LECTURE -I

Intercostal Spaces
&
Its Content

BY
Dr Farooq Khan Aurakzai

Date: 18.04.18
 Nerve supply of intercostal
muscles:
 The intercostal nerves are part of
the somatic nervous system.

 They arise from the anterior rami of

the thoracic spinal nerves from T1 to T11.

 The intercostal nerves are distributed chiefly

to the thoracic pleura and
abdominal peritoneum.
 They differ from the anterior rami of the
other spinal nerves in that each pursues an
independent course without plexus
formation.
 Intercostal nerves…..con’t

 These muscles are innervated by corresponding

intercostal nerves.

 The neurovascular bundles of the intercostal

spaces run between the middle and inner muscle
layer (between the internal intercostal and
innermost intercostal muscles).

 They are arranged in the following order from

above downwards.

 Intercostal vein > Intercostal artery > Intercostal

nerve (VAN)
 Intercostal nerves…..con’t

 The first two nerves supply fibers to the upper

limb in addition to their thoracic branches.

 The next four are limited in their distribution

to the walls of the thorax.

 The lower five supply the walls of the thorax

and abdomen.

 The 7th intercostal nerve terminates at

the Xyphoid process, at the lower end of
the sternum.

 The 10th intercostal nerve terminates at

the navel.

 The twelfth (subcostal) thoracic is distributed

to the abdominal wall and groin.
SPINAL NERVE
 The 1st thoracic nerve
 The anterior division of the first thoracic nerve
divides into two branches.

 One, the larger, leaves the thorax in front of

the neck of the first rib, and enters the brachial
plexus.

 The other and smaller branch, the first

intercostal nerve, runs along the first
intercostal space, and ends on the front of the
chest as the first anterior cutaneous branch of
the thorax.

 Occasionally this anterior cutaneous branch is

missing.

 The first intercostal nerve rarely gives off a

lateral cutaneous branch; but sometimes sends
a small branch to communicate with the
intercosto brachial nerve.
 2nd thoracic nerve

 From the second thoracic nerve it

frequently receives a connecting
twig, which ascends over the neck
of the second rib.

 This nerve was first described by

Kuntz in 1927.

 There is considerable anatomic

variation, but Kuntz nerve may be
present in 40-80% of the
population.
 The upper thoracic nerves: 2nd–6th
 The anterior divisions of the second, third,
fourth, fifth, and sixth thoracic nerves, and
the small branch from the first thoracic.

 They are confined to the walls of the thorax,

and are named thoracic intercostal nerves.

 They pass forward in the intercostal spaces

below the intercostal vessels.

 At the back of the chest they lie between the

internal intercostals and the innermost
intercostals then anteriorly they lie between
the pleura and the internal intercostals.
 Thoraco-abdominal nerves
 The anterior divisions of the seventh, eighth,
ninth, tenth, and eleventh thoracic intercostal
nerves are continued anteriorly from the
intercostal spaces into the abdominal wall.

 Hence they are named thoraco-abdominal

nerves.

• They have the same arrangement as the upper ones

as far as the anterior ends of the intercostal spaces,
where they pass behind the costal cartilages, and
between the Obliquus internus and Transversus
abdominis, to the sheath of the Rectus abdominis,
which they perforate.

• They supply the Rectus abdominis and end as the

anterior cutaneous branches of the abdomen; they
supply the skin of the front of the abdomen.
 Branches of the NERVE
 Numerous slender muscular filaments supply
the Intercostales, the Subcostales, the Levatores
costarum, the Serratus posterior superior, and
the Transversus thoracis.

 At the front of the thorax some of these

branches cross the costal cartilages from one
intercostal space to another.

 Lateral cutaneous branches:

 They are derived from the intercostal nerves,

about midway between the vertebrae and
sternum.

 They pierce the external Intercostal

and Serratus anterior, and divide into anterior
and posterior branches.
 Branches…..con’t

 The anterior branches run forward

to the side and the forepart of the chest
and skin, fourth nerve anterior
branches supplying the breast.
 Those of the fifth and sixth nerves
supply the upper digitations of
the Oblique externus abdominis.

 The posterior branches run

backward, and supply the skin over
the scapula and Latissimus dorsi.

 The lateral cutaneous branch of the

second intercostal nerve does not
divide, like the others, into an anterior
and a posterior branch; it is named
the intercostobrachial nerve.
 Subcostal nerve
 The anterior division of the twelfth
thoracic nerve (subcostal nerve)
 It is larger than the other nerve.

 It runs along the lower border of the twelfth

rib, often gives a communicating branch to the
first lumbar nerve.

 It then runs in front of the quadratus

lumborum, innervates the transversus, and
passes forward between it and the obliquus
internus to be distributed in the same manner
as the lower intercostal nerves.

 It communicates with the iliohypogastric

nerve of the lumbar plexus, and gives a branch
to the Pyramidalis.
 It also gives off a lateral cutaneous branch
that supplies sensory innervation to the skin
over the hip.
 Thoracic wall arteries
 The arterial supply to the thoracic wall is derived from
the following sources:
 1. Thoracic Aorta:
 Through the posterior intercostal arteries.

 2. Subclavian Artery:
 Through the internal thoracic and supreme intercostal
artery.
 3. Axillary Artery:
 Through the superior and lateral thoracic arteries.

 The intercostal arteries course through the thoracic wall

between the ribs.
 With the exception of the 10th and 11th spaces, each
intercostal space is supplied by three arteries i. e:
posterior I. Arteries and its collateral branches and an
anterior I. Arteries.
 Anterior intercostal arteries

 The 1st to 6th anterior intercostal arteries arise

directly from the lateral aspect of the Internal
thoracic artery.

 The 7th to 9th arise from the Musculophrenic

artery a branch of the internal thoracic artery.

 In each interocostal space, the anterior intercostal

artery divides in to paired branches:

 In the 2 most inferior intercostal spaces (10th and

11th spaces), the anterior intercostal artery is
absent, with the posterior intercostal artery
supplying each space solely.
 Internal thoracic artery
 The internal thoracic artery (ITA),
previously known as the internal
mammary artery is an artery that supplies
the anterior chest wall and the breast.

 It is a paired artery, with one running along

each side of the sternum, to continue after
its bifurcation as the superior
epigastric and Musculophrenic arteries.

 It travels downward on the inside of the

ribcage posterior to the costal cartilages,
approximately a centimeter from the sides of
the sternum.

 After passing the sixth intercostal space, the

internal thoracic artery splits into
Musculophrenic and Sup. Epigastric.
 Musculophrenic Artery

 The arises from the internal

thoracic artery.

 It is directed obliquely
downward and laterally, behind
the cartilages of the false ribs.

 It perforates the diaphragm at

the eighth or ninth costal
cartilage, and ends, considerably
by reducing in size.
 POSTERIOR Intercostal Arteries

 The posterior intercostal arteries are

arteries that supply blood to the intercostal
spaces.

 There are eleven posterior intercostal arteries on

each side.

 The 1st and 2nd posterior intercostal arteries

arise from the supreme intercostal artery, a
branch of the costocervical trunk of
the subclavian artery.
 POSTERIOR Intercostal arterIes….con’t
 The lower nine arteries are
the aortic intercostals, so called
because they arise from the back of
the thoracic aorta.

 The right aortic intercostals are

longer than the left because of the
position of the aorta on the left side
of the vertebral column.

 They pass across the bodies of

the vertebrae behind
the esophagus, thoracic duct,
and azygos vein, and are covered by
the right lung and pleura.
 POSTERIOR Intercostal arterIes….con’t
 The left aortic intercostals run backward
on the sides of the vertebrae and are
covered by the left lung and pleura.

 Each artery then divides into an anterior

and a posterior ramus.

 A given posterior intercostal artery travels

along the bottom of the rib with its
corresponding posterior intercostal vein, as
well as the intercostal nerve of the given
space.

 The vein is superior to the artery, and the

intercostal nerve is inferior to it.
Commonly, the mnemonic, "Van," is used
to recall the order of the vein, artery and
nerve, from superior to inferior.