The sympathetic innervation of the upper extremity is derived mainly from the cervicothoracic and middle cervical sympathetic trunk ganglions via gray communicating rami which join the lower cervical nerves from the fifth to the eighth and the first thoracic nerve. The inconstant intrathoracic ramus of the second thoracic nerve which joins the first conveys sympathetic fibers arising in the second thoracic and possibly lower ganglions of the sympathetic trunk into the brachial plexus (Kuntz).1 In consequence of this finding, operative procedures for the sympathetic denervation of the upper extremity have generally been modified to include extirpation of the second thoracic segment of the sympathetic trunk, with the inferior cervical and first thoracic segments. This operation, as usually carried out, interrupts all generally recognized sympathetic pathways into the upper extremity. In some instances it fails to effect complete functional sympathetic denervation of the extremity. The persistence of functionally intact sympathetic
KIRGIS HD, KUNTZ A. INCONSTANT SYMPATHETIC NEURAL PATHWAYS: THEIR RELATION TO SYMPATHETIC DENERVATION OF THE UPPER EXTREMITY. Arch Surg. 1942;44(1):95–102. doi:10.1001/archsurg.1942.01210190098011
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