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Anatomy
Parasympathetic Nervous System

Rashed Jomard

Elham Abu-Shanab

Monday, 19/3/2012

Anatomy Lecture 17

Visceral Sensation & Referred Pain

We have a problem in medicine called the gray area. It means the pathology is somewhere, and the patient comes and complains of pain in a different area. Why do we have this problem? Because the nerve supply of internal organs visceral sensation for a long time, its pathway were not very clear. But since twenty years and at this moment we know that sensations of the stomach, intestines, heart, and esophagus actually do enter the nervous system. We dont have for example a median nerve in the abdomen or the thorax; in other words (and this is what the Dr means when he says we dont have a median nerve) we dont have somatic nerves. We have what we call: visceral nerves which carry visceral sensation. These visceral nerves are autonomic nerves. They do not initiate or end any activity they just modify it. We know for sure that the thorax and the abdomen are full of nerves and plexuses, and all of these nerves are autonomic nerves. There are even more nerves in the thorax, abdomen, and pelvis than in the CNS. Some people go so far as to say and write that the nervous system has another division other than the peripheral and the central which is the enteric nervous system, which is the nervous system in the GIT. We have so many diseases and pathologies in the GIT where the pain is felt somewhere but it is really somewhere else. And this is called referred pain.

Types of Neuronal Circuits

When we say neuronal circuits we mean the way neurons are arranged. Just like electric circuits. 1. Serial Neuronal Circuit: Where one neuron is in series with the other. 2. Diverging Neuronal Circuit: a circuit where if you put a stimulus at the first neuron, this stimulus is going to pass and divide and stimulate two, with each stimulating another two. So you end up with four neurons affected when one is stimulated. 3. Converging Neuronal Circuit: [in the picture, the part that is on the right] this is the problem, this neuron, which is an afferent neuron (sensory neuron) and it is stimulated by a skin dermatome. For example the dermatome of L1, and it is also receiving an afferent from the appendix which is an organ inside the pelvis, as well as another organ like the terminal ileum. This action potential here is going to stimulate the next neuron, which in this case is three neurons converging on one.

When the action potential is here ( ), it doesnt make any difference if it is coming from any of the three neurons converging on it. It is an action potential in any case. You cannot differentiate if the action potential is from neuron 1 or 2 or 3. Its an action potential. This is going to travel up to the brain; it reaches the parietal lobe, the sensory area, where the body is represented in a special pattern (upside down in other words the sensory homunculus). Each part of the body is represented there. For example, the fingers have a large area where you can feel very delicate things like a piece of cloth. You dont put your use your face to feel it, you use your fingers. The lips also have a large representation area. For example, a small child doesnt have mature sensation within his fingers so he tries to feel things with his lips. Now: - There is no area concerning the heart, or concerning the large intestinesThere is a very small area representing the intra-abdominal area. When these impulses, coming from the heart or the esophagus reach the brain. The brain gets confused. It wants to relate it to one of these areas, but it cannot find an area for the heart or the esophagus, so it will relate it to the dermatome! And this is why we have referred pain. If the pain is somatic, like pricking your hand, you immediately with no hesitation can point its location and say theres pain here. Because in the brain immediately it is referred to this dermatome or location. If the pain is in the heart, and you ask a patient Where is the pain? If the patient hesitates, and doesnt point it out immediately with certainty but he tells you hesitantly it is here meaning an area rather than a specific point, because he cannot relate it to an exact location. This is what is called visceral pain. Visceral pain is poorly localized. Of course, thank God we have pain, in any case to tell us there is a problem or pathology. Ex1. Pain in the shoulder joint:- The shoulder joint is C5 and the diaphragm is C5. Ex2. If a patient is having a problem with the appendix its L1 and the skin has L1. Thats why we have this referred pain. The pathology is somewhere and the patient points to a dermatome somewhere else. This is one very logical explanation which is referred pain. Pain in viscera comes to the CNS through the sympathetic and the parasympathetic and they end up in the dorsal root ganglia.

Parasympathetic NS
Last time we were talking about the sympathetic nervous system and we were saying, it is represented in the blue color here(in a slide he showed on the projector), and if we look for the blue color in the brain there is no blue color in any of the cranial nerves and none in the cervical cord. It starts at T1 and goes down to L1-L2 and further down than that there is no blue color. The Sympathetic Ganglia & Sympathetic Supply of Head and Neck. We know why we have these three cervical ganglia (the superior, middle, and inferior cervical ganglia) which receive the sympathetic from T1, T2 and probably T3. The preganglionic will come to the ganglia(I think he means the paravertebral)

and does not synapse. It goes up, if it is going to a structure higher up in the head then it is going to synapse in the superior if it is going to a structure lower down then it is going to synapse in the middle ganglia. So the head and neck receive their sympathetic from the thoracic spinal segments. And it reaches the final target through the blood vessels, and jumps from there to finally reach it through nerves. Note: Just remember that the fibers that are from the thoracic spinal segment until one of the cervical ganglia is preganglionic. Synapse occurs in the cervical ganglia. Then those fibers going to the target structures in the head and neck carried by blood vessels then nerves are postganglionic. The same target organs for the sympathetic are the same for the parasympathetic. So we start to look for the red color. We notice first that the brainstem has the red color and what come through the brainstem are four cranial nerves which have specific and well-localized parasympathetic ganglia. Then we come to the cervical part, no parasympathetic outflow. All along the thoracic and lumbar no parasympathetic out flow. There is parasympathetic outflow from spinal segments S1-S3. There is no similar arrangement in the sympathetic trunk compared to the parasympathetic, because if you look at the first red line which is going to the eye (referring to the Oculomotor N). There is a ganglion, which is usually near the organ. We dont call it paravertebral like the sympathetic, it is as near as possible to the target organ. Number two line, the Facial N goes to the face. Number three is the Glossopharyngeal N. Number four which is the Vagus N is going to travel to the neck(supplying structures in the neck), to the thorax(supplying the heart and esophagus and the lungs), and to the abdomen(supplying most parts of the GIT down to this point which is at a distance of two thirds of the transverse colon where the Vagus ends). The Vagus will do the job of the sympathetic trunk, comparably. Then In the pelvis we have three spinal segments which will send parasympathetic nerves to the pelvis, like the urinary bladder, uterus, prostate, urethra, external genitalia, rectum, sigmoid colon plus descending colon and the left one third of the transverse colon. The outflow in case of the sympathetic is thoraco-lumbar The outflow for the parasympathetic is cranio-sacral

The Four Parasympathetic Ganglia in the Head

First we will go through the general arrangement, and then each one will be discussed in specific.

Fact #1: These parasympathetic ganglia are the place where the preganglionic neurons end and synapse on postganglionic neurons, which will travel a short distance and end up in a target. Fact #2: This ganglion which contains multiple structures is not going to be flying within connective tissue. It is going to be suspended with some structure, which is usually a nerve going to this target organ or to a nearby organ. This nerve is going to send a part of its fibers to run through this ganglion without any synapse. Fact #3: we have a third type of fiber passing through this ganglion, which are the sympathetic. They come from a blood vessel (of course this is since we are talking about the four parasympathetic ganglia within the head and neck!). They join a nerve, enter the ganglia, they dont synapse and end up within the same target. Do we need this sympathetic? Yes. Most targets have double supply by both sympathetic and parasympathetic. Although blood vessels only receive sympathetic. Note: Remember that these ganglia are very close to their target. Note: Remember that there is no synapse for the sympathetic because they have already synapsed within the superior cervical ganglia. So they are postganglionic. Meaning that this ganglion is going to have a preganglionic parasympathetic fiber ending, the cell body and part of the axons of the postganglionic parasympathetic fibers, the postganglionic sympathetic fibers, and the suspending fibers which can be of a sensory modality or a motor. Some references call them suspensory(suspending) fibers, whatever their modality is. Just like hanging the jacket on the hanger. The hanger has nothing to do or is not related to the function of the jacket. So these fibers, running through the ganglia also have nothing to do with the function of the ganglia. (Although some references call them sensory fibers.) (1) Ciliary Ganglion: Suspending Fibers: branches of the Nasociliary N. going to the eye and they are called Ciliary N. The ones that dont pass through the ganglion are called the Long Ciliary N. The ones which pass through the ganglion are called the Short Ciliary N. These are what we call the suspensory fibers or the sensory fibers.

Parasympathetic: comes from the Edinger-Westphal nucleus of the Oculomotor N. These parasympathetic fibers come through the Oculomotor, enter the inferior branch of Oculomotor, enter the ganglion, synapse and the postganglionic will pass through the Short Ciliary N. to the target. Sympathetic: will come from the internal carotid, passing through the superior and inferior branches of the Oculomotor N. and the ones which travel through the inferior branch of the oculomotor will end up passing through the ganglion and reaching the target, which is the eye. Q)What is the Long Ciliary N.? Sensory or motor? A)The fibers of the Long Ciliary are sensory fibers of the Nasociliary. Now you will read in many books, and this is correct, that the sympathetic carried by the internal carotid within the cavernous sinus will join both branches of the Oculomotor, the inferior and superior branches. So the sympathetic will reach the eye through both the Long Ciliary and the Short Ciliary. When the question is only the Long Ciliary, we will say that the Long Ciliary will have (1)sensory fibers bringing pain and sensation from the eye and (2)sympathetic to the eye. Of course keeping in mind that this is the case in not only in the Nasociliary N., but also within the Median N, Ulnar Netc. If you ask yourself what is the component of any peripheral nerve? The answer is: sensory + motor + sympathetic. Unless of course indicated otherwise. There are nerves that contain parasympathetic. They are only the four cranial nerves. Finally, the nerve going to the target from the Ciliary ganglion is going to include sensory from the eye, postganglionic parasympathetic, and postganglionic sympathetic. (2) Pterygopalatine Ganglion: Suspending Fibers: The sensory fibers suspending the Pterygopalatine ganglion is from the Maxillary N. Parasympathetic: The preganglionic fibers going into the ganglion to synapse are coming from: the Facial N. through the Greater Petrosal N. They synapse and the postganglionic will go through the branches of Maxillary. Sympathetic: through the Deep Petrosal N. which comes from the internal carotid artery which dont synapse within the ganglion. They get distributed to target organs. Because in the case of the Pterygopalatine ganglion the target organs are from the Lacrimal gland and down(including the glands of the nose and mouth). Q)Is the Deep Petrosal N itself sympathetic or do sympathetic fibers run with a nerve called the Deep Petrosal? A)The Deep Petrosal N is composed completely of sympathetic fibers. It enters the pterygoid canal, and meets the Greater Petrosal N. Q)A branch of what is the Great Petrosal N?

A)The Maxillary N. (3) Otic Ganglion: Suspending Fibers: the nerve to Medial Pterygoid coming from the main trunk of the Mandibular N which are going to the medial pterygoid, the tensor tympani, and tensor palati as well. This nerve is motor. (While the Maxillary of the Pterygopalatine G and the Nasociliary of the Ciliary G were both sensory this here is motor, which is why it is better to call it suspensory fibers. Since again their function is to hold the ganglia and hang it). Parasympathetic: The preganglionic parasympathetic which is going to enter the Otic ganglion is coming from the Lesser Petrosal N coming from the Glossopharyngeal N. They will synapse, and their target is the Parotid gland. Therefore it will send these postganglionic fibers through the Auriculotemporal branch of the Mandibular N to reach the target which is the parotid. (4) Submandibular Ganglion: Suspending Fibers: The nerve that is suspending this is the Lingual N. Parasympathetic: The parasympathetic fibers are coming from the Facial N, passing through the canal within the middle ear. In the middle ear it(Facial N) sends fibers through the Chorda tympani, and the Chorda tympani reaches the Lingual N, and so reaches this ganglion, where these parasympathetic fibers synapse. The postganglionic parasympathetic fibers, which are again very short, reach the very near target organs which are the Submandibular and Sublingual glands. Sympathetic: The sympathetic fibers come from the Lingual artery.

(Now the Dr is going through the slides, Parasympathetic NS from the beginning, so you can follow up). (Slide 2): There is a difference between the sympathetic and the parasympathetic which you know very well. The Sympathetic being known for its short preganglionic, and long postganglionic. The opposite is true for the parasympathetic, meaning very long preganglionic and very short postganglionic. The neurotransmitter is Acetylcholine. Which is something that is very widely discussed in pharmacology like in cholinergic drugs and anticholinergic drugs. Where certain drugs block specific receptors like muscurinic or nicotinic. Also we have alpha and beta receptors. Why should we talk about sympathomimetic and sympatholytic drugs in NS 2? Because we have so many organs and systems within the body which are affected by these drugs like the heart, the lungs, the GIS, etc. which are all internal organs going to be modified by these drugs. (Slide 3): Again, you have to know this so that you can orient yourself for pharmacology. (Slide 4): We have already gone through this: especially these four ganglia.

 (Slide 5): Again, this is the same story in this picture, since there are so many pics about this topic. As you can see here the Vagus, which is doing a great job is, a very important nerve. Is the Vagus a great motor nerve? Yes. Because it innervates muscles of the lung (bronchiole muscles), large amount of muscles within the GIT, huge number of glands within the respiratory and gastrointestinal system. It is also a great sensory nerve.
One of the recent advancement is that they use the Vagus N in the treatment of epilepsy. They put (just like the artificial pacemaker of the heart), an electrode on either side of the Vagus N, and it makes the fits of epilepsy shorter and wider apart. So that they happen less frequently and last for a shorter time. Why is that? Difficult or not explainable till now.

(Slide 6): Again, for example this is the Sphenopalatine ganglion (Pterygopalatine ganglion), which is suspended from the Maxillary of the Trigeminal. The nerve sending the parasympathetic to synapse within the ganglion is the Facial N, which will end up (through postganglionic parasympathetic) in the nose and mouth and of course the Lacrimal gland. These are the sympathetic fibers which come through the blood vessels (coming from the internal carotid here), and they are postganglionic and dont synapse. (Slide 7): This is showing you that sympathetic and parasympathetic are balanced. If you have increased sympathetic you have decreased parasympathetic. And vice versa is of course true. (Slide 8): Again, dont forget the huge system of nerves in the thorax, abdomen, and pelvis. (Slide 9): Same plan. Red lines somatic, sensory or motor, which enter the ganglia and leave without synapsing, just holding it. The synapsing ones are the green, which are only the parasympathetic. And the brown lines are the sympathetic which pass through without synapsing to the target organ. (Slide 10): Same picture, but not a very good one. This is the Ciliary ganglia. The target is the eye. (Slide 11 + 12): Again, the same pictures. (Slide 13): The pupil and the pupillary reflex. Where we take a look at the pupil and see if the parasympathetic activity is dominating then the pupil is constricted. Why? Because of the effect of the parasympathetic of the Ciliary ganglion. And this causes it to constrict which is the action of Ach. The radial muscles are innervated by sympathetic, because they dilate the pupil. (Slide 14): this is the Ciliary ganglion within the cone of muscles, lateral to the optic nerve. (Slide 15 + 16 + 17): The Pterygopalatine ganglia. This is showing you that this is the sympathetic plexus in the wall of the internal carotid (show in slide 17). It also shows you the Pterygopalatine ganglia in the Pterygopalatine fossa. (Slide 18): This is how the parasympathetic reach the Lacrimal gland. And that was all he went through in the slides.

Parasympathetic NS (Mind Map)

(Dr asked this question explaining that it was to prepare us for the next lecture): How do we regulate our internal organs?

Reflexly & involuntarily. We regulate, not stop or prevent, or initiate. And this is done reflexly and involuntarily. Autonomic reflexes from the: (1)carotid body and carotid sinus, (2) the aortic arch, (3) the pharynx, (4) the respiratory system, and (4) the local GIT system. They will travel through the VAGUS. So this nerve provides huge input. Some people say that 80% percent of the Vagus is sensory, and this is of course difficult to determine. But there is a huge sensory input through the Vagus. *Mechanical receptors in the liver, GIT, airways, heart all travel through the Vagus. *Stretch receptors (which are found wherever we have a cavity and the wall) in the respiratory system pipes, blood vessels and GIT. These travel mainly through the Vagus as well *Baroreceptors coming through both the Glossopharyngeal and Vagus. All these stimuli (baroreceptors, stretch receptors, chemical, mechanical receptors and reflexes), they end up in a structure called the Solitary Complex. It is called a complex because it is made up of a nucleus and a tract. Its arrangement is quite strange, with the tract in the middle and the nucleus is surrounding it. Usually its a nucleus giving a tract or a tract reaching a nucleus. Here it is a special arrangement. Where is it? Most of the length of the medulla + the lower part of the pons. It is also lateral to the motor nucleus of the Vagus. (This relation is important.) Q)I think it was a question about a vagatomy and if that is done then shouldnt the patient lose all of these reflexes and sensory input? A)Yes. Medicine is a balance. When a patient comes to you complaining of hyperacidity with a duodenal ulcer or very bad gastro-esophageal reflux causing a very bad and constricted esophagus. What do you do? You either compromise

this patients sleep, comfort, and the fact that he cannot go to work, with pain. Or you sacrifice this patients Vagus. Its a balance. He is losing his Vagus and its important functions but getting a lot in return.

This huge number of stimuli and reflexes will end up in this nucleus which is divides into two parts: The caudal and the rostral. The caudal being the distal part, and the rostral being the nearer to the head. The caudal is going to receive all of this huge input. The rostral is gustatory. Meaning taste. It is of course receiving taste through the: 1)Trigeminal (anterior two thirds of the tongue?), 2)Vagus, 3)Glossopharyngeal, and 4)Facial. All this input will go to this part of the nucleus. Q)If the solitary tract nucleus (the rostral part receives gestation or taste), then why would it receive input from the trigeminal which does not carry taste? A)The trigeminal does carry taste sensation. (And this is how the Dr explained it): When you start teaching a medical student taste you teach him: anterior 2/3 Facial, posterior 1/3 Glossopharyngeal..etc. This is a small idea, a small picture. When you go to the big picture with more details you need to know that taste buds are not only present on the dorsum of the tongue like you learned but are also present on the soft palate and the floor of the mouth as well. Some people even say that there are taste buds within the pharynx and upper esophagus. (And he insisted on this fact): A few taste buds from the floor of the mouth go through the lingual branch of the Mandibular branch of the trigeminal. So these fibers carrying taste are carried within the trigeminal. People who studied the solitary tract nucleus found this o You always start with an idea and expand on it. Like the facial nerve, people tought you that (probably me included tought you that the Facial N was motor. No w we tell you the facial nerve is motor and sensory. What is the evidence? Ramzi-Hunt syndrome; Herpes-Zoster of the Facial N where the patient will have vesicles and papules on the external ear which is evidence of it having cutaneus sensation.

What is the solitary tract nucleus going to do with all these inputs from organs? (1) the immediate response will be reflex. Which is a group of responses going down immediately from the tract to the organs. These are autonomic reflexes. (2)This solitary complex will send a big arrow to the thalamus so that is goes up to the areas 1,2,3(Primary somatosensory area), (3) sending fibers to many brainstem nuclei, (4) the dorsal motor nucleus, (5)respiratory centers, (6)singulate gyrus(for emotion memory and learning).

Which part of the CNS is going to deal with internal regulation of organs? Solitary tract nucleus. With the major contributor of the system being the Vagus. Finally: a very important example of referred pain: The Vagus of course mediates esophageal reflexes, superficial and deep cardiac reflexes, and pulmonary reflexes. Now pain in the esophagus will be referred to the same area of pain of the heart. Because a patient is going to complain of pain in the cardiac area, and many of them who are diagnoses as having cardiac problems are in reality having esophageal problems. Not all, and not the majority, but many of patients who have esophageal diseases are diagnosed as having cardiac diseases though they dont have a cardiac problem but an esophageal problem. So if you get a patient complaining of problems with the pericardial area, investigate the heart and the esophagus. I am not saying that all pain in the pericardial area is due to the esophagus but I am saying that they have the same limb. The End