What's up!

Let’s go ahead and continue with our Peripheral

Nervous System.

Previously we’ve covered the cervical plexus,

the brachial, lumbar and sacral plexuses.

The next thing that we’re going to talk

about now are nerves that’re located within

the thoracic wall.

The thoracic nerves we call them.

So here we see a plan anterior view of the

thorax.

We see the costal bones, sternum, and the

vertebra.

The Intercostal space is the space between

the ribs, as you see here.

There are 11 spaces on each side and they

are numbered according to the rib which is

the superior border of the space.

1st intercostal space under the 1st rib, 2nd

intercostal space under the 2nd rib, and so

on.

It goes all the way down to the 11, so again

we got 11 intercostal spaces.

Now the Throacic nerves are distributed

Now.

The thoracic spine has 12 nerve roots.

So from T1 all the way down to T12, there

are nerves that go out from the spine on each

side, similar to the rest of the spine.

The anterior root of the nerves in the thoracic

region branch off and control both the motor

and the sensory signals in the thoracic and

the abdominal wall.

These nerves leave the thoracic spine, and

are therefore referred to as the thoracic

nerves.

So we got one nerve that run underneath each

rib, and are numbered according to each nerve

that they run underneath.

As you see here.

If these thoracic nerves run within an intercostal

space, they’ll get the name intercostal

nerves.

So we got 11 intercostal nerves, since we

got 11 intercostal spaces.

The last nerve that run underneath the 12th

rib, is referred to as the subcostal nerve.

So in this video, we’re first going to go

detailed into the intercostal nerves.

We’ll talk about their course, and branches.

And a traditional division of them called

typical and atypical intercostal nerves.

Then we’ll talk a little bit about the subcostal

nerve so that we cover all the thoracic nerves

that’re relevant to know regarding the peripheral

nervous system.

Awesome.

So.

Course.

How do the intercostal nerves go?

Here you see a plan anterior view of the thorax

along with the intercostal muscles.

If we now cross over the thorax like this,

right over the rib.

Then take away the upper part, and schematically

draw what we’ll see from this view.

What we now can see is the vertebra, let’s

say T6, sixth thoracic vertebra.

And the sternum.

In the intercostal space, the most external

muscle is called the external intercostal

muscle.

And remember, unlike the other two intercostal

muscles, the external intercostal muscle does

not retain its muscular character all the

way to the sternum, and so the tissue that’s

left towards the sternum is called the Anterior

intercostal membrane, or the external intecostal

membrane.

Then we got the posterior intercostal memberane,

or the internal intercostal memberane, from

where the internal intercostal muscle come

from.

Then a little more internally.

You know we’re at T6 so we might see a subcostal

muscle.

We can see the Innermost intercostals, which

comprise the third and deepest layer of intercostal

muscles.

They are located deep to the internal and

external intercostals, filling all the 11

intercostal spaces between the ribs.

And then more anteriorly we might have the

Sternocostalis muscle.

And then as you move even more internally

you might find the parietal pleura.

Alright.

Let’s now add the spinal cord.

Let me test your knowledge know.

Off from the spinal cord comes two nerves

that unite.

These are called?

The dorsal root and the ventral root.

They unite and form the spinal nerve.

The spinal nerve give off a branch called

dorsal ramus, which carries information that

supplies muscles and skin sensation to the

back.

They’re also connected to the sympathetic

chain ganglion through the grey and white

rami communicans.

And then we got the anterior division.

And the anterior division of the thoracic

region T1 to T11 are called intercostal nerves.

So let’s go ahead and grey out all the other

nerves.

The intercostal nerves enter their corresponding

intercostal space between the posterior (internal)

intercostal membrane and the parietal pleura.

And then they run anteriorly towards either

the sternum or the rectus abdominis muscle.

The upper six goes to the sternum and the

lower six goes towards the rectus abdominis

muscle.

The typical intercostal nerves are mixed nerves

carrying both motor and sensory innervation

for the thoracic and abdominal walls.

The motor branches for the intercostal muscles

are branches that supply regional muscles.

So, the intercostal nerves supply all the

intercostal muscles, as well as muscles like

the subcostal muscles, serratus posterior

superior, levatores costarum and transversus

thoracis muscles.

The cutaneous branches are the lateral cutaneous

branches, which further divide into anterior

and posterior branches, and the anterior cutaneous

branches which also divide into medial and

lateral branches.

These branches supply segmental sensory innervation

to the skin of the anterolateral walls of

the thorax and abdomen.

And you know you can use this Dermatome map

to see the sensory distribution of each dermatome

across the body.

And so, a dermatome refers to the area of
the skin in which sensory nerves derive from

spinal nerve root.

The dermatomes related to the thorax and abdomen

are T1-T12 anteriorly, each is quite evenly

spaced, with T1-T6 being nearly horizontal

lines that extend over the thoracic wall.

While the dermatomes T7-T12 start horizontally

in the thoracic wall, but anteriorly, they

tend to dip inferiorly and extend onto the

abdominal wall.

And now you might be wondering why I’m showing

you this.

Well this type of mapping is a useful clinical

way to localise lesions, damage, or injury

to specific spinal nerves.

So if you get a patient in which you suspect

damage to the spinal cord.

You can try to localize where the damage is

by checking which dermatome the patient doesn’t

feel any sensation at.

Alright so that was the motor branches and

the sensory branches.

Another branch that we should talk about here

is the collateral branches.

Each intercostal nerve give a collateral branch.

And they arise close to the angles of the

ribs and course along the superior border

of the inferior rib to innervate the intercostal

muscles, parietal pleura, and the periosteum

of the rib.

And if we take a segment of the thoracic wall,

you can see that the intercostal nerves run

in a so called neurovascular bundle, located

in the costal groove right underneath each

rib, between the internal intercostal muscle

and innermost intercostal muscle.

It’s called neurovascular bundle so we got

vessels here aswell, and they’re arranged

as Vein, Artery and Nerve, from the most superior

to the most inferior.

An easy way to remember that is to use a mnemonic

VAN.

And notice how the collateral neurovascular

bundle runs at the lower edge of the space,

and the order is reversed, so we first have

the nerve, artery and then vein from superior

to inferior.

You’ve probably heard about a procedure

called thoracocentesis, or pleural tap.

This procedure si done to evacuate fluid from

the pleural space.

And to do so you have to put a needle right

above the superior margin of a rib.

This ensures that the needle passes through

the lower part of the intercostal space, avoiding

the intercostal neurovascular bundle.

That’s why it’s important to know the

exact anatomy of the intercostal space so

that you reduce the risk of complications

while sticking needles in the patients thorax.

Alright.

So we’ve covered the course, we’ve covered

the branches.

Now.

Although the majority of intercostal nerves

follow a similar pattern from origin to course

and branches, there are some differences among

them.

And these diffences are why we sometimes divide

the intercostal nerves into typical and atypical

intercostal nerves.

The main reason for this division is that

the typical intercostal nerves course solely

in their own intercostal spaces, while the

atypical spinal nerves go beyond the thoracic
wall to supply other regions.

The term ’typical’ refers usually to the

third , fourth, fifth and sixth intercostal

nerve, while the rest are considered to be

atypical.

So first and second intercostal nerve.

As well as 7, 8, 9, 10 and 11 intercostal

nerve.

Alright.

So.

First intercostal nerve.

The first nerve is special.

It’s special because the anterior ramus

of the first thoracic spinal nerve terminates

by bifurcating around the neck of the first

rib into two branches: superior and inferior.

The larger, superior branch exits the thoracic

cavity and joins the brachial plexus.

As you see here

While the inferior branch, also known as the

intercostal branch, becomes the first intercostal

nerve.

This nerve goes within the first intercostal

space below the rib, and ends as the first

anterior cutaneous branch on the anterior

chest wall.

And note that we still have a collateral branch

and a lateral cutaneous branch.

The second intercostal nerve has exactly the

same branches as all the other nerves, except

that the lateral cutaneous nerve is longer.

It’s longer because it’s referred to as

the intercostobrachial nerve.

So the intercostobrachial nerve is a lateral

cutaneous branch of the second intercostal

nerve that supplies sensation to the skin

of the axilla.
So It leaves the second intercostal space
at the midaxillary line and then pierces the

serratus anterior muscle to enter the subcutaneous

tissues of the axilla.

A little fun fact about this nerve is that

it’s also referred to as the ‘tickle’

nerve, given it supplies the skin of the axilla.

Then we got all of those nerves right here.

We got Intercostal nerve number 7, 8, 9, 10,

11.

These nerves also enter and run in their corresponding

intercostal spaces while still providing supply

for the thoracic wall and the intercostal

muscles.

However, after they’ve run in the intercostal

spaces, the nerves course behind the costal

margin into the abdominal wall where it terminates

as anterior cutaneous branches.

These intercostal nerves supply skin and muscles

of this region, as well as the parietal peritoneum.

And since they innervate both thoracic and

abdominal walls, these nerves are referred

to atypical, and also sometimes also referred

to as the thoracoabdominal nerves.

So that was all the atypical nerves.

The typical nerves, the 3rd, 4th , 5h and

6th intercostal nerve are typical because

remember they keep their respected intercostal

space.

And they have the typical branches of the

intercostal nerves.

They have motor branches for all the muscles

in their corresponding area.

They have the lateral cutaneous branches,

which remember divide into anterior and posterior

branches, and the anterior cutaneous branches

which also divide into medial and lateral

branches.
And they also have collateral branches, which
course along the superior border of the inferior

rib to innervate structures like the intercostal

muscles, parietal pleura, and the periosteum

of the rib.

So that was all I had for the intercostal

nerves.

The last nerve is called the subcostal nerve.

This nerve is the last and the largest of

all the thoracic spinal nerves.

For the most part of its course, the nerve

follows the inferior margin of the 12th rib,

running together in a neurovascular bundle

with artery and vein.

Then, it passes in front of the quadratus

lumborum muscle and pierces the transversus

abdominis muscle.

On its course, the subcostal nerve gives off

several types of branches, which are similar

to the intercostal nerves.

It gives off muscular branches, which innervate

the muscles of the abdominal wall including

the pyramidalis muscle, internal oblique,

external oblique and transversus abdominis

muscle.

It also has the Lateral cutaneous branch;

which pierces the internal and external oblique

muscles and runs towards the gluteal region.

It has a collateral branch, which is also

similar to the intercostal branches.

This branch innervates the parietal peritoneum

and the peripheral parts of the diaphragm.

It also has the anterior cutaneous branch,

which you know is also a terminal.

It terminates in the anterior portion of the

abdominal wall supplying the skin over the

lower abdomen, or the suprapubic region and

the inguinal region.

Now what’s special with the subcostal nerve

is that it also give off the communicating

branch.

The communicating branch is a branch that

merges with the iliohypogastric nerve to help

form the lumbar plexus.

Alright guys so that pretty much covers the

thoracic nerves.

Thank you so much for watching another one

of my videos.

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Peace.