalis inferior, it supplies the
sal cavity, to the mucosa of the lateral nasal wall, the nasophar- teeth of the lower jaw with the adjacent gingiva. At the Fora-
ynx and the Tuba auditiva. A branch descending to the septum, men mentale, the N. alveolaris inferior passes as the N. men­
the N. nasopalatinus, finally reaches the oral cavity via the Ca- talis to the surface anatomy (trigeminal pressure point V/3,
nalis incisivus or the mucous membranes via the Os incisivum › Fig. 12.49, left-hand half of the image) and here supplies
of the hard palate and a small section of the nasal septum. These the skin of the chin and the lower lip. Shortly before entering
branches are collectively referred to as Rr. ganglionares ad gan­ the Foramen mandibulae, the N. mylohyoideus branches off
glion pterygopalatinum. for special visceroefferent innervation of the identically
• The N. palatinus major and the Nn. palatini minores leave cau- named muscle and of the Venter anterior musculi digastrici.
dally in identically named canal in the Fossa pterygopalatina and – N. lingualis: It runs medially of the N. alveolaris inferior and
reach the corresponding Foramina palatina major and minores almost parallel to it caudally, although it does not enter the
to the mucosa of the hard and soft palates. Foramen mandibulae, but instead reaches the root of the
tongue. With generally somatoafferent fibres, it innervates the
N. mandibularis anterior two-thirds of the tongue mucosa and the Glandula
The N. mandibularis [V/3], in contrast to the other two branches of sublingualis. Already in its cranial section, the N. lingualis ac-
the N. trigeminus, is a mixed nerve. It forms the strongest outgoing cumulates preganglionic general visceroefferent fibres and
part of the Ganglion trigeminale, which joins the Radix motoria be- special visceroafferent taste fibres from the Chorda tympani of
fore they pass through the Foramen ovale of the middle cranial fos- the N. facialis [VII]. Further along the Ganglion submandibu-
sa in the Fossa infratemporalis. In summary, the N. mandibularis is lare pathway, the general visceroefferent fibres are relayed and
responsible for the general somatoafferent innervation of the entire control the hypersecretion of the Glandulae sublingualis and
mandibular area. It supplies sensory innervation to the chin and an- submandibular. The taste fibres of the Chorda tympani come
terior ear area (› Fig. 12.49), the adjacent lower jaw area with the from taste buds at the back and tip of the tongue, accumulat-
bottom teeth, as well as the mucosa of the cheek and of the dorsum ing on the lingual nerve and ultimately pass via the Fissura
of the tongue (anterior two-thirds) as well as the meninges of the petrosquamosa to the N. facialis [VII].
middle cranial fossa. The special visceroefferent fibres innervate the
muscles leading from the 1st pharyngeal arch myotome. These in- Cranial nerve nuclei of the N. trigeminus
clude the masticatory muscles, but also parts of the mouth floor The N. trigeminus itself only carries 2 fibre qualities, with general
muscles and the ‘tensors’ at the Tuba auditiva and the tympanic visceroefferent fibres accumulating on it only peripherally. This
membrane (M. tensor veli palatini and M. tensor tympani). Only makes it possible to differentiate special visceroefferent fibres with
after leaving the cranial cavity, the N. mandibularis [V/3] releases a a corresponding cranial nerve nucleus and general somatoafferent
• descending R. meningeus which, together with the A. meningea fibres with an associated nucleus complex. The latter forms the ros-
media, gets to the interior of the skull of the dura via the Fora- tral processing of neurons of the spinal dorsal horn, resulting in
men spinosum. Directly below the Foramen ovale, the Ganglion similarities between the spinoafferent system and the trigemi-
­oticum accumulates medially on the N. mandibularis (› Fig. noafferent system. In both systems, depending on the sensory mo-
12.47, turquoise nerve fibres), before it divides into anterior and dality, there are different neural pathways for relays: here, the epi-
posterior parts. critical, proprioceptive and protopathic (management of mechano-

692
 12.5 Cranial nerves

receptors, thermal receptors and nociceptors) stimuli management Nuclei of the general somatoafferent fibres
of the skin and mucous membranes can be separately observed. Nucleus mesencephalicus nervi trigemini
Unlike the usual cranial nerve nuclei, this trigeminal complex can The proprioceptive afferent fibres from the muscle spindles of the
therefore be differentiated into 3 subnuclei, according to the de- masticatory muscles accumulate onto this Radix motoria. In the
scription of their sensory modality (› Fig. 12.50). brainstem, these form the Tractus mesencephalicus nervi trigemini
and pass to the Nucleus mesencephalicus nervi trigemini within the
Nucleus of the special visceroefferent fibres mesencephalon. The perikarya of these proprioceptive primary affer-
The Nucleus motorius nervi trigemini lies in the Pars dorsalis ents do not lie within the Ganglion trigeminale, but directly within
pontis and reaches the lateral area of the periaqueductal zone, as the Nucleus mesencephalicus. Thus the Nucleus mesencephalicus
well as the lateral angle of the IVth ventricle. It contains the peri- nervi trigemini is also referred to as a single central ganglion.
karya of special visceroefferent fibres, which go to the muscles of
mastication as the Radix motoria with the N. mandibularis.

Target organs Reorganisation Cranial nerve Nuclear areas

Ganglion
N. glossopharyngeus [IX]
oticum N. petrosus minor

Muscles of mastication Ganglion

submandibulare

The floor of the mouth: N. facialis [VII]

– M. mylohyoideus
– Venter anterior digastrici N. mandibularis [V/3]
Chorda tympani

Nucleus motorius
M. tensor veli palatini
nervi trigemini
M. tensor tympani

Foramen
The proprioception of the ovale
muscles of mastication

The mechanoreceptors
of the skin of the mandible,
oral cavity, etc. N. trigeminus [V],
Radix motoria
The thermal/nociception
Ganglion trigeminale N. trigeminus [V],
of the skin of the mandible,
Radix sensoria
oral cavity, etc. Nucleus mesencephalicus
trigeminal nerve (proprioceptive)
Foramen
The mechanoreceptors
rotundum
of the skin of the upper jaw Fissura Nucleus principalis
region, nose/maxillary orbitalis trigeminal nerve (epicritical)
sinus, palate, etc. N. maxillaris [V/2] superior

The thermal/nociception of Nucleus spinalis

the skin of the upper jaw trigeminal nerve (protopathic)
(maxillary) region, nose/
Ganglion
maxillary sinus, palate, etc. N. facialis [VII]
pterygopalatinum N.
petrosus
The mechanoreceptors of R. communicans major
the forehead skin, cum n. zygomatico
ethmoid-/sphenoid cavity,
sinus, bulbus, etc.
N. ophthalmicus [V/1]
The thermal/nociception of
the forehead skin,
Ganglion N. oculomotorius [III]
ethmoid-/sphenoid cavity,
ciliare
sinus, bulbus, etc.

Fig. 12.50 N. trigeminus with fibre qualities, cranial nerves nuclei and target organs (diagram). [L127]

693
12 Special neuroanatomy

Nucleus principalis [pontinus] nervi trigemini interna. One-sided lesions of these fibres, such as in the context of
The perikarya of the other primary afferents lie within the Ganglion a stroke, often remain asymptomatic due to the bilateral innerva-
trigeminale. Impulses of the fine discrimination of mechanorecep- tion of the nucleus, whereas direct damage to the nucleus complex
tors are carried via the central axon from here to the 2nd neuron in leads to ipsilateral muscle atrophy.
the Nucleus principalis [pontinus] nervi trigemini in the cranial
pons, approximately at the level of the exit point of the N. trigeminus. Nucleus principalis [pontinus] nervi trigemini
The body is consciously aware of impulses of fine point discrimina-
Nucleus spinalis nervi trigemini tion, vibration and the perception of the chewing pressure on the
Poorly discriminating mechanoreceptors are also projected via the periodontium, by being transferred from the 2nd neuron in the
Ganglion trigeminale, as well as again to a 2nd neuron in the Nucle­ Nucleus principalis nervi trigemini into the somatosensory cortex
us spinalis nervi trigemini. The fibres of the trigeminal thermore- via the thalamus. These efferent axons of the main nucleus mostly
ceptors and nociceptors end in the Pars caudalis of the Nucleus spi- cross onto the opposite side and form the Tractus trigeminotha­
nalis nervi trigemini. The entire Medulla oblongata penetrates rela- lamicus anterior, which joins the Lemniscus medialis and, in the
tively far laterally of the elongated Nucleus spinalis nervi trigemini thalamus, reaches the 3rd neuron in the Nucleus ventralis pos­
and continues caudally to the horn of the spinal cord (C6). Thus it is teromedialis (conversely spinoafferent fibres reach the Nucleus
somotopically divided in a ventrodorsal direction, with the afferent ventralis posterolateralis in the thalamus). Via the Tractus trigem­
fibres or neurons of the N. mandibularis [V/3] furthest dorsally, the inothalamicus posterior, uncrossed fibres reach the ipsilateral
afferent fibres or neurons of the N. ophthalmicus [V/1] furthest ven- thalamus, before being transferred to the cortex. Additionally, this
trally, with an intervening section for the N. maxillaris [V/2]. The posterior tract conducts touch and pressure sensations from the
somatotopy of this cranial nerve nucleus in a rostrocaudal direction oral cavity, including the teeth.
is clinically even more important: afferents from the perioral zone
are furthermost rostrally within the nucleus while the afferents end Nucleus spinalis nervi trigemini
further caudally in the nucleus, increasingly far from the cleft lip. The configuration of impulses of pain and temperature sensations
This somatotopy of the trigeminal fibres corresponds to concentric in the head area (protopathic sensibility) is organised in the same
boundary lines, SÖLDER’s lines, the central sensory innervation ar- way as in the spinothalamic system of the spinal cord. Rather than
eas of the facial skin (› Fig. 12.49, right half of the illustration). being in the spinal ganglion, here the perikaryon of the 1st neuron
is found within the Ganglion trigeminale and carries the impulses
of the 2nd neuron in the Nucleus spinalis nervi trigemini. The cen-
Clinical remarks tral efferents of this nucleus cross over to the opposite side and then
In the case of a nuclear central lesion of the N. trigeminus, we run together with the efferents of the Nucleus principalis nervi tri-
therefore note a somatosensory disorder similar to an onion gemini in the Tractus trigeminothalamicus anterior to the Nucle­
skin, whereas typically in a peripheral lesion of the trigeminal us ventralis posteromedialis of the thalamus (3rd neuron), but also
nerve, the supply areas of the N. ophthalmicus [V/1], of the N. to the intralaminar thalamic nuclei. The impulses of this sensory
maxillaris [V/2] and N. mandibularis nerve [V/3] are affected
modality are also stimulated via thalamocortical projections.
in an isolated or combined manner.
Other neuronal links of the Nucleus spinalis nervi trigemini can be
found at the Formatio reticularis. Functionally, a general increase
in activity in the central nervous system results from this configu-
Central links of the N. trigeminus ration. This is well-illustrated, for example through the irritation of
The central neuronal configurations of the cranial nerve nuclei of the nasal trigeminal fibres with smelling salts (ammonia), which in
the trigeminal nerve include, on the one hand, the regulation of the 18th century was used as a standard treatment for dizziness
masticatory function, e.g., chewing pressure, the control of reflexes, and fainting. Strong trigeminal ganglion stimulation by odours in
as well as voluntary perception of sensations of skin and mucous the nasal cavity [V/2], ‘sharp’ flavouring agents in the oral cavity
membranes in the head area. [V/3] or eyes [V/1], e.g., when slicing onions, often leads to a re-
flex-related increase in saliva production or lacrimation, so we as-
Nucleus mesencephalicus nervi trigemini sume that there are neuronal links to the general visceroefferent
For these control mechanisms, the neurons of the Nucleus mesen- nuclear areas (Nucleus salivatorii superior and inferior).
cephalicus form direct synapses with the neurons of the Nucleus
motorius nervi trigemini. Proprioceptive impulses from the mus- NOTE
cles of mastication are projected through these directly onto moto- In the case of lesions of the brainstem, e.g., in a brainstem stroke,
neurons. This kind of monosynaptic configuration in the motoric there are frequently combined lesions of the nucleus and Tractus
system is ultimately comparable to a proprioceptive muscle reflex spinalis nervi trigemini and the Tractus spinothalamicus, as both
(› Chap. 12.6.7) such as the patellar tendon reflex. Accordingly, are located in close proximity to each other in the lateral brain-
stem. Usually temperature and pain perceptions of the ipsilateral
this is referred to as a masseter muscle reflex. side of the face cease and at the same time, the temperature and
pain sensations are disrupted on the contralateral side of the body,
Nucleus motorius nervi trigemini as these spinal fibres already cross at the segmental level.
The Nucleus motorius nervi trigemini also receives afferent im-
pulses from the face and oral cavity, which arrive secondarily via
neurons of the sensory trigeminal nuclei and interneurons of the Clinical remarks
Formatio reticularis. Via the Formatio reticularis, the limbic sys-
An examination of the N. trigeminus is always carried out
tem has an influence on the activity of the Nucleus motorius. But
comparing both sides, and should provide clues that make it
the nucleus receives the most important afferents for arbitrary mo- possible to distinguish between a peripheral nerve lesion and
tor control via the Fibrae corticonucleares, which reach the nucleus a nuclear central lesion. To do this, the following are checked:
complex bilaterally, going from the motoric cortex via the Capsula

694
 12.5 Cranial nerves

• pain perceptions at the exit points of the 3 peripheral

branches of the trigeminal nerve using bilateral pressure of
the thumb (pressure sensitivity at what are normally
non-painful exit points is a sign of nerve irritation)
• sensitivity in the innervation area of the 3 branches of the
trigeminal nerve and according to the nuclear boundary
lines with a cotton swab
• the functional capability of the mastication muscles by pal-
pation and assessment of the M. masseter and the M. tem-
poralis in a closed jaw position (with a lesion of the Mm.
pterygoidei, the lower jaw typically deviates to the affected
side when opening)
• the corneal reflex by delicately touching the cornea with a
cotton bud
• the masseter reflex by hitting the M. masseter with a reflex
hammer

12.5.9 N. abducens (6th cranial nerve, N. VI)

Michael J. Schmeißer

SKILLS
After working through this chapter, you should be able to: Fig. 12.51 Exit point of the N. abducens. The VIth cranial nerve exits
• name the target organ and cranial nerve nuclei of the N. abducens below the pons; ventral view.
• precisely explain the topographical pathway of the N. abducens
• describe the clinical findings of abducens paralysis and identify
possible causes • Of all the cranial nerves, it has the longest intracranial, extradu-
ral course.
The N. abducens [VI] carries general somatoefferent fibres and is • As the only cranial nerve, it passes right through the Sinus cav-
responsible for the motor innervation of the M. rectus lateralis, ernosus.
which can abduce the Bulbus oculi (› Fig. 12.52).
Cranial nerve nuclei and central links
Pathway and branches Due to its fibre composition, the N. abducens has a general soma-
The N. abducens passes directly below the pons near the midline toefferent cranial nerve nucleus, the Nucleus nervi abducentis.
from the brainstem (› Fig. 12.51). It then runs forwards through This is located in the Pars dorsalis pontis under the floor of the
the Cisterna pontis, arrives at the clivus under the dura, crosses rhomboid cavity. Fibres of the N. facialis [VII] curving dorsally
over the tip of the temporal bone on its further extradural course, round the Nucleus nervi abducentis, easily seen in horizontal
and enters the Sinus cavernosus, where it does not run around its cross-sectional images, is topographically important. This is called
edge as the only cranial nerve, but instead passes through it. the ‘inner genu of the facial nerve’ (see below).
(› Fig. 12.46). In the orbita, it travels mediocaudally through the The configurations of the ‘eye muscle nuclei’ with each other, and
Fissura orbitalis superior between the superior branch of the N. their connection with supranuclear, pre-ocular motor centres, are
­oculomotorius and the N. nasociliaris of the N. ophthalmicus. extremely complex (› Chap. 13.3). Particularly significant for
­Finally, it passes through the Anulus tendineus communis to the conjugated horizontal eye movements is the Fasciculus longitudi­
M. rectus lateralis (› Fig. 12.52). nus medialis (FLM) which connects the Nucleus nervi abducentis
Two aspects should be emphasised in the topographical anatomy nerve with a contralateral subnucleus of the Nucleus nervi oculo-
of the N. abducens: motorii (› Chap. 12.5.6).

Target organs Cranial nerve Nuclear areas

Fissura orbitalis superior

M. rectus lateralis N. abducens [VI] Nucleus nervi

abducentis

Fig. 12.52 Pathway, branches and fibre qualities of the N. abducens, left. Lateral view. [L127]

695
12 Special neuroanatomy

Clinical remarks
Examination
As with the examination of the other ‘eye muscle nerves’, we
firstly observe the position of the bulbi when examining the
N. abducens, then carry out a clinical examination of the eye
tracking movements as described for the N. oculomotorius
and ask about double vision.

Abducens nerve palsy

In the case of an abducens nerve palsy, the eye on the affect-
ed side can no longer be abducted due to the failure of the
M. rectus lateralis and is directed medially inwards. This results
in double vision, which increases especially when looking
sideways. The N. abducens is particularly at risk from fractures
of the skull on its long intracranial, extradural pathway along
the clivus. In addition, a thrombosis of the Sinus cavernosus
can lead to abducens nerve palsy (usually combined with
­other eye muscle paralysis).

12.5.10 N. facialis (7th cranial nerve, N. VII)

Michael J. Schmeißer
Fig. 12.53 Exit point of the N. facialis. The VIIth cranial nerve exits in
the cerebellopontine angle. Ventral view.
SKILLS
After working through this chapter, you should be able to: One of the main jobs of the N. facialis [VII] is the motor innerva-
• name the target organs of the N. facialis
tion of the mimic muscles. It also explains the name ‘facial nerve’.
• describe the cranial nerve nuclei of the N. facialis, explain their
topographical position and correctly explain their respective
Both the facial nerve and the mimic muscles arise from the 2nd
functions pharyngeal arch, so the corresponding motor nerve fibres are spe-
• describe the clinical findings of facial paralysis, distinguish be- cially visceroefferent. As well as this, the fibres of the N. facialis
tween peripheral and central facial paralysis and explain possible contain other qualities that can be summarised as the so-called
causes nervus-intermedius part of the N. facialis:

Ganglion geniculi N. facialis [VII]

M. stapedius, Tendo Proc.

pyramidalis
Stapes
M. tensor tympani, Tendo
M. stapedius
Incus
N. petrosus minor
N. stapedius
Malleus
N. petrosus major
Fig. 12.54 Course of the N.
M. tensor tympani
facialis in the temporal bone.
Semicanalis musculi N. facialis Vertical section through the
tensoris tympani [VII] Canalis facialis, view from the
Tuba auditiva left side. Approximately 1 cm
[auditoria], Chorda after joining the petrous bone
Pars ossea tympani via the Porus acusticus internus,
A. carotis interna
the N. facialis [VII], together with
Proc. the Ganglion geniculi, forms the
Tuba auditiva [auditoria],
A. carotis mastoideus exterior facial genu. The main
Pars cartilaginea stem of the nerve then runs
interna
Fissura sphenopetrosa Foramen within the bony Canalis facialis
Membrana
stylomastoideum towards the Foramen stylomas-
tympanica
Chorda tympani toideum. On the way through
R. stylohyoideus N. auricularis posterior the Os temporale, it releases the
following branches: N. petrous
R. digastricus
M. stylohyoideus major, N. stapedius, Chorda
tympani. At the Foramen stylo-
mastoideum, branches of the
M. digastricus, Venter posterior N. auricularis posterior and the
Rr. digastricus and stylohyoideus
branch off.

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 12.5 Cranial nerves

• general visceroefferent fibres for the parasympathetic innerva- through the Hiatus canalis nervi petrosi majoris to the front sur-
tion of the lacrimal gland and salivary glands (up to the Glandu- face of the temporal bone and arrives in its own groove, covered
la parotidea) by Dura mater, through the Foramen lacerum into the Canalis
• special visceroafferent taste fibres of the anterior two-thirds of pterygoideus of the Os sphenoidale. Here it combines with the
the tongue sympathetic N. petrosus profundus. Both nerves pass together
• general somatoafferent fibres from the outer ear (› Fig. 12.56). into the Fossa pterygopalatina as the N. canalis pterygoidei. In
the Ganglion pterygopalatinum, the general visceroefferent fi-
Pathway and branches bres of the N. petrosus major are relayed from preganglionic to
Intermedius and actual facial parts of the N. facialis leave the brain- postganglionic. The postganglionic, secretory fibres partially
stem rostral of the olive in what is called the cerebellopontine angle accumulate in the continued course of the N. zygomaticus of the
(› Fig. 12.53). They pass via the Porus or Meatus acusticus internus N. maxillaris [V/2] and pass with it into the orbita and via the
with the N. vestibulocochlearis [VIII] into the petrous pyramid and N. lacrimalis of the N. ophthalmicus [V/1] to the Glandula lacri-
then run as a common nerve root inside a bony canal, the so-called malis, or they run as Nn. palatini and Nn. nasales posteriores to
Canalis nervi facialis. About 1 cm after entering this canal, the the upper palate or rear nasal glands.
nerve root in the geniculate ganglion (Ganglion geniculi) turns to- • N. stapedius: This is a special visceroefferent branch, which pro-
wards dorsolateral and runs arch-shaped in the rear wall of the tym- vides the motor innervation for the M. stapedius of the middle ear.
panic cavity caudally to the Foramen stylomastoideum, through • Chorda tympani or tympanic string: This facial branch predom-
which it leaves the cranial base. Finally, it divides into its terminal inantly contains general visceroefferent and special visceroaffer-
branches within the Glandula parotidea which is however neither ent taste-related fibres. The Chorda tympani passes retroactively
efferently nor afferently innervated by it. As it runs through the Ca- back from the Canalis nervi facialis through its own bony canal
nalis nervi facialis, the N. facialis provides the following branches to the middle ear. Here it runs medially of the tympanic mem-
from proximal to distal (› Fig. 12.54): brane between the hammer and the anvil. Finally it runs via the
• N. petrosus major: This general visceroefferent branch leaves Fissura sphenopetrosa or the Fissura petrotympanica (various
the trunk of the N. facialis at the Ganglion geniculi, passes information in the literature) in the Fossa infratemporalis and

N. petrosus profundus (Plexus caroticus internus) Ganglion geniculi

N. petrosus major M. stapedius

N. canalis pterygoidei Meatus acusticus internus

Ganglion pterygopalatinum N. stapedius

M. occipitofrontalis, Venter frontalis
N. intermedius
M. orbicularis oculi

M. corrugator supercilii N. facialis [VII]

M. zygomaticus major 1 M. occipitofrontalis,

1
Venter occipitalis
M. zygomaticus minor 1
1
M. procerus Chorda tympani
1
M. levator labii superioris N. facialis [VII]
alaeque nasi
2
M. levator labii superioris N. auricularis posterior,
2 R. occipitalis
M. nasalis
2 2
N. auricularis posterior, R. auricularis
M. depressor septi nasi

M. levator anguli oris Foramen stylomastoideum

3
M. orbicularis oris 3
3 N. auricularis posterior
M. depressor anguli oris
N. glossopharyngeus [IX]
M. depressor labii inferioris
4 5
4 4
M. mentalis M. digastricus, Venter posterior
5
M. buccinator 5

Glandula sublingualis M. stylohyoideus

Platysma Terminal motor branches:
Mm. auriculares 1 Rr. temporales
2 Rr. zygomatici
Glandula submandibularis Chorda tympani 3 Rr. buccales
4 Rr. marginales mandibulae
Ganglion submandibulare N. lingualis (V/3) 5 Rr. colli

Fig. 12.55 N. facialis. Overview of the pathway of the N. facialis after leaving the cerebellopontine angle up to where it branches off into the
Glandula parotidea (diagram).

697
12 Special neuroanatomy

accumulates dorsally on the N. lingualis [V/3] so that its fibres • The special visceroefferent fibres supplying the facial muscles
pass to the Ganglion submandibulare or to the anterior two- and the Mm. stapedius, digastricus and stylohyoideus originate
thirds of the tongue. In the Ganglion submandibulare, the gen- in the Nucleus nervi facialis. This nuclear motor complex, which
eral visceroefferent fibres are relayed from preganglionic to has an upper and a lower cell group, is located in the caudal part
postganglionic. The latter ensures the secretory supply of the of the Pars dorsalis pontis. Its efferent fibres run initially dorsally
Glandulae sublingualis and submandibularis. and, from caudal, loop dorsally around the abducens nucleus
At the Foramen stylomastoideum, the N. auricularis posterior, ventrolaterally, thereby forming the so-called inner facial genu
the R. digastricus and the R. stylohyoideus branch off from the N. (Genu nervi facialis). The facial genu forms a swelling, the Col-
facialis. Via its special visceroefferent fibres, the N. auricularis pos- liculis nervi facialis, which can be observed in a dorsal view of
terior supplies the M. occipitofrontalis (R. occipitalis), and via its the brainstem or the rhomboid fossa.
general somatoafferent fibres (R. auricularis) supplies the skin • The original neurons of the general visceroefferent fibres are lo-
above the outer ear. The Rr. digastricus and stylohyoideus inner- cated in the parasympathetic Nucleus salivatorius superior,
vate the Venter posterior of the M. digastricus and stylohyoideus which lies in the immediate vicinity of the Nucleus nervi facialis
by special visceroefferent means (› Fig. 12.55). in the pons.
After the N. facialis [VII] leaves the Canalis nervi facialis through • The special visceroafferent taste fibres of the N. facialis end in
the Foramen stylomastoideum, it forms a network of special viscero- the upper section of the Solitarius nucleus complex, also referred
efferent fibres, the (Plexus intraparotideus) within the Glandula to as the Nucleus ovalis of the Nuclei tractus solitarii, and
­parotidea in the Fossa retromandibularis. From this, 2 main nerve which is located in the Medulla oblongata.
trunks are formed, of which the one lying furthest cranially (R. tem- • In the Nucleus spinalis nervi trigemini, a few general soma-
porofacialis, clinically: ‘frontal branch’) innervates the muscles of the toafferent fibres from the skin of the outer ear terminate.
forehead and the eyelids together with the Rr. temporales, and the The special visceroefferent Nucleus nervi facialis receives direct
one lying further caudally (R. cervicofacialis) innervates the muscles and indirect afferents from key areas of the motor system, includ-
of the cheeks, lips and chin with the Rr. zygomatici and buccales, ing from the motor cortex, from the motor brainstem centres and
via the R. marginalis mandibulae and the R. colli (› Fig. 12.55). from the spinal cord. Voluntary facial expression is controlled, for
These branches all arise in a fan shape from the front edge of the pa- example, by direct projections that originate from the motor cortex
rotid gland and pass subcutaneously to the mimic (facial) muscles. and run via the Tractus corticonuclearis into the Nucleus nervi fa-
cialis. Emotional facial expression, on the other hand, appears to
Cranial nerve nuclei and central links be controlled by indirect projections into the Nucleus nervi facialis
Corresponding with its 4 fibre qualities, the N. facialis has 4 cranial from the limbic system. The lateral zone of the Formatio reticularis
nerve nuclei (› Fig. 12.56): in the brainstem acts as an intermediate switching station.

Target organs Reorganisation Cranial nerve Nuclear areas

Glandula lacrimalis Nucleus

Ganglion
Glandulae nasales salivatorius superior
pterygopalatinum
and palatinae

Glandula Ganglion
submandibularis, submandibulare
Glandula sublingualis

M. stapedius N. facialis [VII] Nucleus nervi facialis

M. digastricus, N. intermedius
Venter posterior, Nucleus spinalis
M. stylohoideus Porus acusticus nervi trigemini
internus
Mimetic muscles

Skin of the auricle Nucleus tractus

solitarii, Pars superior
Taste (front two-thirds (Nucleus ovalis)
of the tongue)

Fig. 12.56 Pathway, branches and fibre qualities of the N. facialis, left. Lateral view. [L127]

698
 12.5 Cranial nerves

In addition, the Nucleus nervi facialis includes afferent input from • dry eyes due to a reduction of lacrimation (damage before
acoustic relay nuclei, e.g., from the upper olivary nucleus com- the exit of the N. petrosus major)
plex. Where there is a lot of noise, this acts to contract the M. sta- • increased sensitivity to acoustic stimuli (damage before the
pedius which is innervated by the N. stapedius and stabilises the exit of the N. stapedius)
• taste and saliva secretion disorders (damage before the exit
movement of the stapes, thus attenuating the transmission of
of the Chorda tympani).
sound to the inner ear.
There is another important link between the Nucleus ovalis of the Facial paralysis/palsy
Solitarius nucleus complex, the Formatio reticularis and the Nuclei A basic distinction is made between peripheral and central
nervi facialis, motorius nervi trigemini and salivatorii. This is highly facial palsy. The main clinical symptom in both forms is the
important in the making of food choices (gustatory signal transduc­ drooping paralysis of the facial muscles, whereby the contra-
tion via the Chorda tympani of the N. facialis) and food intake (e.g., lateral side is affected by a central, supranuclear paralysis and
the induction of saliva secretion via the Chorda tympani of the N. fa- the eye and forehead muscles are spared (see above). This is
due to the fact that the upper nuclear group of the respective
cialis).
Nucleus nervi facialis, which control the eye and forehead
muscles via the ‘frontal branch’, are innervated by corticonu-
Clinical remarks clear fibres on both sides of the brain. Therefore, in the event
of damage to the contralateral side, central innervation is en-
Examination sured by the fibres of the ipsilateral side (› Fig. 12.57).
It is extremely important clinically to be able to differentiate
By examining and comparing the two sides of the face, facial
between central and peripheral facial paralysis, because in
symmetry can be checked, as well as the function of the special
contrast to peripheral paresis, central paralysis is almost al-
visceroefferent branches of the mimic muscles. A drooping
ways due to a stroke (ischemia or bleeding in the area of the
­corner of the mouth gives the first indication about which side
Capsula interna) affecting the supranuclear fibres. Diagnostic
is affected. Now the patient is asked to close their eyes and fur-
and therapeutic measures must be rapidly initiated to limit
row their forehead (checking the function of the cranially locat-
the extent of brain damage. Conversely, peripheral facial palsy
ed R. temporofacialis of the Plexus intraparotideus with the
occurs for example due to traumatic brain trauma with frac-
Rr. temporales – clinically known as the ‘frontal branch’), inflate
tures of the petrous bone or infections in the middle and inner
the cheeks, purse the lips to whistle, and show their teeth
ear and the temporal bone. Often, however, no clear cause
(checking the function of the caudally located R. cervicofacialis
can be determined. In this case it is referred to as idiopathic
of the Plexus intraparotideus with Rr. zygomatici, buccales,
nerve paralysis.
marginalis mandibulae and colli). Special care must be taken
here to observe whether the patient can still furrow their fore-
head on both sides and if both eyes are able to close or not:
• If there is central facial paralysis, the frown often remains
intact on both sides, in contrast to the rest of the facial mus-
cles on the affected side. 12.5.11 N. vestibulocochlearis
• On the other hand, if there is peripheral facial paralysis, all (8th cranial nerve, N. VIII)
of the mimic muscles on the affected side are paralysed. Michael J. Schmeißer
When trying to furrow the forehead, it remains smooth, and
when trying to close the eyes, the physiological upwards ro-
tation of the Bulbus is visible (BELL’s palsy) due to the in- SKILLS
complete closure of the lids (lagophthalmus). After working through this chapter, you should be able to:
Where a central facial palsy is clinically excluded, characteris- • give an accurate outline of the fibre qualities of the N. vestibulo-
tic associated symptoms can suggest the location of the dam- cochlearis
age in the peripheral pathway of the N. facialis. These include: • describe the clinical symptoms which can arise in acoustic neuroma

Rr. temporales

Gyrus precentralis
Nucleus nervi facialis

Ganglion geniculi

Fibrae corticonucleares N. stapedius

N. auricularis posterior
Central (supranuclear) N. facialis [VII]
lesion (failure of the
1st motor neuron) Rr. zygomatici

Rr. buccales
Nucleus nervi facialis
Peripheral (infranuclear) R. colli
lesion (failure of the
N. facialis [VII] 2nd motor neuron) Rr. marginales mandibulae

Fig. 12.57 Corticonuclear compounds and peripheral course of the N. facialis. On the left, the central connections to the Nucleus nervi facialis
are presented in simplified form. The corticonuclear tracts to the upper part of the nucleus derive from both hemispheres (green). The lower
part is only reached by the contralateral hemisphere (red). On the right, the fibres leaving from the top and bottom nuclear section are presented
correspondingly up to the peripheral. On the left is an example of possible locations for damage in the context of central (supranuclear) and
peripheral (infranuclear) facial palsy.

699
12 Special neuroanatomy

within the Meatus acusticus internus, they pass over to the

N. cochlearis, with which they reach the hair cells (› Fig. 12.59).

Pathway and branches

The N. vestibulocochlearis arises somewhat caudolaterally of the
N. facialis nerve [VII] from the brainstem rostral of the olive in the
so-called cerebellopontine angle (› Fig. 12.58) and runs together
with the N. facialis after branching off into the N. vestibularis and
N. cochlearis through the Porus and Meatus acusticus internus of
the temporal bone (› Fig. 12.59).

Cranial nerve nuclei and central links

Six nuclei are assigned to the N. vestibulocochlearis:
• Two cochlear nuclei lie within the pons (Nuclei cochleares pos-
terior and anterior, › Chap. 13.4). Their most important central
efferents run in the Lemniscus lateralis – the part of the audito-
ry system that connects the cochlear nuclei with the Colliculi in-
feriores of the mesencephalon.
• Four vestibular nuclei lie in the pons and in the Medulla oblon-
gata (Nuclei vestibularis superior [BECHTEREW], vestibularis
inferior [ROLLER], vestibularis lateralis [DEITER's nucleus]
and vestibularis medialis [SCHWALBE], › Chap. 13.5). Cen-
trally, they have a much more complex configuration than the
Fig. 12.58 Exit point of the N. vestibulocochlearis. The VIIIth cranial
cochlear nuclei. They receive primary afferents from the vestibu-
nerve exits in the cerebellopontine angle. Ventral view.
lar organ, the spinal cord and the cerebellum and project efferent
via the thalamus to the cortex, to the pre-oculomotoric centres
The N. vestibulocochlearis [VIII] (syn.: N. statoacusticus) consists and the eye muscle nuclei, and back to the cerebellum and into
of both the N. vestibularis (vestibular or ‘balance’ nerve) and the the spinal cord. Ultimately, these numerous fibre connections
N. cochlearis (cochlear or ‘auditory’ nerve) and includes both special are used to keep the body balanced and able to follow objects
somatoafferent and efferent fibres. The special somatoafferent fibres: with the eyes, even when the body position changes.
• of the N. vestibularis are central afferent projections of the 1st
neuron of the balance system (bipolar, perikaryon in the Gangli-
on vestibulare in the Meatus acusticus internus, › Chap. 13.5)
Clinical remarks
• of the N. cochlearis are central afferent projections of the 1st Examination
neuron of the auditory system (bipolar, perikaryon in the Gan- Hearing can be checked by a one-sided or two-sided simulta-
glion spirale in the cochlea, › Chap. 13.4). neous snap at ear level. In order to make the findings more
A characteristic is the efferent fibers of the N. vestibulocochlearis. objective, it is possible to differentiate between a conductive
These efferent axonal projections of neurons from the upper oli- and a sensorineural hearing disorder with a tuning fork. Where
vary complex are responsible for the efferent innervation of the there is damage to the cochlear part, it is probably a sensori-
neural hearing disorder.
hair cells of the inner ear. They are known as the olivocochlear
bundle. Initially, the fibres run in the N. vestibularis and then,

Sensors Cranial nerve Nuclear areas

Porus
acusticus
internus
N. vestibulo-
Hair cells of Utriculus cochlearis [VIII]
and Sacculus and hair Ganglion vestibulare
cells of the three semi- N. vestibularis Nuclei vestibulares
circular canals
N. cochlearis Nuclei cochleares
The inner hair cells Ganglion spirale
of the CORTI organ cochleae

Outer and inner Nucleus olivaris

hair cells of the superior
CORTI organ

Fig. 12.59 Pathway, branches and fibre qualities of the N. vestibulocochlearis. [L127]

700
 12.5 Cranial nerves

The vestibular part is tested using a balance test (e g. ROM-

BERG’s test, › Chap. 12.4.6 ) and detailed analysis of
eye-tracking movements. Where there is a lesion or failure of
the vestibular part, falling and nystagmus can occur.

Acoustic neuroma
An acoustic neuroma is a benign tumour which grows out of
the SCHWANN cells of the nerve sheath of the N. vestibulo
­cochlearis and grows slowly but progressively. Due to the result-
ing compression of the nerve, gradual hearing loss, dizziness,
nausea, a tendency to fall to the affected side and pathologi-
cal nystagmus occur. Often the compression not only affects
the N. vestibulocochlearis, but also the N. facialis running in
the immediate topographical vicinity, so that in addition, a
peripheral facial palsy may occur.

12.5.12 N. glossopharyngeus
(9th cranial nerve, N. IX)
Anja Böckers

SKILLS
After working through this chapter, you should be able to: Fig. 12.60 Exit point of the N. glossopharyngeus. The IXth cranial
• name the target organs of the N. glossopharyngeus nerve exits in the Sulcus retroolivaris between the olive and the ­lower
• list the cranial nerve nuclei of the N. glossopharyngeus and cor- cerebellar stem in the Medulla oblongata.
rectly explain their function
• recognise a one-sided paralysis of the N. glossopharyngeus with
a simultaneous examination of the mouth and phonation general visceroafferent fibres. It passes into the middle ear via
the Canalis tympanicus to form the Plexus tympanicus on the
The name of the IXth cranial nerve already identifies its target or- promontorium, together with the sympathetic fibres, the Nn.
gans: the N. glossopharyngeus [IX] is a branchiogenic cranial caroticotympanici:
nerve of the 3rd pharyngeal arch, particularly responsible for the – From here, the R. tubarius reaches the Tuba auditiva to pro-
innervation of the rear third of the tongue (‘glosso’) and the contig- vide its sensory innervation.
uous area of the pharynx (‘pharyngeus’), including the soft palate. – The N. petrosus minor leaves the Cavitas tympani again by
It undertakes critical functions in the coordination of the swallow- penetrating the Tegmen tympani through the Hiatus or Ca­
ing process, especially in the prerequisite separation of the wind- nalis nervi petrosi minoris and returning to the internal sur-
pipe and the digestive tract at the soft palate, in language forma- face of the cranial base. It proceeds on the front side of the
tion, in the perception of bitter tastes on the dorsal third of the Pars petrosa, the petrous bone of the Os temporale, to the Fo­
tongue, and in the regulation of breathing and circulation. ramen lacerum, in order to get into the Fossa infratemporalis
by this route. The relay onto postganglionic general visceroef-
Pathway and branches ferent fibres takes place in the Ganglion oticum, lying directly
The nerve leaves the brainstem together with the N. vagus [X] and on the Foramen ovale, medial of the N. mandibularis [V/3].
the N. accessorius [XI] in the Sulcus retroolivaris between the olive This connection between the N. tympanicus and the Ganglion
and the lower cerebellar stem (› Fig. 12.60). Together with these oticum is also known as the JACOBSON’s anastomosis. Ulti-
nerves, it leaves the cranial cavity in the Foramen jugulare. mately, the postganglionic fibres accumulate on the N. auricu-
The N. glossopharyngeus is a mixed cranial nerve with 5 different lotemporalis from the N. mandibularis [V/3] passing via this
fibre qualities. Disregarding the subdivision of the Nucleus tractus and the N. facialis [VII] to the parotid gland. Smaller branch-
solitarii [Nucleus solitarius] into a Pars superior and a Pars inferior, es reach the small salivary glands in the mouth of the cheek
4 cranial nerve nuclei can be distinguished (› Fig. 12.61). As with and lips, the Glandulae buccales and labiales.
the N. vagus, the N. glossopharyngeus forms 2 ganglia at the Fora- • R. sinus carotici: It runs to the chemoreceptors and barorecep-
men jugulare: tors in the Glomus caroticum and the Sinus caroticus.
• The Ganglion superius is the smaller of the two and contains the • R. musculi stylopharyngei: It innervates the guiding muscle of
Perikarya pseudounipolarer, general somatoafferent nerve cells. the N. glossopharyngeus, the M. stylopharyngeus.
• The Ganglion inferius is slightly larger and contains perikarya of • Rr. pharyngei: Together with the nerve branches of the N. vagus
general and special visceroafferent pseudo-unipolar nerve cells. [X], they form the Plexus pharyngeus for the motor and senso-
The main trunk of the nerve passes in an arc-shape between the M. ry innervation of the pharynx. Additional motor fibres reach the
stylopharyngeus, its ‘guiding’ muscle, and the medially-positioned Mm. palatoglossus and palatopharyngeus, the M. salpingopha-
M. styloglossus to caudal, reaching the root of the tongue (› Fig. ryngeus as well as the muscles and mucosa of the soft palate.
12.62). On its route, it releases branches to the middle ear, to the • Rr. tonsillares: They are responsible for the sensory innervation
parotis and to the Glomus and Sinus caroticus: of the tonsils, the tonsillar fossa and the Isthmus faucium.
• N. tympanicus: The N. tympanicus leaves the N. glossopharyn- • Rr. linguales: With sensory fibres, they reach the rear third of
geus at the Ganglion inferius with general visceroefferent and the tongue with the Papillae vallatae at the Sulcus terminalis.

701
12 Special neuroanatomy

Target organs Reorganisation Cranial nerve Nuclear areas

Via N. auriculotemporalis,
N. mandibularis [V/3] and N. facialis [VII]
Glandula parotis Nucleus salivatorius
Glandulae labiales Ganglion oticum inferior
Glandulae buccales

Pharyngeal muscles Hiatus canalis nervi petrosi minoris

M. stylopharyngeus Canaliculus tympanicus
M. palatopharyngeus Nucleus ambiguus
Mm. constrictores N. tympanicus
N. glosso-
pharyngis
pharyngeus [IX]
Palate muscles
M. palatoglossus
M. levator veli palatini Foramen jugulare

Mucosa of the Oro-

and nasopharynx,
rear third of the tongue
Ganglion Nucleus spinalis
superius [IX] nervi trigemini
Mucosa of the Tuba
auditiva, middle ear,
area of the outer
acoustic meatus
Nucleus tractus
Sinus caroticus, Ganglion solitarii, Pars inferior
Glomus caroticus inferius [IX]
Nucleus tractus
Taste on the back Ganglion solitarii, Pars superior
third of the tongue inferius [IX] (ncl. gustatorius)

Fig. 12.61 N. glossopharyngeus with its fibre qualities, cranial nerve nuclei and target organs. [L127]

Clinical remarks • The nuclear area of the general visceroefferent fibres, the Nucleus
salivatorius inferior, is responsible for the innervation of the
The N. glossopharyngeus runs from its exit point on the brain-
stem in topographical proximity to the A. inferior anterior cere- salivary glands and is positioned furthest caudal in the brain-
belli. The aberrant pathway of the A. inferior anterior cerebel- stem. This nuclear area is located on the border between the
li, e.g., between the exit points of the N. glossopharyngeus pons and the Medulla oblongata.
and the N. vagus, can lead to pathological impulse control. • The taste fibres of the N. glossopharyngeus as well as those of the
This can cause incipient, stabbing, one-sided pain in the N. facialis [VII] and the N. vagus [X] end in the Nucleus tractus
tongue, the soft palate or throat with drinking and swallowing solitarii. The Tractus solitarius extends caudally from the facial
problems (Glossopharyngeus neuralgia). The pathological
nucleus to the pyramidal intersection. It shows somatotopic and
stimulation can also be transferred via the Nucleus tractus
solitarius to the N. dorsalis nervi vagi and can in rare cases functional organisation. The target neurons of the Chorda tympa-
lead to reflex bradycardia or reflex asystole (cardiac arrest). ni and the N. petrosus major from the N. facialis [VII] are located
The treatment is to separate vessels and nerves from each in the rostral section, while the target neurons of the N. glosso-
other microsurgically. pharyngeus are arranged caudally from here, followed by those of
the N. vagus [X]. The upper part, die Pars superior or the Nucle­
us gustatorius for the taste fibers, can thus be differentiated from
the Pars inferior of the Nucleus tractus solitarii, which is respon-
Cranial nerve nuclei and central links sible for the general visceroafferent fibres, including the barore-
There are 4 different cranial nerve nuclei: ceptors and chemoreceptors of the Sinus and Glomus caroticus.
• The motor neurons of the special visceroefferent fibres of the • The perikarya of general somatoafferent fibres are located in the
N. glossopharyngeus are located (together with those of the N. va- Ganglion superius of the N. glossopharyngeus and end in the
gus [X] and the N. accessorius [XI]) in the N. ambiguus. This Nucleus spinalis nervi trigemini. This nuclear area extends ros-
nuclear area lies in the ventrolateral Formatio reticularis of the trally from the border area between the pons and the medulla and
Medulla oblongata. the Nucleus principalis nervi trigemini far caudally, merging by

702
 12.5 Cranial nerves

Plexus tympanicus Nucleus salivatorius inferior Nucleus tractus

solitarii
N. petrosus profundus [Radix
sympathica ganglii pterygopalatini] Nucleus
ambiguus
N. caroticotympanicus
(Plexus caroticus internus)

N. petrosus minor

N. mandibularis [V/3]

Ganglion oticum

Glandula parotidea N. glosso-

pharyngeus [IX]
N. auriculotemporalis

R. tubarius (Plexus tympanicus) Ganglion superius

Foramen jugulare
Tuba auditiva [auditoria]
N. tympanicus [JACOBSON]

Ganglion inferius

Plexus pharyngeus
N. vagus [X]

R. lingualis

R. sinus carotici

Truncus sympathicus

A. carotis interna
A. carotis externa
Sinus caroticus Fig. 12.62 Pathway of the N.
Glomus caroticum glossopharyngeus. Schematic
A. carotis communis representation in the median
section.

flowing into the laminae I–V of the spinal cord. The general so- ferred to as the pre-BÖTZINGER complex and transfer impulses
matoafferent fibres also end here, originating from the N. facialis to the N. phrenicus and the Nn. intercostales. The respiratory drive
[VII] and the N. vagus [X], but taken primarily via the N. tri- and therewith the impulses of the supplying afferents to these neu-
geminus as a ‘service provider’. rons come from central and peripheral chemoreceptors for the
The cranial nerve nuclei of the N. glossopharyngeus receive prima- measurement of the pH of fluids and blood or they arise
ry afferents from the cortex, as well as from the Formatio reticu- non-chemically as a result of the stimulation of expansion recep-
laris. Efferent impulses, particularly the taste management, are re- tors in the lungs. Respiration is also regulated by the Nuclei
directed, starting from the Nucleus tractus solitarii to reach the parabranchiales in the pons, which on the basis of impulses from
Nucleus ambiguus and, ultimately, the ipsilateral Nucleus basalis the limbic system, e.g., with anxiety-inducing situations, signal an
ventralis medialis thalami via the tegmental tract. After another increase in the respiratory rate to the respiratory centre.
relay in this nuclear area, the taste fibres reach the parietal operculum
or the insular cortex.
Due to its neuronal connections, the Nucleus tractus solitarii is
Clinical remarks
also a crucial hub in the regulation of the circulation as well as the Damage to the respiratory centre, e.g., when there is in-
basis of the baroreflex: increased blood pressure activates the baro- creased intracranial pressure, can lead to a centrally modified
receptors in the Sinus caroticus. Via the hub of the Nucleus tractus breathing pattern. For example, a breathing pattern where ad-
solitarii, afferent fibres project onto cardio-inhibiting neurons in equate, even and deep breathing is always interrupted by
pauses in breathing, is referred to as BIOT's respiration.
the ventral part of the Nucleus ambiguus. From there, the descend-
ing tracts reach the N. intermediolateralis in the thoracic spine and
the ascending tracts reach the hypothalamus, which results in the The N. glossopharyngeus is also an important component of the
inhibition of the sympathetic nervous system. As a result, the heart swallowing reflex (see below). The act of swallowing itself requires
rate and peripheral vascular resistance decreases and the blood coordinated interaction between the tongue (N. XII), mucosal sen-
pressure is lowered. sitivity in the mouth and throat (N. trigeminus [V] and the N.
What is referred to as the respiratory centre is closely associated glossopharyngeus [IX]), the pharynx (N. glossopharyngeus [IX]),
with the nuclear areas which regulate the circulation, and it is lo- the larynx (N. vagus [X]) and the oesophagus. The neurons in-
cated in the ventrolateral section of the Nucleus tractus solitarii or of volved are activated and inhibited in a coordinated manner by
the ventrolateral medulla; it is the rhythm generator for inspiration close links between the involved cranial nerve nuclei via the lateral
and expiration. These rhythmogenic respiratory neurons are re- and intermediate Formatio reticulares in the Medulla oblongata.

703
12 Special neuroanatomy

Furthermore, an important role is played by the N. glossopharyn-

geus and/or the Nucleus tractus solitarii in the process of the vom­
iting reflex. The vomiting reflex is a protective reflex, the aim of
which is to protect the body from harmful substances. A variety of
stimuli can trigger it: the mechanical irritation of the pharynx via
the N. glossopharyngeus, intoxication, hormonal changes, or trig-
gered by optical, vestibular or olfactory stimuli. Ultimately, these
afferent pulses stimulate the Nucleus tractus solitarius and the Area
postrema (‘vomiting or emetic centre’), to activate the required tar-
get organs for vomiting via the Formatio reticularis.

Clinical remarks
The function of the N. glossopharyngeus can be tested by the
gag reflex. The gag reflex is a foreign reflex, of which the affer-
ent impulses trigger a reflex response via the N. vagus, after
touching the oropharynx. By doing so, the absence or weaken-
ing of the gag reflex can be evaluated by comparing both
sides. Since the N. glossopharyngeus, as well as the N. vagus
is involved in the innervation of the soft palate muscles, care
should be taken to examine both cranial nerves on the soft
palate contour and the position of the uvula (› Chap.
12.5.13). When saying ‘aaah’, an asymmetrical contraction of
the soft palate can be observed with a displacement to the
healthy side. This symptom is known as uvular deviation. Fig. 12.63 Exit point of the N. vagus. The Xth cranial nerve exits in
The taste function of the nerve can be checked using bitter the Sulcus retroolivaris between the exit points of the N. glossopha-
substances (such as quinine) and thereby the sense of taste ryngeus [IX] (cranial) and the N. accessorius [XI] (caudal).
in the rear third of the tongue can be determined.

the N. facialis [VII] and the N. glossopharyngeus [IX], it also leads

special visceroafferent fibres, taste fibres, from receptors of the cau-
dal pharynx and of the epiglottis. To summarise, the N. vagus is a
12.5.13 N. vagus (10th cranial nerve, N. X) mixed cranial nerve with 5 different fibre qualities, which in the
Anja Böckers brainstem, disregarding the subdivision of the Nucleus tractus soli-
tarii into a Pars superior and a Pars inferior, are expressed as 4 dif-
ferent cranial nerve nuclei (› Fig. 12.64).
SKILLS
After working through this chapter, you should be able to: Course and branches
• name the target organs of the N. vagus
Similar to the N. glossopharyngeus [IX], the N. vagus [X] leaves
• list the cranial nerve nuclei of the N. vagus nerve and correctly ex-
plain their function
the Medulla oblongata in the Sulcus retroolivaris (› Fig. 12.63),
• indicate the pathway of the N. vagus on a dissection or on › Fig. passes through the subarachnoid space and leaves the internal sur-
12.65and explain it in your own words face of the cranial base together with the N. glossopharyngeus and
the N. accessorius [XI] through the Foramen jugulare. Here, the
The N. vagus [X] (Lat. vagari = wander around, spread out) spreads N. vagus thickens into a Ganglion superius (syn.: Ganglion jugu­
out from all the cranial nerves furthermost caudally and thus lare) and a Ganglion inferius (syn.: Ganglion nodosum). In the
reaches the thoracic and abdominal cavities. It is the largest para- same way as for the N. glossopharyngeus [IX], there are perikarya
sympathetic nerve in the body and includes the upper portion of of the general somatoafferent neurons in the upper ganglion, and
the parasympathetic autonomic nervous system. It is also a bran- perikarya of the general and specific visceroafferent pseudo-unipo-
chiogenic cranial nerve, formed from the merger of the 4th, (5th) lar neurons in the lower ganglion. The N. vagus runs caudally to-
and 6th pharyngeal arch nerves. The N. vagus shares its cranial gether with the internal jugular vein, and its continuing course di-
nerve nuclei for the most part with the N. glossopharyngeus [IX], vides correspondingly into a Pars cervicalis, a Pars thoracica and
resulting here in neuroanatomical and functional similarities or a Pars abdominalis.
overlaps. Directly at the level of the Foramen jugulara at the Ganglion supe-
The N. vagus ensures the special visceroefferent innervation of the rius, the N. vagus starts 2 general somatoafferent branches (› Fig.
larynx, as well as partially that of the pharynx (M. constrictor 12.65):
pharyngis inferior) and that of the soft palate (M. levator veli pala- • R. meningeus: It innervates the Dura mater in the posterior cra-
tini). Without it, stable breathing and speech functions are impos- nial fossa.
sible. Its general visceroefferent fibres supply the smooth muscles • R. auricularis: It passes through the Canaliculus mastoideus
and glands from the throat area down to the Flexura coli sinistra, and the Fissura tympanomastoidea to the Canalis acusticus ex-
the CANNON’s point by which it controls hypersecretion and ternalis, to which it provides sensory innervation.
peristalsis in the gastrointestinal tract. In addition, it ensures im- A little further caudally at the Ganglion inferius, the cervical part
portant functions in the regulation of respiration – as does the of the N. vagus nerve releases the two following branches:
N. glossopharyngeus [IX] – via the impulse management of exten- • R. pharyngeus: This is essentially formed from fibres of the Ra-
sion receptors in the lungs or in the regulation of circulation, via dix cranialis of the N. accessorius nerve [XI], initially adhering
receptors in the right atrium and in the aortic wall. Together with to the N. vagus, but radiating later into the Plexus pharyngeus.

704
 12.5 Cranial nerves

Target organs Reorganisation Cranial nerve Nuclear areas

Glands, smooth Nucleus dorsalis nervi vagi

muscles to
CANNON-BÖHM point

– Throat area
(e.g. Glandulae
tracheales) Near the organs,
mostly intramural
– Chest ganglia
(e.g. heart and lungs)
Nucleus ambiguus
– Abdomen
(e.g. intestinum)
Foramen jugulare
Pharyngeal muscles

Palate muscles N. vagus [X]

Nucleus spinalis
Laryngeal muscles nervi trigemini

Skin of the
– external auditory canal Ganglion
– outer ear superius [IX]
Nucleus tractus solitarii,
– Dura mater Pars inferior
Stretch receptors of
aorta and lung

Mucosa of the Ganglion Nucleus tractus solitarii,

pharynx and larynx inferius [IX] Pars superior (Nucleus
gustatorius)
Mucosa of the
gastrointestinal tract

Taste Ganglion
(pharynx and epiglottis) inferius [IX]

Fig. 12.64 The N. vagus with its fibre qualities, cranial nerve nuclei and target organs. [L127]

Together with the N. glossopharyngeus [IX], the general vis- On its continued caudal route between the V. jugularis interna and
ceroefferent fibres of this nerve branch reach the pharyngeal the A. carotis interna, the N. vagus branches off into:
glands, the special visceroefferent fibres reach the pharyngeal • Rr. cardiaci cervicales superiores and inferiores: They run to
muscles, and the general visceroafferent fibres of this branch the Plexus cardiacus, accumulating on the aortic arch from the
reach the pharyngeal mucosa. rear. Cardioinhibitory impulses reach the atrial muscles via these
• N. laryngeus superior: This divides into an R. externus and an fibres. Thus the fibres of the right N. vagus nerve have a prefer-
R. internus. The R. externus innervates the single outer larynx ential effect on the sinus nodes, and fibres of the left N. vagus
muscle, the M. cricothyroid. The R. internus passes through the have a preferential effect on the AV nodes of the impulse con-
Membrana thyrohyoidea and supplies the sensory innervation of duction system. The N. vagus has an overall negative chrono-
the mucosa above the Rima glottis. tropic effect and a negative inotropic effect on the heart. Afferent

705
12 Special neuroanatomy

R. meningeus Nucleus ambiguus N. accessorius [XI],

Radix cranialis
N. vagus [X]
Nucleus dorsalis
nervi vagi
R. auricularis
Nucleus tractus
Ganglion superius (X) solitarii

Foramen jugulare

Ganglion inferius (X)

R. pharyngealis

Rr. linguales R. communicans

cum ramo sinus carotici (IX)

Plexus pharyngeus
R. cardiacus cervicalis
superior R. internus
N. laryngeus superior
Rr. tracheales and oesophageales R. externus

R. cardiacus cervicalis inferior

A. subclavia dextra R. cardiacus thoracicus

N. laryngeus recurrens sinister

N. laryngeus recurrens dexter
Plexus pulmonalis
Plexus pulmonalis Plexus cardiacus
and Rr. bronchiales
Plexus oesophageus
Truncus vagalis anterior
Truncus vagalis posterior

R. hepaticus
Rr. gastrici anteriores

Rr. coeliaci
Plexus coeliacus, Ganglia coeliaca
and mesentericum superius
Plexus hepaticus

Plexus splenicus

Plexus suprarenalis

Plexus renalis

(Rr. intestinales)

Fig. 12.65 Pathway of the

N. vagus in the head, chest and
abdominal area.

fibers of these nerve branches conduct impulses from the pres- As they continue through the chest cavity, the Rr. cardiaci thoraci­
sure receptors of the aortal vessel wall or of the right atrium, ci depart directly from the N. vagus. They also reach the Plexus
thus forming the afferent femoral anti-hypertensive reflexes of cardiacus. The innervation of the lungs is done bilaterally by both
the N. vagus. Nn. vagi via the Rr. bronchiales, which accumulate dorsally on the
• N. laryngeus recurrens: In terms of its historical development, main bronchi, forming the Plexus pulmonalis.
it is seen as the nerve of the 6th pharyngeal arch. It leaves the N. Around the oesophagus, the N. vagus forms another neuronal net-
vagus in the area of the upper thoracic aperture. The N. laryn- work, the Plexus oesophageus, which converges caudally with the
geus recurrens sinister loops from ventral to dorsal around the Trunci vagales. In accordance with the embryological rotation of
aortic arch, and in the same way, the N. laryngeus recurrens dex- the stomach by 90° to the right, the left N. vagus thus forms the
ter loops around the A. subclavia dextra. Both nerve branches Truncus vagalis anterior, running on the ventral side of the oe-
then emerge again between the trachea and oesophagus to cranial sophagus and accordingly the N. vagus dexter forms the Truncus
and release the identically named branches to the adjacent organs vagalis posterior on the dorsal side. Both leave the chest cavity
of the throat area. Finally, the N. laryngeus recurrens reaches the through the Hiatus oesophageus and reach the anterior and poste-
interior of the larynx as the N. laryngeus inferior, by passing be- rior sides of the stomach. The anterior truncus only supplies the
tween the Cartilago cricoidea and the Cartilago thyroidea of the stomach (up to the pylorus) and the liver, whereas the Truncus
larynx skeleton, and there supplies the sensory innervation of vagalis posterior also reaches the Ganglion coeliacum and, togeth-
the mucosa below the Rima glottis and all the remaining laryn- er with the sympathetic nerve fibres, reach the abdominal organs
geal muscles. up to the CANNON's point (transition is in the middle to the low-

706
 12.5 Cranial nerves

er third of the transverse colon). Unlike the N. glossopharyngeus r­ eceptors), the pharynx and the larynx are passed on. Likewise,
or the N. facialis in the head area, the preganglionic parasympa- subconscious information is also conveyed which is essential for
thetic fibres are usually only relayed onto postganglionic fibres respiratory regulation (HERING-BREUER reflex) or for circula-
close to organs in intramural ganglia. Aboral from the CANNON’s tory regulation (baroreceptors in the right atrium, in the wall of
point, the parasympathetic innervation of sacral neurons takes the aorta or in the Sinus caroticus). Up to 80% of the N. vagus is
place in the lateral horn of the spinal cord. made up of afferent nerve fibres, illustrating the high value of
this afferent information from inside the body.
• To a lesser extent, the N. vagus also carries general somatoaffer-
Clinical remarks ent impulses of the sensations of touch, pain and temperature
A 13-year-old girl was treated in the neurological outpatient clin- from small areas of skin of the external ear, the rear wall of the
ic for several months due to bouts of loss of consciousness, or external acoustic meatus and the hard meninges in the posterior
so-called absences. Diagnostic x-rays showed nothing con- cranial fossa. The central axons of the 1st neurons form synapses
spicuous, and drug treatment carried out so far did not lead to in the Nucleus spinalis nervi trigemini with the corresponding
any improvement. Firstly, the taking of a new in-depth history
2nd neuron. In a somatopic arrangement, the N. trigeminus [V],
made it clear that the disturbances to consciousness were
preceded by a stimulus, such as the mechanical cleaning of the N. facialis [VII], the N. glossopharyngeus [IX] and the N.
the external acoustic meatus. Finally, function tests confirmed vagus [X] share this section of the vein of the Vth cranial nerve
that irritating the rear wall of the Canalis acusticus externus nucleus. This nucleus forms the rostral progression of the lami-
led to an overreaction of the N. vagus (R. auricularis) with con- nae I–V of the dorsal horn of the spinal cord and ends rostrally
secutive bradycardia. After stopping these manipulations, the at the Nucleus principalis nervi trigemini (› Chap. 12.5.8).
patient was once again free of symptoms. The Nucleus ambiguus – in the same way as the N. glossopharyn-
The N. laryngeus recurrens is particularly at risk on its path-
geus [IX] – is closely associated in neuronal terms with the Nu­
way at the rear of the thyroid gland in thyroid gland surgery,
such as with thyroid removal (thyroidectomy). Where it is in- cleus tractus solitarii. In addition, it receives afferent impulses
jured on one side, this can lead to hoarseness. A bilateral in- from the Formatio reticularis and via corticonuclear tracts from
jury could suffocate the patient because the N. laryngeus re- the cortex. The Nucleus tractus solitarii is a central hub for both
currens innervates the M. cricoarytenoideus posterior which is the glossopharyngeal nerve and the N. vagus for controlling respi-
crucial for opening the vocal ligaments when breathing in. ratory and circulatory functions. In addition, the Nucleus ambigu-
us also sends fibres to the Nucleus dorsalis nervi vagi. The latter,
in turn, receives afferents from the Nuclei salivatorii and is con-
trolled by hypothalamic centres (Nucleus paraventricularis thala-
Cranial nerve nuclei and central links mi) and by the limbic system (Nucleus centralis amygdalae). These
In the same way as the N. glossopharyngeus [IX], the N. vagus [X] neuronal connections are the basis for the regulation of food intake
is a mixed nerve of which the fibre qualities are also assigned 4 cra- and digestion: even before food intake occurs, in what is called the
nial nerve nuclei (› Fig. 12.64): cephalic phase, impulses from the Formatio reticularis act to stim-
• Neurons in the Nucleus ambiguus are responsible for the spe- ulate the Nucleus dorsalis nervi vagi. During actual food intake,
cial visceroefferent innervation of the pharyngeal arch muscles chemo- and mechanoreceptors in the stomach and small intestine
of the pharynx, larynx and soft palate. This nucleus lies in the are stimulated and take impulses via vagal afferents to the Nucleus
Medulla oblongata and can be divided into a dorsal and ventral tractus solitarii. Neurotransmitters (glutamate), as well as entero-­
nucleus column: endocrine hormones, such as cholecystokinin, thus act on the
– The dorsal nucleus column encompasses the visceroefferent ­Nucleus tractus solitarii. This projects in an inhibitory way into the
neurons in that, the N. vagus is shared with the N. glossopha- Nucleus dorsalis nervi vagi, the axons of which reach the intramu-
ryngeus [IX] and the N. accessorius [XI], thereby presenting a ral ganglia in turn. Together these neuronal configurations are re-
roughly somatotopic structure. ferred to as vagovagal reflexes.
– The ventral nuclear column does not contain any branchio- The Nucleus spinalis nervi trigemini is part of the somatosensory
motor neurons, but instead is functionally assigned to the system or more correctly, the trigeminoafferent system. From here,
­Nucleus dorsalis nervi vagi due to its cardioinhibitory neurons. amongst others, impulses of pain and temperature sensation cross
• The general visceroefferent fibres of the N. vagus derive from the and are projected into the thalamus to the Nucleus ventralis pos-
Nucleus dorsalis nervi vagi. This cranial nerve nucleus reaches teromedialis (3rd neuron) (trigeminothalamic fibres), passing from
from the rostral medulla to caudal, to the pyramidal tract inter- here to the somatosensory cortex.
section. This nuclear area forms the Trigonum nervi vagi near
the obex and laterally to the Trigonum nervi hypoglosi on the
floor of the rhomboid fossa.
Clinical remarks
• The perikarya of the special visceroafferent neurons are located in The gag reflex is one of the functional tests for checking the
the Ganglion inferius of the N. vagus and send their centrally tar- N. vagus and the evaluation of the soft palate in phonation
geted axon to the Nucleus tractus solitarii [Nucleus solitarius]. In (› Chap. 12.5.12). Additionally, the voice should also be as-
the same way as the N. facialis [VII] and the N. glossopharyngeus sessed: aphonia and hoarseness can be signs that the inner-
vation of the larynx is not what it should be. When taking a
[IX], these taste fibres end in the rostral section of the nuclear
history, the patient should also be asked about any swallow-
complex, the Nucleus gustatorius. In the caudal part of this crani- ing difficulties, the passing of stools and sweat secretion. To
al nerve nucleus, the centrally-directed axons of the general vis- make a rough preliminary examination of the autonomic ner-
ceroafferent neurons, of which the perikarya are located in the vous functions, the heart rate and rhythm should be taken and
Ganglion inferius nervi vagi, are relayed synaptically. Here, im- assessed.
pulses from the viscera (e.g., intestinal pain due to the activation
of pain receptors, ‘bloating’ due to the activation of stretch

707
12 Special neuroanatomy

12.5.14 N. accessorius (11th cranial nerve, N. XI) the M. sternocleidomastoideus. It is however controversial as to
Anja Böckers whether it is a real cranial nerve, because its spinal nuclear area, the
Nucleus nervi accessorii, lies in the cervical anterior horn cells of
the spinal cord, whereas its cranial nuclear area is assigned to the
SKILLS basal section of the Nucleus ambiguus and and thereby to the
After working through this chapter, you should be able to: N. vagus. Accordingly, the fibres derived from C1–7 are encapsu-
• name the organs of the N. accessorius
lated in a Radix spinalis nervi accessorii and the fibres from the
• list the cranial nerve nuclei of the N. accessorius and correctly ex-
plain their function
Nucleus ambiguus in a Radix cranialis nervi accessorii.
• recognise the typical functional failures of the N. accessorius on
the basis of text descriptions or images Pathway and branches
The Radix spinalis nervi accessorii rises to cranial behind the olive
The N. accessorius [XI] is a branchiogenic cranial nerve which between the anterior and posterior root of the spinal cord and
supplies special visceroefferent innervation to the M. trapezius and passes through the Foramen magnum to the internal surface of the
cranial base. After merging with the Radix cranialis in the Pars
nervosa of the Foramen jugularis, the N. accessorius exits outwards
again via the cranial base (› Fig. 12.66).
Immediately after exiting – usually between the Ganglia superius
and inferius nervi vagi – the fibres of the Radix cranialis leave the
N. accessorius again as the R. internus and adhere to the N. vagus,
in order to innervate with this pharyngeal and laryngeal muscle
(› Fig. 12.67, › Fig. 12.68). The main trunk of the R. externus
eventually reaches the Regio cervicalis lateralis and there releases
the visceroefferent branches of the M. sternocleidomastoideus. It
continues along the M. levator scapulae further dorsally to the
M. trapezius. However, both muscles also receive direct fibres from
the cervical segments (C1–C4); via these, proprioceptive impulses
of these muscles are transferred to the Nucleus nervi accessorii.

Cranial nerve nuclei and central links

In addition to the primary afferents from the actual muscles, the
Nucleus nervi accessorius receives reticospinal fibres of the extra-
pyramidal motor system, as well as pyramidal afferents via cortico-
spinal or nuclear fibres from the pre-central area of the cortex. The
central connections of the Nucleus ambiguus have already been
given for the N. glossopharyngeus [IX] (› Chap. 12.5.12) and the
N. vagus [X] (› Chap. 12.5.13).

Fig. 12.66 Exit point of the Radix spinalis of the N. accessorius. The
XIth cranial nerve exits at the ventral side of the brainstem, dorsal of
the olive.

Target organs Entry Cranial nerve Nuclear areas

Foramen jugulare
Radix
M. sternocleido- cranialis Portions of the Nucleus
N. accessorius [XI]
mastoideus ambiguus
Foramen
M. trapezius magnum Nuclei nervi accessorii
Radix
spinalis
Pharyngeal and N. vagus [X]
laryngeal muscles

Fig. 12.67 N. accessorius with its fibre qualities, cranial nerve nuclei and target organs. [L127]

708
 12.5 Cranial nerves

N. accessorius [XI], N. vagus [X]

Radix spinalis
N. accessorius [XI],
Radix cranialis
Nucleus Foramen
ambiguus jugulare
N. vagus [X], Ganglion
superius jugulare

Truncus nervi accessorii

Nucleus nervi R. internus

accessorii
N. vagus [X], Ganglion
inferius (nodosum)
N. cervicalis [C1]
R. externus
N. cervicalis [C2] M. sternocleidomastoideus

N. cervicalis [C3]

N. cervicalis [C4]

M. trapezius

Connection to the
Plexus brachialis

Plexus brachialis, Truncus superior

Fig. 12.68 N. accessorius. Fron-

tal view, vertebral canal and
skull are opened.

Clinical remarks
Pathway and branches
Examination It leaves the brainstem on the ventral side of the Medulla oblongata
One-sided contraction of the M. sternocleidomastoideus leads between the pyramid and the olive as a single cranial nerve in the
to a turning of the head to the opposite side and a tilting of the Sulcus anterolateralis (› Fig. 12.69). It runs in the Canalis nervi
head to the same side. The functional capability of the M. ster- hypoglossi through the base of the skull to innervate both the in-
nocleidomastoideus is checked by the examining doctor by ternal and the external tongue muscles as a general somatoefferent
turning the head against the pressure of his/her own hand.
nerve, with the exception of the M. palatoglossus (› Chap. 9.7.5).
Consequently, the functionality of the Pars descendens of the
M. trapezius can be measured by raising the shoulder girdle After leaving the bony skull, the N. hypoglossus passes dorsolater-
(by shrugging) and pushing against the hand carrying out the ally in an arc-shaped course into the Spatium lateropharyngeum
examination or by abduction of the arm over an angle of 90°. and loops around the N. vagus and the A. carotis externa. It then
Following a longer standing lesion of the N. accessorius, con- crosses below the Venter posterior of the M. digastricus and ends
sideration should be given to muscular atrophy, which in ex- up in the cranial section of the Trigonum caroticum, before finally
treme cases can lead to a twisted neck or to a Scapula alata. reaching the tongue between the Mm. hyoglossus and mylohyoide-
us. For 3–4 cm on its peripheral pathway, it accumulates onto fibres
of the ventral branches of the upper 2 cervical nerves (C1–2), then
exits these again as the so-called Radix superior of the Ansa cervi­
12.5.15 N. hypoglossus (12th cranial nerve, N. XII) calis nervi hypoglossi. Some of these fibres will however also con-
Anja Böckers tinue in the N. hypoglossus to innervate the M. thyrohyoideus and
the M. geniohyoideus. Together with fibres from segments C2–3, of
the Radix inferior, the Radix superior forms the Ansa cervicalis
SKILLS nervi hypoglossi at the level of the transition from the Venter su-
After working through this chapter, you should be able to: perior to the Venter inferior of the M. omohyoideus. This is im-
• name the organs of the N. hypoglossus
portant for the innervation of the infrahyoid muscles. There is
• indicate the position of the Trigonum nervi hypoglossi on a model
or a dissection of the Fossa rhomboidea
however a wide range of deviations from this simplified course,
• extrapolate a one-sided lesion of the N. hypoglossus, using an il- such as in approximately 15% of the cases, where there is an addi-
lustration or a description of the findings of a clinical investigation tional root arising from the N. vagus (› Fig. 12.70).

Cranial nerve nuclei and central links

The 12th cranial nerve, the N. hypoglossus [XII], is a cranialised The nuclear area of the N. hypoglossus, the Nucleus nervi hypo­
spinal nerve, which arises from the anterior branches of the upper glossi, lies in the Medulla oblongata, paramedially of the Sulcus
cervical segment. medianus near the floor of the Fossa rhomboidea. Subjacent to the

709
12 Special neuroanatomy

Unlike the spinal nerves, the Nucleus nervi hypoglossi does not re-
ceive direct somatoafferents from its target muscles. Hence there
are also no monosynaptic reflex arches, although there are disynap-
tic or polysynaptic reflex arches which are important for coordinat-
ing the chewing process. Their afferents are taken to the Nucleus
nervi hypoglossi via the trigeminal nucleus complex or conducted
via the Nucleus tractus solitarii. Other afferents originate from the
Formatio reticularis and the motor cortex, of which the impulses
reach the cranial nerve nuclear primarily by crossing over via corti-
conuclear fibres running in the Capsula interna. Therefore lesions
of these central afferents result in contralateral tongue weakness,
whereas lesions of the Nucleus nervi hypoglossi nerve itself lead to
ipsilateral tongue weakness.

Clinical remarks
Examination
To evaluate the functional capability of the N. hypoglossus, the
patient is asked to stick out the tongue (saying ‘aaah’ simulta-
neously is part of the clinical examination for the N. vagus).
This helps you to evaluate whether there is atrophy or fascicu-
lations (muscle twitching/shaking) of the tongue muscles or
whether the tongue can be stuck straight out or deviates to one
Fig. 12.69 Exit point of the N. hypoglossus. The XIIth cranial nerve side. In addition, language formation (‘slurred speech’), drink-
exits at the ventral side of the brainstem in the Sulcus anterolateralis ing and swallowing should be assessed.
between the olive and the pyramid.
Damage to the nerve
In case of damage to the peripheral nerve section or the crani-
nucleus area on the floor of the Fossa rhomboidea is the Trigonum al nerve nucleus, the tip of the tongue deviates to the paralysed
nervi hypoglossi. The Nucleus nervi hypoglossi is surrounded by side due to the predominant pull of the N. genioglossus to the
small groups of neurons, known collectively as perihypoglossary healthy side. In case of a supranuclear lesion, the contra later-
al tongue muscles are damaged, so that the central defect is in
nucleus groups. In the main nuclear itself, several subgroups can be
the half of the brain controlling the tip of the tongue. A bilater-
distinguished which can be assigned to the respective branches and
target muscles of the N. hypoglossus, according to their arrangement.

Target organs Entry Cranial nerve Nuclear areas

Canalis n. hypoglossi

Mm. longitudinales
N. hypoglossus [XII] Nucleus nervi hypoglossi
superior and inferior
linguae,
M. verticalis linguae,
M. transversus linguae

M. styloglossus,
M. hypoglossus
(retraction)

M. genioglossus
(protrusion)

Fig. 12.70 N. hypoglossus with its fibre qualities, cranial nerve nuclei and target organs. [L127]

710
 12.6 Spinal cord

al lesion of the Nuclei nervi hypoglossi is common due to the hibits a metameric segmentation in somites, a segmental structure
close paramedial position. of the spinal cord is also induced. This segmental structure of the
In addition to an isolated lesion of the N. hypoglossus, such as spinal cord is not visible from the outside, but can be understood
following surgery on the A. carotis externa, systemic diseases of by referring to the branches of the exiting spinal roots. The spinal
inflammatory, vascular or neoplastic origin can also be causing
roots are assigned to the mesodermal structures of their original
the symptoms. Because the N. accessorius, together with the N.
vagus [X], the N. glossopharyngeus [IX] and the V. jugularis exits segment, called dermatomyotomes. In terms of development, on
the cranial base through the Foramen jugulare, all 3 nerves can the one hand, afferents are derived from receptors of the segmen-
frequently be affected simultaneously by lesions at the Fora- tally assigned skin areas, the dermatomes, and, on the other hand,
men jugulare. This results in a combination of symptoms, indi- their association with segment-specific muscles, known as indica-
cated by difficulty with swallowing or paralysis of the M. trape- tor muscles (› Fig. 12.71, › Table 12.10).
zius, as well as in clinical examination by a positive uvular devi- A total of 31–33 spinal cord segments can be distinguished, divid-
ation (› Chap. 12.5.12) or by failure of the gag reflex. Because
ed into
the meningeal branch of the A. pharyngea ascendens goes
through the Foramen jugulare into the interior of the skull, pa- • 8 cervical (Pars cervicalis)
tients' symptoms may be accompanied by headaches which • 12 thoracic (Pars thoracica)
may be due to reduced circulation in the meninges. Overall, it is • 5 lumbar (Pars lumbalis) and
referred to as Foramen jugular syndrome. If the N. hypoglossus • 5 sacral (Pars sacralis)
is also affected, this combined damage to the caudal cranial spinal cord segments and an irregular number of coccygeal seg-
nerves is also referred to as COLLET-SICARD syndrome. ments (Pars coccygea).

Fila radicularia
Each segment releases strands of multiple root threads, the Fila ra­
12.6 Spinal cord dicularia, which come together as the front and rear root, Radices
Anja Böckers anterior and posterior, forming a spinal nerve. The cervical Radices
posterior and anterior demonstrate a virtually horizontal course to
their exit point from the vertebral canal, the Foramen interverte-
SKILLS brale. Here the first spinal nerve (C1) leaves the spinal cord canal
After working through this chapter, you should be able to: between the occiput and the atlas. The roots of the spinal cord seg-
• give a free presentation with regard to › Fig. 12.74and, more
ments, which are located further caudally, run increasingly verti-
importantly, › Fig. 12.75
• describe the position of the neuronal chain (perikarya, axon path-
cally, because after the relative ascent of the spinal cord they have a
way and intersections of fibre pathways) in the ascending and de- long journey inside the vertebral canal, in order to reach the Fora-
scending pathway systems men intervertebrale associated with their segment. Thus the lum-
• describe the blood supply of the spinal cord in your own words bar spinal cord segments are generally at the level of the thoracic
and differentiate the associated clinical consequences, in partic- vertebrae X–XI. It should be noted that in the living, the vertebral
ular any malfunctions body itself cannot be palpated, only its Proc. spinosus, the tip of
which is mostly at the vertebral level of 1.5 further caudally. The
spinal cord segments Co1–3 lying furthest caudally correspond to
the level of the Conus medullaris (vertebral body height LI/LII).
12.6.1 Overview However, the associated spinal nerve roots run up to the end of the
dura sac (vertebral body height SI/SII), here leaving the vertebral
The spinal cord, the Medulla spinalis, is located in and protected by canal or the Hiatus sacralis. Collectively, these lumbar and sacral
the vertebral canal, wrapped in meninges. In adults, it is approxi- Fila radicularia form the Cauda equina. Their fila float in the flu-
mately 40–45 cm long and as thick as a pencil, but cervically and id-filled Cisterna terminalis and – unlike the spinal cord itself – are
sacrally there is a thickening, the Intumescentiae cervicalis and not at risk of injury by lumbar puncture. The Conus medullaris is
lumbosacralis. Cranially it borders the Medulla oblongata in the
Decussatio pyramidum area and with its caudal end, the Conus Table 12.10 The most common clinically-examined spinal cord seg-
medullaris, it goes up to the Ist or IInd lumbar interbody. As with all ments, Segmenta medullae spinalis, and their associated indicator
brain sections of the CNS, the inside of the spinal cord is hollow but muscles.
it only consists of a narrow, occluded tube called the Canalis centra­
Spinal cord Indicator muscle Dermatome
lis. Characteristically for the spinal cord, it is divided into Substantia segment
grisea and Substantia alba, into a somatic and autonomous nervous
system, as well as into efferent and afferent fibre systems. Efferent fi- C5 M. deltoideus Lateral upper arm; shoulder
area
bres refer to the superior, controlling descending tracts which, for
example, control motor functions. Afferent fibres are, correspond- C6 M. biceps brachii; M. brachio­ Thumb; thenar area
radialis
ingly, ascending tracts to the brain which, for example, transfer im-
pulses from the interior of the body or the body surface. C7 M. triceps brachii Middle finger
C8 Mm. interossei of the hand Digitus minimus; hypothenar
area
12.6.2 Segmental structure of the Medulla spinalis L3 Quadriceps femoris; M. ilio- Inner knee
psoas
Spinal cord segments L4 M. tibialis anterior Medial lower leg side
Already by the 4th week of pregnancy, the spinal cord starts to de-
L5 M. extensor hallucis longus Big toe area
velop from the neural tube (› Chap. 12.5.2). Under the influence
S1 M. triceps surae Lateral foot and leg area
of the mesoderm, which accumulates on the neural tube and ex-

711
12 Special neuroanatomy

C3
1
2
3
4
5 Intumescentia
6 cervicalis
1 7
C4
2 8
1
3
2
Pediculi arcuum
C5 4 3 vertebrarum

5 4 Ganglion
spinale
5
6
6
T 7
C6 7
8
8

9 9
C7
10 10
C8
11
11
T1 12

T2 12 1

2
3
4
5
1
Intumescentia
2
3
lumbosacralis
4
5
1
L1

Cauda equina
L2

L3

L4

L5
S1
Fig. 12.71 Spinal cord seg-
S2
ments, Segmenta medullae spi-
a S3 b
nalis, and their associated der-
matomes. b [E402]

attached by a delicate strand of fibrous connective tissue containing posterior and posterolateralis, dividing the Fasciculi gracilis and
glial cells, called the Filum terminale, attached to the dura sac cuneatus from each other (› Fig. 12.72b).
(vertebral body height SI/SII) or via its Pars duralis at the vertebral
canal (vertebral body height CoI/CoII) (› Fig. 12.72a). Cross-sectional anatomy
Cross-sections through the Medulla spinalis clarify the typical dis-
tribution of grey and white matter (› Fig. 12.72b): unlike in the
12.6.3 Surface and cross-sectional anatomy encephalon, the Substantia grisea here is shaped like a butterfly on
the inside of the spinal cord and is enveloped by white matter.
Surface anatomy
The surface anatomy of the Medulla spinalis is characterised by Substantia grisea
longitudinally-running furrows. The deepest furrow, the Fissura In the grey matter, particularly in the thoracic-lumbar section, we
mediana anterior, is found in the median plane of the anterior differentiate a posterior horn (Cornu posterius), a lateral horn
surface of the medulla. On the dorsal side, it superficially forms the (Cornu laterale) and an anterior horn (Cornu anterius). In the
longitudinal furrow, so is referred to as a Sulcus medianus poste­ same way, if one wishes to describe this area in three-dimensional
rior. Even flatter and marked by the exit of the respective Fila ra- terms one also talks of the Columna posterior (posterior column),
dicularia, the Sulcus anterolateralis is positioned on the lateral Columna intermedia (side column) and Columna anterior (ante-
side of the Fissura mediana anterior with the exiting Radix anterior rior column), (› Fig. 12.74). The Cornu posterius is divided from
or motoria, and the Sulcus posterolateralis is correspondingly po- ventral to dorsal into the basis, cervix, caput and apex and finally
sitioned laterally of the Sulcus medianus posterior with the exiting reaches the Sulcus posterolateralis dorsally via the so-called Sub­
Radix posterior or Radix sensoria. In the cervical section a Sulcus stantia gelatinosa. Both Cornua lateralia are connected to each
intermedius is the distinct separation between the Sulci mediani other by a bridge of grey matter positioned in front of and behind

712
 12.6 Spinal cord

Sulcus medianus Sulcus inter-

posterior medius posterior
Sulcus postero-
Canalis lateralis
centralis Columna posterior,
Cornu posterior
Intumescentia
cervicalis Columna anterior,
Cornu anterior

Fissura mediana Sulcus antero-

Pediculi arcuum anterior lateralis
vertebrarum

Funiculus posterior

Columna Funiculus
intermedia lateralis

Commissura Funiculus anterior

alba anterior

Intumescentia
lumbosacralis

Conus
medullaris

End of the
spinal cord [L1–L2] b
Pars
pialis Lower portion of
Arachnoidea mater spinalis
Filum
terminale
Fig. 12.72 Spinal cord, Medulla
End of the sub- spinalis and cross-sections.
Pars
duralis
arachnoidal space [S2] a Ventral view. b Cross-sections
at the level of the dotted lines in
a the Pars cervicalis, Pars thoraci-
ca, Pars lumbalis and Pars
sacralis. a[E402]

the Canalis centralis, the Commissurae griseae anterior and pos­ motor pathways leaving the spinal cord decreases. At the Intumes-
terior. centiae cervicalis and lumbosacralis, the Cornu anterioris is partic-
ularly large and broad due to a large number of α-motor neurons
Substantia alba for the innervation of the muscles of the extremities. In a thoracic
The Substantia alba is divided into: cross-section, the Cornu laterale is particularly recognisable with
• an anterior funiculus (Funiculus anterior) between the Fissura the sympathetic nerve cells found there (› Fig. 12.72b).
mediana anterior and the Sulcus anterolateralis
• a lateral funiculus (Funiculus lateralis) between the Sulcus an- Spinal roots, spinal nerves and plexus
terolateralis and the Sulcus posterolateralis In the Radix anterior there are axons of nerve cells of the anterior
• A posterior funiculus (Funiculus posterior) between the Sul- and lateral horn which leave the spinal cord at the Sulcus anterolat-
cus posterolateralis and the Sulcus medianus posterior eralis and are therefore described as being efferent. Since these ax-
The two anterior funiculi – like the structure in the grey matter – ons arise, amongst others, from motor neurons lying in the Cornu
are connected with each other by fibres which overlap the midline, anterius, the Radix anterior is also known as the Radix motoria.
known as the Commissura alba anterior. The Radix posterior conversely contains axons of pseudounipolar
By comparing the cross-sections of the spinal cord at different nerve cells of the spinal ganglion (Ganglion sensorium nervi spi­
heights, as well as seeing the varying diameters of the spinal cord, it nalis), which is located in the Foramen intervertebrale at the tran-
is also possible to recognise that the amount of Substantia alba de- sition point from the CNS into the PNS (› Fig. 12.73a). These ax-
creases from cranial to caudal. It is formed primarily in the cervical ons forward impulses to the spinal cord, so are therefore afferent;
spine, which explains on the one hand why there is an increase in this is called a Radix sensoria.
the number of sensory pathways accumulating at the spinal cord Immediately after the spinal ganglion, the fibres of the Radices mo-
from caudal to cranial, and that on the other hand, the number of toria and sensoria join together to form the root of the spinal

713
12 Special neuroanatomy

Somatic plexus Visceral plexus

C1
C2 Parasympathicus (N. vagus [X])
C3
Plexus cervicalis – C4
Rr. anteriores C5 Rr. cardiaci
C1–C4 C6
C7
C8
R. pulmonalis
T1
Plexus brachialis –
T2
Rr. anteriores
Plexus cardiacus
C5–T1 T3
Ganglion sensorium Rr. pulmonales
T4
nervi spinalis
Truncus nervi spinalis T5

R. posterior T6
R. meningeus Plexus
T7
R. communi- oesophageus
cans albus T8
Plexus aorticus
R. communi- T9 thoracicus
cans griseus
Motoneuron T10 Trunci vagales
R. anterior
Major
Post- Sympathetic para- T11
ganglionic vertebral ganglion Nn. splanchnici Minor
neuron T12
N. splanchnicus Minimus
R. intergang- L1
lionaris
L2
Somatoefferent fibres (Plexus
L3
Visceroefferent fibres prevertebralis)
L4
a Somato-/visceroafferent fibres Plexus lumbalis –
Rr. anteriores L5 Nn.
L1–L4 splanchnici
pelvici
S1
S2
S3
S4
Plexus sacralis – S5
Rr. anteriores
Nn. splanchnici sacrales
L4 or L5–S4
Nn. splanchnici pelvici S2–S4
(parasympathicus)
b Ganglion impar

Sympathicus Parasympathicus

Fig. 12.73 Spinal nerve and plexus. a Composition and branching of a thoracic spinal nerve [L126]. b Somatic (left half of image) and autono-
mous (right half of image) nerve plexus. [E402]

nerve, which thus contains mixed fibre qualities (somatic motor, fibres from various segments become mixed. As a result, a spinal
somatosensory and autonomous). This spinal nerve root quickly cord segment may innervate several muscles or dermatomes and
divides into its terminal branches: R. meningeus, R. posterior, vice versa, a muscle or dermatome can be associated with several
R. anterior and in the thoracic-lumbar area as a R. communicans spinal cord segments (plurisegmental).
albus, which carries preganglionic fibres to the sympathetic chains
(Truncus sympathicus). Conversely, sympathetic impulses are
conducted back to the spinal nerve via a less stongly myelinised
Clinical remarks
R. communicans griseus (› Fig. 12.73a). Irritation or damage to the nerve roots is referred to as a
The R. posterior of the spinal nerve is responsible for the motor in- pinched spinal nerve or radiculopathy. One of the most com-
nervation of the autochtonous back muscles and the sensory inner- mon causes for this is disc problems, where most of the Nucle-
vation of the overlying skin area, whereas the R. anterior innervates us pulposus of a Discus intervertebralis presses on the nerve
roots running in the immediate vicinity. The most frequently
the ventral abdominal wall or forms nerve plexus in the cervical
affected intervertebral discs are in the lower cervical spine
and lumbosacral section to innervate the extremities; these are (C4–C7) and the lumbosacral transition (e.g., L4/5 and L5/
called somatic nerve plexus. Here the following plexus can be dis- S1). Typical symptoms are loss of sensitivity, muscle weak-
tinguished (› Fig. 12.73b, left half): ness or paralysis and the loss of muscle reflexes. In clinical
• Plexus cervicalis (C1–4) practice, from a differential diagnostic viewpoint, it is critical
• Plexus brachialis (C5–T1) to make a distinction between a radicular localisation and a
• Plexus lumbalis (L1–L4) peripheral position of a nerve lesion. Radicular symptoms fol-
low the segmental structure of the spinal cord, i.e., a lesion of
• Plexus sacralis (L4–S4)
the nerve root L4 displays loss of sensitivity in dermatome L4
The original unisegmental association of a spinal cord segment
with a dermatomyotome disappears in these areas, since the nerve

714
 12.6 Spinal cord

or a weakness of the reference muscle for the segment L4, the to REXED, a total of 10 layers, laminae, are distinguished, num-
M. tibialis anterior. If peripheral nerves lying distally of the bered from dorsal to ventral. To simplify, the Columna posterior is
plexus formation become damaged, along with fibres from assigned to laminae I–VI, the intermediate column is assigned to
several segments, the symptoms no longer follow segmental lamina VII and the area around the Canalis centralis is assigned to
classification; instead they follow the innervation pattern of
lamina X while the Columna anterior includes laminae VIII and IX
the peripheral nerve.
(› Fig. 12.74).
The significant laminae are presented below in terms of their ana-
tomical or clinical relevance. The Columna posterior receives so-
In addition to the formation of somatic plexus, autonomic nerve mato- and visceroafferents. The nerve cell bodies of the pseudoun­
plexus are also formed (› Fig. 12.73b, right half). The nerve cell ipolar neurons which convey these sensory qualities (e.g., pain and
bodies of the sympathetic fibres are located in the Cornu laterale of temperature sensations), are in the spinal ganglion. This 1st neuron
the spinal cord (C8–L3), leaving the Medulla spinalis via the Radix takes exteroceptive impulses, e.g., from pain receptors in the skin,
anterior and reaching the Truncus sympathicus via the Rr. commu- interoceptive impulses from the intestines or proprioceptive im-
nicantes albi (› Fig. 12.73b). This is composed of 21–25 paraver- pulses from the skeletal muscles or from joint and tendon receptors
tebrally-arranged ganglia connected together with Rr. intergang­ (see › Fig. 12.76). The centrally-oriented axon of the spinal gan-
lionares. Via these compounds and the returning Rr. communi- glion cells reaches the laminae I–III via the posterior root in the
cantes grisei, the sympathetic impulses are also distributed via Cornu posterior. Here there are tract cells, such as the Nucleus
segments C8–L3 further cranially and caudally (divergence cir- marginalis (in the lamina I, Substantia spongiosa, or in laminae
cuit). Ultimately, the spinal nerves in all segments are fed by sym- II–III, Substantia gelatinosa). These tract cells are therefore the
pathetic fibres, thereby also autonomically supplying the glands 2nd neuron for pain sensation (nociception) and send their cen-
and blood vessels of the extremities, e.g., for perspiration or vaso- trally-oriented axons to cranial spinal cord segments or to nuclear
constriction. Further non-configured efferent fibre pathways of areas of the brain (e.g., the thalamus). In laminae I and II, not only
sympathetic trunk ganglia are the Nn. splanchnici, which form does pain management occur, but also the processing of pain sen-
visceral prevertebral plexus, particularly in the chest and abdomen. sation, e.g., meaning the inhibition of pain transfer to the 2nd neu-
In addition to sympathetic fibres, these nerve plexus also contain ron (› Chap. 13.8).
parasympathetic fibres, which either come from the upper part of Proprioceptive impulses of depth sensitivity also pass via the poste-
the parasympathetic nervous system, the N. vagus [X], or from rior root of the Cornu posterior. The tract cells or the 2nd neuron
nerve cell bodies of the Cornu laterale of the sacral spinal cord seg- are located in the Nucleus proprius in laminae III and IV, and also
ments S2–4. in the thoracic lumbar spine in the nuclear pillar of the Nucleus
thoracicus posterior (Nucleus dorsalis, Nucleus STILLING-­
CLARKE) of the laminae V–VI, an area of origin for spino­
12.6.4 Structure of the Substantia grisea cerebellar pathways. Lamina VII includes the majority of the Co-
lumna intermedia. Here there are two important key groups: on
The Substantia grisea of the spinal cord consists of nerve cell bod- the one hand, in the thoracic spine, the perikarya of the 1st sympa-
ies, but also from interconnections of glia cell processes, dendritic thetic neuron is found in the Nucleus intermediolateralis, and on
cells and myelinised and non-myelinised axons. Collectively this the other hand, in the 2nd or 3rd sacral spine, the 1st parasympa-
network is referred to as neuropile. thetic neuron is found in the Nuclei parasympathici sacrales.
In laminae VIII and IX of the Cornu anterior, as well as intermedi-
Classification by target structures ate cells and interneurons, there are root cells, the α and γ-moto-
The various nerve cells can be differentiated into 3 groups, accord- neurons. The cell groups or pillars located in these laminae show a
ing to the respective target structure of its axons: root cells, inter- somatotopic arrangement, which is of vital importance for localisa-
mediate cells and tract cells: tion diagnosis in case of damage to the spinal cord. The motor
• The root cells are within the Columna anterior or intermedia; neurons of the axial muscles, i.e. those near the torso, are located
their fibres are somatoefferent or visceroefferent and form the furthest medially near the Fissura mediana anterior, whereas mo-
Radix anterior. tor neurons of the distal body parts, such as the hand and foot, are
• The nerve cell processes of intermediate cells do not leave the located furthest laterally. The neurons of the extremity muscles are
Substantia grisea. Intermediate cells frequently act as glycinergic
inhibitory interneurons of the spinal cord. Nucleus marginalis
• The nerve fibres of the tract cells combine together into fibre (Substantia spongiosa) Columna posterior,
pathways or tracts which then remain within the spinal cord, i.e. I Cornu posterius
II Substantia gelatinosa
forming a part of the proprioceptive apparatus of the spinal
cord, or producing an ascending connection to higher-level III Nucleus proprius Nucleus thoracicus
IV posterior
structures of the CNS and thus forming a part of the association
V
fibres. This third type of nerve cell in grey matter, the tract cells, VI
Columna intermedia,
Cornu laterale
are located mainly in the Columna posterior.
VII Nucleus
The functional differentiation of neurons in tract or root cells or X
VIII intermediolateralis
the division into a front and rear horn is induced during embryo-
logical development by the Chorda dorsalis or by the signal mole- IX
Canalis Columna anterior,
centralis Cornu anterius
cules released by it.
(Substantia grisea intermedia Nuclei
centralis)
Classification by cyto-architecture
The Substantia grisea of the spinal cord is also classified according Fig. 12.74 Laminar structure of the Substantia grisea. Cross-section
to REXED on the basis of the specific cyto-architecture. According through a thoracic spinal cord segment (T10).

715
12 Special neuroanatomy

also somatotopically arranged in the sagittal direction, so that neu- those that connect to the other sections of the CNS (association
rons of the extensor muscles are more likely to be found in the ven- fibres). The latter makes up the main mass of the Substantia alba,
tral portion of the Cornu anterior and the neurons of the flexor while the fibres of the proprioceptors envelop the Substantia grisea
muscles accumulate here dorsally. with a thin layer of Fasciculi proprii, and manufacture interseg-
mental connections (› Fig. 12.75).
Clinical remarks Proprioceptors
Isolated damage to specific nerve cell groups of the spinal cord The proprioceptors control the internal work done by the spinal
are particularly clinically relevant. Here, nerve cell groups of the cord, which takes place involuntarily and independently of supra-
laminae VIII and IX, the α-motoneurons are frequently affected. spinal centres. However, supraspinal centres can have an influence
The isolated loss of this 2nd neuron of the motor pathway sys- on the internal working of the spinal cord, modulating via de-
tem results in slack muscle paralysis and the loss of muscle
scending pathways, in the sense of strengthening or inhibiting. In-
­reflexes with retained sensitivity. While the 1st motor neuron in
the Gyrus precentralis remains intact, the motor neurons of the cluded in the work done by the spinal cord in the narrower sense
spinal cord and the motor cranial nerve nuclei are affected. In are spinal reflexes, such as muscle proprioceptive reflexes, flexor
the past, a relatively frequent reason for such cell death was reflexes and visceral reflexes. Morphologically, in addition to the
endemically-occurring infections by the polio virus. In 95% of Fasciculi proprii which are divided according to their position into
cases, the infection is asymptomatic, but if the CNS is involved anterior, lateral and posterior groups, the Tractus posterolateralis
in the disease it can lead to infantile paralysis (­ poliomyelitis). is demarcated at the tip of the Cornu posterior by intersegmental
Due to a systematic vaccination programme, initially with live
fibres. Also assigned to the proprioceptors are the descending col-
vaccine, but from 1998 also using a dead ­vaccine, the disease
has become largely extinct in western countries. laterals of the Funiculus posterior which push into the cervical
A further cause of the loss of α-motor neurons is summarised marrow as the Fasciculus interfascicularis (comma tract of
under the collective term of spinal muscular atrophy and in- SCHULTZE) between the Fasciculus cuneatus and gracilis or into
cludes a full spectrum of genetic neuromuscular disorders. the thoracic marrow as the Fasciculus septomarginalis
Spinal muscular atrophy is particularly a childhood disease, (FLECHSIG field), in the median plane of the Funiculus posterior.
displ