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Background: Radiological diagnosis of thoracic nerve diseases is difficult because they are rare, and nerves cannot be seen directly on radiological images. The major nerves of the thorax can be listed as the phrenic, vagus, recurrent laryngeal, long thoracic nerve pairs, sympathetic chains, costal nerves, and brachial plexus. Diseases of thoracic nerves have various causes, including traumatic injury, neuromuscular diseases, infection, compression, radiation, drugs, and tumors., Objective: This pictorial review aims to describe the anatomic locations of the major thoracic nerves on radiological images, comprehensively describe the causes of thoracic nerve diseases and define the clinical signs and primary and secondary imaging findings of dysfunction of the thoracic nerves., Methods: This paper was designed to illustrate primary and secondary imaging findings of nerve diseases. Firstly, the normal anatomy of nerves is shown with diagrams. Secondly, we explained primary and secondary imaging features with variable radiological methods, including chest X-Ray, magnetic resonance imaging, and computed tomography., Conclusion: Primary findings of nerve diseases can be detected if radiologists are familiar with the courses of the nerves on radiological images. Knowledge of the normal functions of the nerves can aid in diagnosing thoracic nerve diseases identified from secondary imaging findings such as diaphragmatic elevation, muscular atrophy, and winged scapula. It is essential to know the normal anatomy, function, and possible causes of thoracic nerve diseases to make a correct diagnosis and apply the prompt treatment., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Introduction: Thoracolumbar interfascial plane (TLIP) block has been discussed widely in spine surgery. The aim of our study is to evaluate analgesic efficacy and safety of TLIP block in spine surgery., Method: We performed a quantitative systematic review. Randomized controlled trials that compared TLIP block to non-block care or wound infiltration for patients undergoing spine surgery and took the pain or morphine consumption as a primary or secondary outcome were included. The primary outcome was cumulative opioid consumption during 0-24-hour. Secondary outcomes included postoperative pain intensity, rescue analgesia requirement, and adverse events., Result: 9 randomized controlled trials with 539 patients were included for analysis. Compared with non-block care, TLIP block was effective to decrease the opioid consumption (WMD -16.00; 95%CI -19.19, -12.81; p<0.001; I2 = 71.6%) for the first 24 hours after the surgery. TLIP block significantly reduced postoperative pain intensity at rest or movement at various time points compared with non-block care, and reduced rescue analgesia requirement ((RR 0.47; 95%CI 0.30, 0.74; p = 0.001; I2 = 0.0%) and postoperative nausea and vomiting (RR 0.58; 95%CI 0.39, 0.86; p = 0.006; I2 = 25.1%). Besides, TLIP block is superior to wound infiltration in terms of opioid consumption (WMD -17.23, 95%CI -21.62, -12.86; p<0.001; I2 = 63.8%), and the postoperative pain intensity at rest was comparable between TLIP block and wound infiltration., Conclusion: TLIP block improved analgesic efficacy in spine surgery compared with non-block care. Furthermore, current literature supported the TLIP block was superior to wound infiltration in terms of opioid consumption., Competing Interests: The authors have declared that no competing interests exist.

Rationale: Anterior spinal meningoceles are rare neuroanatomic abnormality formed by protrusion of the spinal meninges through a defect in the vertebral column. Presently, therapeutic options for anterior spinal meningoceles are still controversial. The objective of this study is to discuss the individualized management of giant anterior spinal meningoceles., Patient Concerns and Diagnoses: We analyzed 4 patients with anterior spinal meningoceles between 2007 and 2014 in our department by retrospective chart review, two of whom were anterior sacral meningoceles (ASMs), and another2 were intrathoracic meningoceles (ITMs)., Interventions and Outcomes: Patients mainly presented with compressive symptoms including rectal irritation, dyspnea (patient 3) and fixed neurologic deficits (patient 4). Three out of 4 patients received surgical treatment, one of which underwent reoperation. After surgery, meningoceles in 1 patient completely disappeared. Two patients acquired the stability of the size of the meningoceles., Lessons: Management of anterior spinal meningoceles often requires precise treatment based on the different conditions of each patient. Surgical intervention has been proposed for the treatment of symptomatic anterior spinal meningoceles. The goal of surgery is to safely disconnect the linkage between the cyst and CSF from subarachnoid space to prevent further enlargement of the cyst or reaccumulating of cystic fluid.

The incorporation of nerve stimulation and ultrasound guidance to veterinary regional anesthesia allows accurate performance of techniques to block the thoracic limb and the thorax. When performed correctly, regional anesthesia can either constitute an alternative to the use of opioids and other systemic analgesics, or have a significant opioid-sparing effect. This article provides an overview of some techniques described using objective methods of nerve location, which can be used to provide perioperative locoregional anesthesia and analgesia to the thoracic limb and thorax. The approaches described may be used to decrease the perioperative use of opioids in small animals., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Veterinary regional anesthesia (RA) has been rapidly increasing in popularity over the last 10 years, as evidenced by the increasing amount of literature available and the continuous development of new techniques in small animals. The introduction of new technologies such as nerve stimulation and ultrasound (which increased the objectivity and precision of the procedure) and the promising beneficial perioperative effects conferred by RA are encouraging clinicians to incorporate these techniques in their daily perioperative anesthetic and analgesic animal care. However, there is a lack of consensus regarding outcomes when RA is used, as well as outcome comparisons between regional anesthetic techniques. Further large-scale clinical studies are still necessary. This article is the first part of a two-part review of RA in small animals, and its aim is to discuss the most relevant studies in the veterinary literature, where objective methods of nerve location have been used, and to illustrate in pictures the currently used techniques for providing RA to the thoracic limb and the thorax in small animals., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Communicating fibres between the phrenic nerve and sympathetic nervous system may exist, but have not been characterized histologically and immunohistochemically, even though increased sympathetic activity due to phrenic nerve stimulation for central sleep apnoea may entail morbidity and mortality. We, therefore, conducted a histological study of the phrenic nerve to establish the presence of catecholaminergic fibres throughout their course. The entire phrenic nerves of 35 formalin-fixed human cadavers were analysed morphometrically and immunohistochemically. Furthermore, the right abdominal phrenic nerve was serially sectioned and reconstructed. The phrenic nerve contained 3 ± 2 fascicles in the neck that merged to form a single fascicle in the thorax and split again into 3 ± 3 fascicles above the diaphragm. All phrenic nerves contained catecholaminergic fibres, which were distributed homogenously or present as distinct areas within a fascicle or as separate fascicles. The phrenicoabdominal branch of the right phrenic nerve is a branch of the celiac plexus and, therefore, better termed the "phrenic branch of the celiac plexus". The wall of the inferior caval vein in the diaphragm contained longitudinal strands of myocardium and atrial natriuretic peptide-positive paraganglia ("caval bodies") that where innervated by the right phrenic nerve.

Proteases and protease-activated receptors (PARs) are major mediators involved in irritable bowel syndrome (IBS). Our objectives were to decipher the expression and functionality (calcium signaling) of PARs in human dorsal root ganglia (DRG) neurons and to define mechanisms involved in human sensory neuron signaling by IBS patient mediators. Human thoracic DRG were obtained from the national disease resource interchange. Expression of PAR1, PAR2, and PAR4 was assessed by immunohistochemistry and quantitative reverse transcription PCR (RT-qPCR) in whole DRG or in primary cultures of isolated neurons. Calcium signaling in response to PAR agonist peptides (PAR-AP), their inactive peptides (PAR-IP), thrombin (10 U/mL), supernatants from colonic biopsies of patients with IBS, or healthy controls, with or without PAR1 or PAR4 antagonist were studied in cultured human DRG neurons. PAR1, PAR2, and PAR4 were all expressed in human DRG, respectively, in 20%, 40%, and 40% of the sensory neurons. PAR1-AP increased intracellular calcium concentration in a dose-dependent manner. This increase was inhibited by PAR1 antagonism. By contrast, PAR2-AP, PAR4-AP, and PAR-IP did not cause calcium mobilization. PAR1-AP-induced calcium flux was significantly reduced by preincubation with PAR4-AP, but not with PAR2-AP. Thrombin increased calcium flux, which was inhibited by a PAR1 antagonist and increased by a PAR4 antagonist. Supernatants from colonic biopsies of patients with IBS induced calcium flux in human sensory neurons compared with healthy controls, and this induction was reversed by a PAR1 antagonist. Taken together, our results highlight that PAR1 antagonism should be investigated as a new therapeutic target for IBS symptoms.

The crab-eating fox (Cerdocyon thous) is a wild canid distributed throughout South America. It is one of the wild canids reported being hit by vehicles and injured in snares, thus inducing trauma or injury to the musculoskeletal system, possibly occurring in the brachial region. The main objective of this research was to provide an anatomic description of the crab-eating fox's intrinsic brachial muscles including shape, origin, insertion, innervation and arterial blood supply, compared with that of the domestic dog. We dissected from superficial to deep two thoracic limbs of seven dead specimens donated to the University of Caldas by CORPOCALDAS. These muscles presented anatomic characteristics similar to those reported in the domestic dog (Canis lupus familiaris) but with a variant in arterial blood supply, allowing us to suggest that surgical procedures that need the knowledge of intrinsic brachial muscles in the crab-eating fox may be homologous to the domestic dog. However, one should consider its variant arterial distribution by part of the collateral radial artery and deep brachial artery to prevent incorrect incisions that may damage these arteries., (© 2017 Blackwell Verlag GmbH.)

The emergence of spatial patterns in developing multicellular organisms relies on positional cues and cell-cell communication. Drosophila sensory organs have informed a paradigm in which these operate in two distinct steps: Prepattern factors drive localized proneural activity, then Notch-mediated lateral inhibition singles out neural precursors. Here we show that self-organization through Notch signaling also establishes the proneural stripes that resolve into rows of sensory bristles on the fly thorax. Patterning, initiated by a gradient of Delta ligand expression, progresses through inhibitory signaling between and within stripes. Thus, Notch signaling can support self-organized tissue patterning as a prepattern is transduced by cell-cell interactions into a refined arrangement of cellular fates., (Copyright © 2017, American Association for the Advancement of Science.)

Direct or indirect impairment of breathing in humans by diseases or environmental factors can either cause long-term disability and pain, or can ultimately result in death. Automatic respiratory centers in the brainstem control the highly structured process of breathing and signal to a specialized group of motor neurons in the cervical spinal cord that constitute the phrenic nerves. In mammals, the thoracic diaphragm separates the thorax from the abdomen and adopts the function of the primary respiratory musculature. Faithful innervation by the phrenic nerves is a prerequisite for correct functionality of this highly specialized musculature and thus, ultimately, the viability of the entire organism.To analyze the effects of diseases and genetic defects responsible for deleterious or lethal respiratory phenotypes, accurate imaging of respiratory innervation during embryonic development, e.g., in genetically modified mouse models enables the characterization of specific marker genes and pathways that underlie appropriate wiring of the diaphragm. Among the different available immunostaining techniques, wholemount staining methods provide the advantage of clear and faithful three-dimensional information about the location of the antigens of interest. In comparison to routine histological techniques, however, the researcher has to deal with technical challenges, such as antibody penetration, the stability and availability of the antigen, and clearing of the relevant tissue, and the need to be equipped with state-of-the-art microscope equipment.In this methodological chapter, we explain and share our expertise concerning wholemount processing of mouse embryos and thoracic diaphragms for the analysis of mammalian respiratory innervation.

While in many cases they are not directly visualized, awareness of the thoracic nerves and their courses at cross-sectional imaging is important for radiologists. An understanding of the normal function of each nerve is important, as many patients present with neurologic signs and symptoms that can be used to reinforce search patterns for disease and detection of supportive radiologic abnormalities. In the case of primary neoplasms, understanding the expected presence of a nerve in the location of a mass can enhance and improve the accuracy of differential diagnoses. Even in the absence of neurologic symptoms, secondary involvement of these structures by malignancy or close proximity to other intrathoracic disease can prompt significant alterations in oncologic or surgical management. The major components of the thoracic nervous system with which the thoracic radiologist must be familiar are the phrenic, vagus, recurrent laryngeal, intercostal, and long thoracic nerves in addition to the sympathetic chain and brachial plexus. The anatomic structure and course of each component are described including its major functions. Major clinical signs and symptoms attributable to nerve dysfunction or disease are reviewed as well as any associated radiologic signs. Emphasis is placed on primary and secondary malignant involvement of the nerves and iatrogenic and traumatic injuries. Online supplemental material is available for this article. © RSNA, 2016.

A kinship between cranial and pelvic visceral nerves of vertebrates has been accepted for a century. Accordingly, sacral preganglionic neurons are considered parasympathetic, as are their targets in the pelvic ganglia that prominently control rectal, bladder, and genital functions. Here, we uncover 15 phenotypic and ontogenetic features that distinguish pre- and postganglionic neurons of the cranial parasympathetic outflow from those of the thoracolumbar sympathetic outflow in mice. By every single one, the sacral outflow is indistinguishable from the thoracolumbar outflow. Thus, the parasympathetic nervous system receives input from cranial nerves exclusively and the sympathetic nervous system from spinal nerves, thoracic to sacral inclusively. This simplified, bipartite architecture offers a new framework to understand pelvic neurophysiology as well as development and evolution of the autonomic nervous system., (Copyright © 2016, American Association for the Advancement of Science.)

Purpose: To report the clinical outcomes of thoracodorsal nerve (TDN) transfers to the triceps motor branches for elbow extension restoration in patients with partial brachial plexus injuries (BPI)., Methods: Eight male patients of mean age 23 years and suffering from a partial BPI underwent direct coaptation of the TDN to the nerve of the upper medial and long heads of the triceps, an average 6 months after their accident., Results: Seven patients achieved M4 elbow extension strength and one patient M3, according to the BMRC scale, after a mean follow-up of 21 months., Discussion: Direct TDN transfer might be a valid surgical procedure for the restoration of elbow extension in patients with partial BPI., (© 2015 Wiley Periodicals, Inc.)

Aim: The surgical assumption of responsibility of the pancreatic pain requires either a truncular coelioscopic or radicular neurectomy of greater splanchnic nerves (gsn). The goal of our work is to describe the way and relations of the right gsn which are variable and rarely described. This constitutes an undeniable peroperational hemorrhagic risk during splanchnicectomy., Material and Methods: After a double side thoracotomy and a bilateral sterno-clavicular desarticulation on 15 adult cadaveric subjects preserved by method of Winckler we removed the sterno-costal drill plate as well as the ventral rib arch and proceeded to a mediastinal evisceration of the thorax. Then we respected only the thoracic aorta and the oesophagus, the azygos venous system, the thoracic duct and the thoracic sympathetic chain. In some of the subjects, the azygos vein was injected (after catheterization of its stick) using gelatine coloured with blue paint. We studied the way and vascular relations of the right gsn. We measured the transverse distances between the origin of the gsn on one hand and the longitudinal axes of the azygos vein and the thoracic duct on the other hand., Results: The relations of the right gsn trunk during its way related to the azygos vein in particular its constitutive origin and its affluents: ascending lumbar vein and twelfth intercostal vein. Sometimes the thoracic duct even a lymphatic node was near the gsn in the posterior infra-mediastinal space. A classification of the way and vascular relations of the right gsn in the thorax identified 3 anatomical types. The average distances separating the right gsn on one hand from the azygos vein and the thoracic duct on the other hand were respectively 5.7 mm and 11.2 mm., Conclusion: The vascular relations of the right gsn are very variable from one subject to another but primarily venous, sometimes lymphatic. They concerned the great thoracic vessels whose respect is essential in particular at the time of mini-invasive access procedure for a cœlioscopic splanchnicectomy., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

It was recently reported that the internal branch of the accessory nerve not only comprises the cranial root but also various combinations of the cranial root, spinal root, and the vagal component of the vagus nerve. The aim of this study was to demonstrate the anatomical distribution of each component of the internal branch of the human accessory nerve. Ten half-heads and necks of adult cadavers were used. The internal branch of the accessory nerve had three courses: the pharyngeal branch, the descending branch to the thorax, and the recurrent laryngeal nerve. The pharyngeal branch of the internal branch originated mainly from the vagus nerve, rather than from the cranial root of the accessory nerve. All of the components of the internal branch descended to the thorax along the vagus nerve. The recurrent laryngeal nerve comprised the internal branch and the vagus nerve in all specimens, and it was separated into bundles originating from the internal branch and vagus nerve. Both bundles gave off branches to the trachea and esophagus. The laryngeal distribution of the internal branch and vagus nerve was confirmed in the posterior cricoarytenoid, lateral cricoarytenoid, and thyroarytenoid muscles. These three laryngeal muscles were innervated by the cranial root and/or vagus nerve, but the distribution pattern was different in each specimen. Although the vagus nerve and cranial root are morphologically distinct nerves in the cranial cavity, they can be regarded functionally as the same nerve based on their distribution in the laryngeal muscles.

Background: Stellate ganglion nerve activity (SGNA) is important in cardiac arrhythmogenesis. However, direct recording of SGNA requires access to the thoracic cavity. Skin of upper thorax is innervated by sympathetic nerve fibers originating from the stellate ganglia and is easily accessible., Objective: The purpose of this study was to test the hypothesis that thoracic skin nerve activity (SKNA) can be used to estimate SGNA., Methods: We recorded SGNA and SKNAs using surface electrocardiogram leads in 5 anesthetized and 4 ambulatory dogs. Apamin injected into the right stellate ganglion abruptly increased both right SGNA and SKNA in 5 anesthetized dogs. We integrated nerve activities and averaged heart rate in each 1-minure window over 10 minutes. We implanted a radiotransmitter to record left SGNA in 4 ambulatory dogs (2 normal, 1 with myocardial infarction, 1 with intermittent rapid atrial pacing). After 2 weeks of recovery, we simultaneously recorded the SKNA and left SGNA continuously for 30 minutes when the dogs were ambulatory., Results: There was a positive correlation [average r = 0.877, 95% confidence interval (CI) 0.732-1.000, P <.05 for each dog] between integrated skin nerve activity (iSKNA) and SGNA (iSGNA) and between iSKNA and heart rate (average r = 0.837, 95% CI 0.752-0.923, P <.05). Similar to that found in the anesthetized dogs, there was a positive correlation (average r = 0.746, 95% CI 0.527-0.964, P <.05) between iSKNA and iSGNA and between iSKNA and heart rate (average r = 0.706, 95% CI 0.484-0.927, P <.05)., Conclusion: SKNAs can be used to estimate SGNA in dogs., (Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

The effect of proprioceptive feedback on the control of posture and locomotion was studied in the crayfish Procambarus clarkii (Girard). Sensory and motor nerves of an isolated crayfish thoracic nerve cord were connected to a computational neuromechanical model of the crayfish thorax and leg. Recorded levator (Lev) and depressor (Dep) nerve activity drove the model Lev and Dep muscles to move the leg up and down. These movements released and stretched a model stretch receptor, the coxobasal chordotonal organ (CBCO). Model CBCO length changes drove identical changes in the real CBCO; CBCO afferent responses completed the feedback loop. In a quiescent preparation, imposed model leg lifts evoked resistance reflexes in the Dep motor neurons that drove the leg back down. A muscarinic agonist, oxotremorine, induced an active state in which spontaneous Lev/Dep burst pairs occurred and an imposed leg lift excited a Lev assistance reflex followed by a Lev/Dep burst pair. When the feedback loop was intact, Lev/Dep burst pairs moved the leg up and down rhythmically at nearly three times the frequency of burst pairs when the feedback loop was open. The increased rate of rhythmic bursting appeared to result from the positive feedback produced by the assistance reflex., (Copyright © 2015 the American Physiological Society.)

Neuromechanical simulation was used to determine whether proposed thoracic circuit mechanisms for the control of leg elevation and depression in crayfish could account for the responses of an experimental hybrid neuromechanical preparation when the proprioceptive feedback loop was open and closed. The hybrid neuromechanical preparation consisted of a computational model of the fifth crayfish leg driven in real time by the experimentally recorded activity of the levator and depressor (Lev/Dep) nerves of an in vitro preparation of the crayfish thoracic nerve cord. Up and down movements of the model leg evoked by motor nerve activity released and stretched the model coxobasal chordotonal organ (CBCO); variations in the CBCO length were used to drive identical variations in the length of the live CBCO in the in vitro preparation. CBCO afferent responses provided proprioceptive feedback to affect the thoracic motor output. Experiments performed with this hybrid neuromechanical preparation were simulated with a neuromechanical model in which a computational circuit model represented the relevant thoracic circuitry. Model simulations were able to reproduce the hybrid neuromechanical experimental results to show that proposed circuit mechanisms with sensory feedback could account for resistance reflexes displayed in the quiescent state and for reflex reversal and spontaneous Lev/Dep bursting seen in the active state., (Copyright © 2015 the American Physiological Society.)

Background: The root mean square surface electromyographic activity of lumbar extensor muscles during dynamic trunk flexion and extension from a standing position and task specific spine ranges of motion objectively assess muscle function in healthy young and middle age individuals. However, literature on neuromuscular activation and associated spine and hip kinematics in older individuals is sparse. This cross sectional study sought to examine the sex and age (<40 versus >60 years) related differences in the neuromuscular activation profiles of the lumbar extensors and the related spine and hip kinematics from healthy individuals during a standardized trunk flexion-extension task., Methods: Twenty five older (13 females, 60-90 years) and 24 younger (12 females, 18-40 years) healthy individuals performed trunk flexion-extension testing by holding static positions at half-flexion way and full range of motion between standing and maximum trunk flexion. The associated lumbar extensor muscle activity was derived from measurements at standing, half, and maximum flexion positions. The range of motion at the hip and lumbar spine was recorded using 3d accelerometers attached to the skin overlying the multifidus and semispinalis thoracis muscles lateral to the L5 and T4 spinous processes, respectively. Statistical calculations were performed using a permutation ANOVA with bootstrap confidence intervals., Results: The muscle activity in the half related to the maximum flexion position (half flexion relaxation ratio) was significantly smaller in older males when compared with younger males. Moreover, measurements revealed smaller activity changes from standing to the half and from half to the maximum flexion position in older compared to younger individuals. Older males displayed smaller gross trunk range of motion from standing to maximum flexion than any other group., Conclusions: Gender and normal aging significantly affect both the activation patterns of the lumbar extensor muscles and the kinematics of the trunk during a standardized trunk flexion-extension task. Measurement results from healthy young and middle age individuals should not be used for the assessment of individuals older than 60 years of age.

The thoracic outlet syndrome is characterized by a variety of clinical signs due to multiple causes resulting in compression of a neurovascular bundle in a relatively narrow anatomical space. Despite the frequently encountered clinical symptoms, inadequate attention is paid to their analysis, and their diagnostic and surgical aspects require a modern approach. The study included 46 patients. The main clinical sign is a persistent pain syndrome of the cervico-occipital localization that affects the shoulder girdle, suprascapular and infrascapular regions and spreads to the arm in combination with trophic, sensory and vascular disorders. SCT angiography of the superior thoracic outlet structures has been used as a priority instrumental method of research. The macro- and micro factors of compression are the main cause for the development of neurological symptoms, and their removal is the main task of surgical treatment. Surgical approaches were planned depending on the nature and extent of injury. 36 patients underwent 42 surgical interventions. The proper assessment of the neurological status in combination with modern paraclinical diagnostic methods and selection of an adequate surgical approach provided satisfactory outcomes in 33 cases.

Standard cutaneous innervation maps show strict midline demarcation. Although authors of these maps accept variability of peripheral nerve distribution or occasionally even the midline overlap of cutaneous nerves, this concept seems to be neglected by many other anatomists. To support the statement that such transmedian overlap exists, we performed an extensive literature search and found ample evidence for all regions (head/neck, thorax/abdomen, back, perineum, and genitalia) that peripheral nerves cross the midline or communicate across the midline. This concept has substantial clinical implications, most notably in anesthesia and perineural tumor spread. This article serves as a springboard for future anatomical, clinical, and experimental research., (© 2014 Wiley Periodicals, Inc.)

Idiopathic onset of unilateral vocal fold paralysis (UVP) is caused by damage to the recurrent laryngeal nerve (RLN) and results in difficulty speaking, breathing, and swallowing. This damage may occur in this nerve as it loops around the aortic arch, which is in a dynamic biomechanical environment. The goal of this study is to determine if the location-dependent biomechanical and microstructural properties of the RLN are different in piglets versus adolescent pigs. The neck/distal and thoracic/proximal (near the aortic arch) regions of the RLN from eight adolescent pigs and six piglets were isolated and mechanically assessed in uni-axial tension. Two-photon imaging (second harmonic) data were collected at 5%, 10%, and 15% strain during the mechanical test. The tangential modulus (TM) and the strain energy density (W) were determined at each level of strain. The mean mode of the preferred fiber angle and the full width at half maximum (FWHM, a measure of fiber splay) were calculated from the imaging data. We found significantly larger values of TM, W, and FWHM in the proximal segments of the left RLN when compared to the distal segments (18.51 MPa ± 1.22 versus 10.78 MPa ± 1.22, p < 0.001 for TM, 0.046 MPa ± 0.01 versus 0.026 MPa ± 0.01, p < 0.003 for W, 15.52 deg ± 1.00 versus 12.98 deg ± 1.00, p < 0.001 for FWHM). TM and W were larger in the left segments than the right (15.32 MPa ± 1.20 versus 11.80 MPa ± 1.20, p < 0.002 for TM, 0.038 MPa ± 0.01 versus 0.028 MPa ± 0.01, p < 0.0001 for W). W was larger in piglets when compared to adolescent pigs (0.042 MPa ± 0.01 versus 0.025 MPa ± 0.01, p < 0.04). The proximal region of the left porcine RLN is more stiff than the distal region and has a higher degree of fiber splay. The left RLN of the adolescent pigs also displayed a higher degree of strain stiffening than the right. These differences may develop as a result of the more dynamic environment the left RLN is in as it loops around the aortic arch.

The goal of this study was to create a heat map indicating the probabilistic location of major ganglia of the cervical sympathetic trunk (CST). Detailed dissections of human cadaveric specimens, followed by spatial registration and analysis of the cervical sympathetic ganglia in the neck and upper thorax regions (C1-T1) were performed in 104 neck specimens (both sides from 52 cadavers). Unbiased parametric mapping, visualized with a heat map, revealed a general pattern of two major ganglia located on both sides of the neck: The superior cervical ganglion (SCG) was located 80-90 mm superior to the point at which the vertebral artery entered the transverse foramen (VA-TF); the stellate ganglion (SG) was located approximately 10 mm inferior to the VA-TF in 80% of our sample, or surrounding the VA-TF in the remaining 20% of our sample. In between these ganglia, a highly variable number of smaller and less prevalent ganglia were present on either side of the neck. The middle ganglia on the right side of the neck were located closer to the SCG, possibly indicative of the middle cervical ganglion. On the left side the middle ganglia were located closer to the SG, perhaps indicative of the vertebral ganglion or the inferior cervical ganglion. Individual specimens could be classified into one of seven different patterns of cervical trunks. The results may help surgeons and anesthesiologists more accurately target and preserve these structures during medical procedures., (Copyright © 2014 Elsevier B.V. All rights reserved.)

In the dorsal horn of the spinal cord in the plates I-IV on the thoracic and lumbar levels different subpopulations of interneurons immunoreactive for calbindin 28 kDa (CAB IR), which are specific to each plate. In the area of the medial edge of the dorsal horn, we have found a special subpopulation of CAB IR interneurons whose morphometric characteristics differ from CAB IR interneurons subpopulations of said plates. The number of CAB IR interneurons was maximal in the plate II at all levels of the spinal cord. Leveled differences are more CAB IR interneurons and larger area of the cross sections at the lumbar level.

Background and Purpose: Radiofrequency ablation (RFA) is associated with low neural morbidity compared with surgery, which commonly causes debilitating long-term pain. The purpose was to review the thoracic neural anatomy relevant to percutaneous RFA and to retrospectively review symptomatic nerve injury after lung RFA at our institution., Materials and Methods: We retrospectively examined all symptomatic nerve injuries occurring after computed tomography (CT)-guided RFA treatment of lung tumors for 462 patients/509 procedures/708 lesions treated at our large tertiary referral centre during 10 years., Results: Eight patients experienced neurological complications after heating during the RFA procedure. These complications occurred in the phrenic (n = 1), brachial (n = 3), left recurrent (n = 1), and intercostal nerves (n = 2) and the stellate ganglion (n = 1). Three were grade 2, four grade 3 and one grade 4 injuries (CTCAE v3)., Conclusion: Although rare, neurological complications can occur after RFA, and they can occasionally be severe. To prevent these complications, it is important for the interventional radiologist to be aware of the anatomy of nervous structures and to attempt to identify nerves on CT scans during the RFA procedure. Creating a pneumothorax can be useful to avoid nerve damage and related clinical complications.

The use of the intercostal artery perforator (ICAP) flap has recently become popular in reconstructions of the breast, upper arm and trunk. Lateral cutaneous branches (LCBs) are a group of the ICAPs that penetrate the fascia near the middle axillary line. However, reports on its precise anatomy and clinical applications are quite limited. We performed an anatomical study of LCBs using cadavers. Based on the findings, we developed novel clinical application methods as follows: (1) sensate superficial circumflex iliac perforator (SCIP) flap, (2) supercharged SCIP flap, (3) ICAP-based propeller flap (IBPF) and (4) free ICAP flap based on LCB. LCBs have the following advantages: (1) Long pedicles can be obtained in the supine position without risk of pneumothorax. (2) The neurovascular bundle is consistently available, allowing elevation of sensate flaps. (3) Donor-site morbidity is low. Therefore, we believe that LCBs offer a versatile option in reconstructive surgery., (Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

This study aims at clarifying the detailed morphological and topographical changes of the thoracic part of the sympathetic trunk of sheep during fetal development. Bilateral micro-dissection of the thoracic sympathetic trunk was performed on 40 sheep fetuses aged 6-20 weeks (18 males and 22 females) under a stereomicroscope. The cervicothoracic ganglion (CTG) was observed on 75/80 sides (93.7%) and was composed of the caudal cervical and the first thoracic ganglia on 45/80 sides (56.2%), and of the caudal cervical and the first two thoracic ganglia on 30/80 sides (37.5%). The presence of the two last (12th-13th) thoracic ganglia was not constant. The influence of the sex, the side of the body, and the ages of the fetus on the morphology and topography of the thoracic sympathetic trunk in sheep were identified. In spite of the differences in the morphology and topography of the thoracic sympathetic trunk between early and late fetal developments, the morphology and topography of the older fetal thoracic sympathetic trunk tended to be similar to that of the adult sheep. To comprehend the comparative morphology of the fetal thoracic sympathetic trunk more completely, our results were compared with previous studies. Consequently, differences and similarities in the composition and position of the CTG, presence of single caudal cervical ganglion without fusion to the thoracic ganglia, and absence of the thoracic ganglia, and presence of splitting of the interganglionic branch were found among sheep, pig, and human fetuses. Therefore, sheep might be the appropriate animal model to be applied in human sympathetic nervous system., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Objective: To investigate whether combined trunk and gluteal neuromuscular electrical stimulation (NMES) alters seated posture and improves pelvic tissue health in persons with a spinal cord injury., Design: Intervention study; case series., Setting: Research laboratory, medical center., Participants: Seven persons with spinal cord injury recruited from a group of experienced implanted lower extremity NMES system users., Intervention: Combined trunk and gluteal NMES in the sitting position. Five minutes of preintervention sitting was assessed, followed by 5 minutes of NMES application, and then 5 minutes of postintervention., Main Outcome Measures: Pelvic tissue health was evaluated by concurrently measuring transcutaneous oxygen tension (TcPO2) bilaterally over the ischia and the seating interface pressure (IP). TcPO2 data were binned into low (<10 mm Hg), medium (10-30 mm Hg), and high (>30 mm Hg) ranges, and the percentage time that TcPO2 was in each range was calculated. Ischial and sacral regions of interest were defined and the maximum region of interest and mean IP were determined, together with the maximum IP gradient for the entire contact area. Initial seating postures varied; 4 persons were initially sacral sitters. Tissue health responses to NMES were reviewed for sacral and nonsacral sitters., Results: For sacral sitters, the sacral region IP and the maximum IP gradient tended to decrease during NMES and increased again after the intervention. Mean ischial TcPO2 increased during NMES and remained elevated after the intervention, increasing high TcPO2 percentage time for 50% of the sacral sitters both during and after the intervention. Nonsacral sitters showed few changes in tissue health as the result of the application of NMES., Conclusions: Trunk and gluteal stimulation acutely corrects anterior/posterior IP distribution, improving regional tissue health for sacral sitters. This correction requires constant application of NMES. The potential for positive changes in tissue health would be maximized by regular NMES use incorporating weight shifting., (Copyright © 2013 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Pharmacological therapies in type 1 diabetes for efficient control of glycemia and changes in pain alterations due to diabetic neuropathy are a continuous challenge. Transient receptor potential vanilloid type 1 (TRPV1) from dorsal root ganglia (DRG) neurons is one of the main pharmacological targets in diabetes, and its ligand capsaicin can be a promising compound for blood-glucose control. Our goal is to elucidate the effect of intraperitoneal (i.p.) capsaicin administration in type 1 diabetic mice against TRPV1 receptors from pancreatic DRG primary afferent neurons. A TCR(+/-)/Ins-HA(+/-) diabetic mice (dTg) was used, and patch-clamp and immunofluorescence microscopy measurements have been performed on thoracic T(9)-T(12) DRG neurons. Capsaicin (800 μg/kg, i.p. three successive days) administration in the late-phase diabetes reduces blood-glucose levels, partly reverses the TRPV1 current density and recovery time constant, without any effect on TRPV1 expression general pattern, in dTg mice. A TRPV1 hypoalgesia profile was observed in late-phase diabetes, which was partly reversed to normoalgesic profile upon capsaicin i.p. administration. According to the soma dimensions of the thoracic DRG neurons, a detailed analysis of the TRPV1 expression upon capsaicin i.p. treatment was done, and the proportion of large A-fiber neurons expressing TRPV1 increased in dTg capsaicin-treated mice. In conclusion, the benefits of low-dose capsaicin intraperitoneal treatment in late-phase type-1 diabetes should be further exploited.

Background: Many organisms, from bacteria to human hunter-gatherers, use specialized random walk strategies to explore their environment. Such behaviors are an efficient stratagem for sampling the environment and usually consist of an alternation between straight runs and turns that redirect these runs. Drosophila larvae execute an exploratory routine of this kind that consists of sequences of straight crawls, pauses, turns, and redirected crawls. Central pattern generating networks underlying rhythmic movements are distributed along the anteroposterior axis of the nervous system. The way in which the operation of these networks is incorporated into extended behavioral routines such as substrate exploration has not yet been explored. In particular, the part played by the brain in dictating the sequence of movements required is unknown., Results: We report the use of a genetic method to block synaptic activity acutely in the brain and subesophageal ganglia (SOG) of larvae during active exploratory behavior. We show that the brain and SOG are not required for the normal performance of an exploratory routine. Alternation between crawls and turns is an intrinsic property of the abdominal and/or thoracic networks. The brain modifies this autonomous routine during goal-directed movements such as those of chemotaxis. Nonetheless, light avoidance behavior can be mediated in the absence of brain activity solely by the sensorimotor system of the abdomen and thorax., Conclusions: The sequence of movements for substrate exploration is an autonomous capacity of the thoracic and abdominal nervous system. The brain modulates this exploratory routine in response to environmental cues., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: The clipping of the thoracic sympathetic nerve, which has been a technique used for approximately the past 10 years, has rapidly become popular because of its "bring-back" claim. However, the information regarding the mechanism behind this claim is based on investigator's comments and has not been proven by objective research, such as the histopathological examination of the clipped nerve and/or ganglion. We aimed to evaluate sympathetic regeneration and degeneration after clip removal., Methods: The rabbits were divided into two groups with six rabbits per group. For the first group (group A), the sympathetic chain was clipped using two titanium clips, and a right thoracotomy was made at the T4 and T5 levels. For the second group (group B), the animals were also operated on, which was similar to the rabbits in group A. At the end of a 48-hour follow-up period, the clips were removed after a second operation. The rabbits in group B were followed for 45 days and sympathetic nerves were also examined histopathologically., Results: In group A, hemorrhage, fibrinous material, polymorphonuclear leukocyte infiltration, and acute inflammation with fat necrosis were observed in and around the sympathetic ganglia and trunk. Loss of nuclei and vacuolization in some sympathetic ganglia cells were also observed. These findings demonstrated severe degeneration of the sympathetic ganglia and trunk. For group B, microscopic examination revealed a loss of sympathetic ganglion cells as well as fibrosis within and around the ganglia. No signs of regeneration were detected and the progression of nerve degeneration was observed., Conclusions: The clips used in our study were shown to cause the degeneration of neural structures within 2 days. At the end of the 45 days following the removal of the clips, progressive, degenerative changes radiating along the axons of the sympathetic cells were seen., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Clavicle fractures are rarely associated with more severe neurologic or vascular injuries. When these associated injuries are encountered, prompt recognition and treatment are paramount to optimize outcome. The majority of fractures that result in neurovascular compromise are from high-energy trauma; however, a high index of suspicion should be present in all cases as low-energy trauma can also result in more catastrophic injury. This article describes a case of a low-energy clavicle fracture in a 28-year-old woman that resulted in intrathoracic penetration of the fracture fragment with hemopneumothorax. The patient underwent successful chest tube placement and open reduction and internal fixation of the fracture. A multidisciplinary team was used during surgery, including cardiothoracic, trauma, and orthopedic surgery. Two years postoperatively, the patient was back to normal activities with no neurologic, pulmonary, or vascular sequelae. This case highlights the importance of a comprehensive physical examination and inspection of all radiographs so that associated injuries are not missed., (Copyright 2011, SLACK Incorporated.)

Surface anatomy is an integral part of a thoracic surgeon's armamentarium to assist with the diagnosis, staging, and treatment of thoracic pathology. As reviewed in this article, the surface landmarks of the lungs, heart, great vessels, and mediastinum are critical for appropriate patient care and should be learned in conjunction with classic anatomy., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Purpose: We characterized key intercostal anatomical relationships relevant to supracostal percutaneous nephrostolithotomy using anatomical dissection., Materials and Methods: We performed 20 cadaveric dissections of the 11th intercostal space to characterize key anatomical relationships relevant to percutaneous upper pole renal access. Specific data recorded included intercostal rib distance at the lateral border of the paraspinous muscles, and the mid scapular and posterior axillary lines. We also recorded the distance between the 12th and 11th ribs to the intercostal nerve, artery and vein at the same 3 sites., Results: The average intercostal distance was 21, 23 and 26 mm at the lateral border of the paraspinous muscles, and the mid scapular and posterior axillary lines, respectively. The intercostal nerve was exposed to injury in 85%, 100% and 100% of patients at the 3 sites, respectively. The intercostal artery was exposed below the 11th rib in 30%, 60% and 70% of cadavers, respectively, and it was 6 mm from the rib in 25% of interspaces. The intercostal vein, which was exposed below the 11th rib in 0%, 5% and 10% of cadavers, respectively, was least likely to be injured., Conclusions: Intercostal vessels are at risk for damage during percutaneous nephrostolithotomy in a significant number of patients. Access placement lateral to the paraspinous muscles and in the lower half of the 11th intercostal space may decrease damage to the intercostal artery and nerve. Injury to the intercostal vessels and nerve may explain the increased risk of bleeding and pain during supracostal percutaneous nephrostolithotomy. Minimizing injury may decrease blood loss and pain., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

We present a case of profound bradycardia and cardiac arrest in a 61-year-old man, which occurred during left upper lobectomy and lymph node dissection for the ligamentum arteriosum. General anesthesia was maintained by propofol TIVA combined with epidural anesthesia. During the electrocautery dissection of the lymph node of the ligamentum arteriosum the patient became extremely bradycardic for 10 min. Subsequent traction with forceps further aggravated the bradycardia leading to cardiac arrest. In order to continue the procedure, we initiated epicardial pacing and switched to isoflurane anesthesia. Given the close proximity of the lymph node of the ligamentum arteriosum to the thoracic cardiac branch of the vagus nerve and the cardiac plexus, we believe that the observed bradycardia and cardiac arrest are likely attributable to vasovagal stimulation.

Neural crest cells (NCCs) are migratory cells that delaminate from the neural tube early in development and then disseminate throughout the embryo to give rise to a wide variety of cell types that are key to the vertebrate body plan. During their journey from the neural tube to their peripheral targets, NCCs progressively differentiate, raising the question when the fate of an individual NCC is sealed. One hypothesis suggests that the fate of a NCC is specified by target-derived signals emanating from the environment they migrate through, while another hypothesis proposes that NCCs are already specified to differentiate along select lineages at the time they are born in the neural tube, with environmental signals helping them to realize their prespecified fate potential. Alternatively, both mechanisms may cooperate to drive NCC diversity. This review highlights recent advances in our understanding of prespecification during trunk NCC development.

It has long been thought that the same molecules guide both trunk neural crest cells and motor axons as these cell types grow and extend to their target regions in developing embryos. There are common territories that are navigated by these cell types: both cells grow through the rostral portion of the somitic sclerotomes and avoid the caudal half of the sclerotomes. However, these cell types seem to use different molecules to guide them to their target regions. In this review, I will talk about the common and distinct methods of migration taken by trunk neural crest cells and motor axons as they grow and populate their target regions through chick embryos at the level of the trunk.

Neural crest cells are pluripotent cells that emerge from the neural epithelium, migrate extensively, and differentiate into numerous derivatives, including neurons, glial cells, pigment cells and connective tissue. Major questions concerning their morphogenesis include: 1) what establishes the pathways of migration and 2) what controls the final destination and differentiation of various neural crest subpopulations. These questions will be addressed in this review. Neural crest cells from the trunk level have been explored most extensively. Studies show that melanoblasts are specified shortly after they depart from the neural tube, and this specification directs their migration into the dorsolateral pathway. We also consider other reports that present strong evidence for ventrally migrating neural crest cells being similarly fate restricted. Cranial neural crest cells have been less analyzed in this regard but the preponderance of evidence indicates that either the cranial neural crest cells are not fate-restricted, or are extremely plastic in their developmental capability and that specification does not control pathfinding. Thus, the guidance mechanisms that control cranial neural crest migration and their behavior vary significantly from the trunk. The vagal neural crest arises at the axial level between the cranial and trunk neural crest and represents a transitional cell population between the head and trunk neural crest. We summarize new data to support this claim. In particular, we show that: 1) the vagal-level neural crest cells exhibit modest developmental bias; 2) there are differences in the migratory behavior between the anterior and the posterior vagal neural crest cells reminiscent of the cranial and the trunk neural crest, respectively; 3) the vagal neural crest cells take the dorsolateral pathway to the pharyngeal arches and the heart, but the ventral pathway to the peripheral nervous system and the gut. However, these pathways are not rigidly specified because of prior fate restriction. Understanding the molecular, cellular and behavioral differences between these three populations of neural crest cells will be of enormous assistance when trying to understand the evolution of the neck.

The complexity of the anatomy of the sympathetic trunk and intercostal veins in the third and fourth intercostal space may lead to intraoperative or postoperative bleeding. The purpose of this study was to investigate the anatomical variations of the sympathetic trunk and intercostal veins in the third and fourth intercostal spaces. The size and crossing type of veins in the third and fourth intercostal spaces in 44 Korean patients with palmar hyperhidrosis were analyzed. We classified intercostal veins by their size (small, medium, and large) and crossing type (anterior or posterior to sympathetic nerve). Large intercostal veins susceptible to bleeding were found in 36.4 and 68.2% of patients in the right third and fourth intercostal spaces, respectively and in 2.3 and 4.5% of left third and fourth intercostal spaces, respectively. More than 80% of the left third and fourth intercostal veins were small. Anterior crossing intercostal veins, which often cause problems at the third and fourth right intercostal spaces, were found in 27.3% (third) and 15.9% (fourth). However, there were only two cases of anterior crossing veins on the left side. Large anterior crossing veins were found only on the right side. In conclusion, surgical procedures of the right sympathetic ganglia may have increased risks due to a higher frequency of large anterior crossing intercostal veins. Careful dissection is necessary to decrease the incidence of intraoperative or postoperative bleeding.

Thoracic paravertebral blockade is a simple and easy-to-learn technique with a low incidence of complications. It should be considered as a safe alternative to thoracic epidural analgesia/anaesthesia. We reviewed the techniques of thoracic paravertebral blockade with special interest to ultrasound guidance.

Anatomical variation of the thoracic splanchnic nerves is as diverse as any structure in the body. Thoracic splanchnic nerves are derived from medial branches of the lower seven thoracic sympathetic ganglia, with the greater splanchnic nerve comprising the more cranial contributions, the lesser the middle branches, and the least splanchnic nerve usually T11 and/or T12. Much of the early anatomical research of the thoracic splanchnic nerves revolved around elucidating the nerve root level contributing to each of these nerves. The celiac plexus is a major interchange for autonomic fibers, receiving many of the thoracic splanchnic nerve fibers as they course toward the organs of the abdomen. The location of the celiac ganglia are usually described in relation to surrounding structures, and also show variation in size and general morphology. Clinically, the thoracic splanchnic nerves and celiac ganglia play a major role in pain management for upper abdominal disorders, particularly chronic pancreatitis and pancreatic cancer. Splanchnicectomy has been a treatment option since Mallet-Guy became a major proponent of the procedure in the 1940s. Splanchnic nerve dissection and thermocoagulation are two common derivatives of splanchnicectomy that are commonly used today. Celiac plexus block is also a treatment option to compliment splanchnicectomy in pain management. Endoscopic ultrasonography (EUS)-guided celiac injection and percutaneous methods of celiac plexus block have been heavily studied and are two important methods used today. For both splanchnicectomies and celiac plexus block, the innovation of ultrasonographic imaging technology has improved efficacy and accuracy of these procedures and continues to make pain management for these diseases more successful., ((c) 2010 Wiley-Liss, Inc.)

In response to repetitive proprioceptive disturbances (vibration) applied to postural muscles, the evoked response has been shown to decrease in amplitude within the first few trials. The present experiment investigated whether this attenuation of the response to vibration stimulation (90Hz, 5s) was muscle specific or would be transferred to the antagonist muscles. Sixteen participants stood upright with eyes closed. One half of the participants practiced 15 tibialis vibrations followed by 15 calf vibrations (TIB-CALF order), while the other half practiced the opposite order (CALF-TIB order). Antero-posterior trunk displacements were measured at the level of C7 and centre of foot pressure (COP). EMG activity of the tibialis anterior (TA) and gastrocnemius lateralis (GL) was also measured. Results showed that evoked postural responses as well as EMG activity decreased with practice when vibration was applied to either calf or tibialis muscles. However, such attenuation of the response appeared muscle specific since it did not generalise when the same vibration stimulus was later applied onto the antagonist muscles., (Copyright 2010 Elsevier B.V. All rights reserved.)

Objective: To study mortality and causes of death in an unselected geographically defined cohort of patients with traumatic spinal cord injury (TSCI), 1952-2001., Methods: Patients were identified from hospital records. The date of death was obtained from the National Population Register, and causes of death recorded by linkage to the Norwegian Cause of Death Registry. Patient mortality was compared with mortality in the Norwegian population using standardised mortality ratios (SMR) adjusted for age and gender., Results: 401 patients (70 women and 331 men) were identified. By 31 August 2008, 173 were dead. Median survival time in deceased patients was 7.4 years; 6.9 years for patients with cervical injuries and 8.2 years for patients with thoracolumbosacral injuries (TLS). TSCI patients had an increased mortality (SMR 1.85) compared with the Norwegian population. SMR did not change during the observation period. SMR was significantly higher for women than for men (2.88 vs 1.72), and higher in patients with complete TSCI compared with patients with incomplete TSCI (4.23 vs 1.25). SMR was 6.70 for patients with complete cervical injuries and 3.07 for patients with complete TLS injuries. Cause specific SMR were 1.96 for respiratory disease, and for suicide including accidental poisoning 3.70 for men and 37.59 for women., Conclusions: Patients with a TSCI, and especially women, have an increased mortality despite modern treatment and care. Special attention should be paid to respiratory dysfunction and pulmonary infections, and to prevent suicide and accidental poisoning.

Objective: To test the feasibility of implanting intramuscular electrodes (Permaloc, Synapse Biomedical Inc, Oberlin OH) with self-securing polypropylene anchors to stimulate upper-intercostal and abdominal muscles plus the diaphragm., Methods/results: In 6 anesthetized dogs, 12 Permaloc electrodes were implanted in the 3 respiratory muscles (4 in each muscle group). Tidal volume with diaphragmatic stimulation was 310 +/- 38 mL (mean +/- SE); with upper intercostal stimulation, it was 68 +/- 18 mL; and with combined diaphragm intercostal stimulation, it was 438 +/- 78 mL. By study design, stimulation in the upper intercostal muscles was limited to not more than slight/moderate contraction of the serratus and latissimus muscles overlying the ribs. Abdominal muscle stimulation produced exhaled volumes of 38 +/- 20 mL (this stimulation was limited by the maximal output of the stimulator of 25 milliamperes). Combined diaphragm intercostal stimulation followed by abdominal muscle stimulation increased exhaled volumes from 312 +/- 31 mL to 486 +/- 58 mL (P = 0.024)., Conclusions: Permaloc electrodes can be successfully implanted in upper intercostal and abdominal muscles in addition to the diaphragm. Combined diaphragm intercostal stimulation followed by abdominal muscle stimulation increased the exhaled volumes recorded with diaphragmatic stimulation alone.