Lumbar Plexus and Pain Flashcards by Sarah Gillen

Locations of parasympathetic pre-ganglionic cell bodies

CN III, VII, IX, and X

Sacral cord (S2-4)

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Location of preganglionic parasympathetic cell bodies for vagus nerve

Dorsal motor nucleus

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Location of parasympathetic postganglionic cell bodies relevant to the abdomen

Wall of the organ (terminal)

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Parasympathetic NTs and receptors

ACh - pre and post synaptic

Nicotinic receptor

Muscarinic receptor

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Location of sympathetic preganglionic cell bodies

Intermediolateral cell column, T1-L2

[aka lateral horn]

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Location of sympathetic postganglionic cell bodies

Superior cervical ganglion

Sympathetic chain ganglion

Prevertebral ganglion (celiac, superior mesenteric, inferior mesenteric)

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Sympathetic NTs and receptors

ACh - pre-ganglionic

NE - post-ganglionic to alpha and beta receptors

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Sympathetics supplying parietal GI structures

Abdominal body wall: T7-T11

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General Sympathetics supplying visceral GI structures

Body wall abdominal viscera = T7-T11

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Which sympathetics supply viscera of stomach, liver, gallbladder, pancreas?

T6-T9

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Which sympathetics supply viscera of appendix and colon?

T10, T11

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Which sympathetics supply viscera of small bowel?

T7-T10

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Which sympathetics supply visceral pelvic and lower limb structures

T12-L2(3)

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Trace pathway of presynaptic sympathetic neurons, which all follow the same course from CNS to sympathetic trunk

Cell body in presynaptic neuron of lateral horn (T1-L2/3)

Leaves via anterior root of spinal n., becoming mixed spinal n

Fibers exit spinal nerves to autonomic paravertebral ganglion via white rami communicans to sympathetic trunk

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T/F: paravertebral ganglia run the entire length of the vertebral column

True

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4 options for presynaptic fibers entering sympathetic trunks

Ascend to higher level to synapse

Descend to lower level to synapse

Synapse at level of entry

Traverse the trunk without synapsing to become part of abdominopelvic splanchnic n. or for innervation of the suprarenal glands

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Postsynaptic fibers of the sympathetic trunks exit at level of cell body to supply the body wall and limbs via _____ nerves in _____ rami communicantes

Spinal; gray

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Postsynaptic sympathetic nerves travel to body wall and limbs. What are their 3 main functions?

Vasomotion (typically vasoconstriction)

Sudomotion (sweating)

Pilomotion (goosebumps)

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Sympathetic innervation to the lower limbs has presynaptic fibers take descent option, travelling on nerves or vessels.

Sympathetic innervation to upper limbs has presynaptic fibers take ascent option, travelling on brachial plexus or blood vessels like the subclavian.

Sympathetic innervation to the head has presynaptic fibers take ascent option where they synapse with superior cervical ganglion, travelling with the carotids.

Describe sypathetic innervation to the abdomen

4th option! Presynaptic fibers pass through sympathetic trunk without synapsing to enter an abdominopelvic splanchnic nerve, which they travel with to prevertebral ganglion like celiac, superior mesenteric, or inferior mesenteric

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T/F: abdominopelvic splanchnic nn pierce the diaphragm

True

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What do sympathetic fibers do once they have joined up with abdominopelvic splanchnics and synapsed at prevertebral ganglion?

Hop on periarterial plexus to their intended abdominopelvic viscera

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Abdominopelvic splancnic nerves include greater, lesser and least. What are their respective spinal levels?

Greater = T5-9

Lesser = T10,11

Least = T12

Visceral branches of sympthetic trunks:
Splanchnic nn arise as _____ branches of the trunks

Cardiopulm splanchnic nn convey _____ fibers to thoracic viscera and synapse in ____ ganglia

Abdominopelvic splanchnic nn convey ____ fibers to innervate the abdominal and pelvic viscera and synapse in _____ ganglia

Medial

Postsynaptic; paravertebral

Presynaptic; prevertebral

Cell bodies of sympathetic postsynaptic fibers are found in what 2 places?

Paravertebral ganglia of sympathetic trunks - fibers distributed to all parts of body EXCEPT abdominopelvic viscera (pass thru but do not synapse)

Prevertebral ganglia of paraaortic plexus; clustered around roots of major branches, fibers distributed to abdominopelvic viscera

One exception to the normal path taken by abdominal sympathetics is innervation of the suprarenal glands. What path do autonomics to the suprarenals follow?

The same path as abdominopelvic splanchnics until the prevertebral ganglia - where they will bypass the ganglia without synapsing! They synapse directly on secretory cells of the medulla which act as neurons

Sympathetic nerves have short presynaptic fibers and long postsynaptic fibers Parasympathetic nerves have _______ presynaptic fibers that synapse on intrinsic ganglia such as the _______ plexus of visceral organs

Very long; myenteric

Parasympathetic presynaptic neuron fibers are transmitted only via which 2 pathways? Which one is dominant?

Cranial outflow = CN III, VII, IX, or X = dominant (extends to left colic flexure of gut) Sacral outflow = S2-S4

What is the difference between postsynaptic ganglia in the trunk vs. the head?

In the trunk, ganglia are widely scattered, irregularly spaced, microscopic, and usually located in/on effector organ In the head there are 4 discrete ganglia: ciliary, otic, pterygopalatine, submandibular

T/F: parasympathetic nerves travel with spinal nerves and their peripheral branches

False, this is never the case. Parasympathetics usually travel with vagus n.

Functions of sympathetics in GI tract

Constriction of blood vessels of skin and GI tract (diverting blood to skeletal muscle) Decreases peristalsis, constricts sphincters Stimulates suprarenal galnds to release adrenaline Vasomotion, sudomotion, pilomotion

Functions of parasympathetics in the GI tract

Stimulates peristalsis Inhibits sphincters, stimulates contraction of bladder and rectum Primary stimulator of GI tract Active in elimination

A “splanchnic nerve” is made up of what 2 nerve components?

Visceral afferent (sensory) fiber - receptors for pain and reflexes Visceral motor (autonomic) fiber - smooth muscle, glands, etc.

Visceral afferent fibers travel with sympathetics or parasympathetics?

Both! 80% of fibers in vagus are afferents, 20% of fibers in splanchnic nn are afferent

Physiologic receptors, such as those detecting O2 saturation, travel with parasympathetics or sympathetics?

Parasympathetics (vagus or pelvic splanchnics)

Pain travels with sympathetics or parasympathetics?

Sympathetics, EXCEPT below the pelvic pain line (distal to middle of sigmoid colon)- where it travels with parasympathetics

Acute vs. chronic vs. subacute abdomen

Acute = less than 3 days duration Chronic = greater than 3 weeks duration Subacute = 3 days - 3 weeks

Pathologies of abdomen that cause pain

``` Inflammation Ischemia Stretching Obstruction Trauma Functional disease (IBS) ```

2 types of abdominal pain

Visceral - diffuse, poorly localized, often referred to somatic regions, injury to internal organs and tissues that support them Somatic - well localized, caused by injury to skin, muscles, joint, bone, and CT

Parietal pain, in contrast to visceral pain, can be localize to the ______ superficial to the site of painful stimulus Visceral pain that progresses can lead to parietal pain

Dermatome

Visceral pain can be localized by the sensory cortex to an approximate spinal cord level determined by the embryologic origin of the organ involved. Where does pain localize from foregut vs midgut vs hindgut?

Foregut (stomach, duodenum,biliary tract) = epigastric pain Midgut (small bowel, appendix, cecum) = periumbilical pain Hindgut (most of colon, including sigmoid) = suprapubic or hypogastric pain

Visceral pain travels with what sympathetics for: ``` Liver Stomach Pancreas Spleen Small intestine Kidneys Cecum Ascending colon Transverse colon Descending colon Sigmoid colon Rectum/anus ```

``` Liver = T6-9 Stomach = T6-9 Pancreas = T6-9 Spleen = T6-8 Small intestine = T8-10 Kidneys = T10-L1 Cecum = T10 Ascending colon = T10 Transverse colon = T11 Descending colon = T12-L1 Sigmoid colon = L2(3) Rectum/anus = S2-4 ```

Esophagitis Peptic ulcer Perforated ulcer Pancreatitis The above would refer pain to what embryologic origin?

Foregut

Early appendicitis Mesenteric adenitis Meckel’s diverticulitis Lymphomase The above would be referred to what embryologic origin

Midgut

Testicular torsion Urinary retention Cystitis Placental abruption The above would refer pain to what embryologic origin?

Hindgut

Intermittent cramp like pain caused by obstruction of hollow muscular viscus

Colicky pain

Pain associated with gastric ulcer

Foregut visceral pain | Worse on eating, patient tends to avoid meals

What condition might be indicated by the following? Foregut chronic visceral pain Sudden severe pain spreading all over abdomen Signs of generalized peritonitis

Perforated gastric ulcer

What condition might be indicated by the following? ``` foregut visceral pain Somatic pain in RUQ Referred pain to right shoulder Nausea/vomiting Fever Tender RUQ Positive Murphy’s sign ```

Acute cholecystitis

What condition might be indicated by the following? ``` Midgut visceral pain Somatic pain in RLQ N/V Fever Tender RLQ ```

Acute appendicitis

What condition might be indicated by the following? ``` Midgut visceral colicky pain Vomiting No flatus or bowel action Possible dehydration Distended soft abdomen, nontender Increased bowel sounds Hx of abdominal surgery ```

Adhesive SBO

What condition might be indicated by the following? ``` sudden onset severe colicky pain from loin to groin Severe back pain Patient writhing or pacing about Possible hematuria Afebrile Soft abdomen CVA tenderness ```

Passage of kidney stone

What condition might be indicated by the following? ``` Older age Weight loss Hindgut visceral colicky pain No flatus or feces Distended abdomen Increased bowel sounds Mass in LLQ ```

Obstructing cancer of descending colon

What condition might be indicated by the following? ``` Woman of childbearing age Missed LMP Sudden onset severe hypogastric pain radiating to sacral area Afebrile Localized peritonitis in suprapubic area Tenderness in rectouterine pouch ```

Ruptured ectopic pregnancy

What condition might be indicated by the following? Elderly male with hx of atherosclerotic disease such as HTN or cardiac disease Sudden onset severe back pain Pale and shocked, hypotensive Tender epigastrium Palpable impulse from aneurysm in epigastrium

Leaking aortic aneurysm