Phrenic Nerve By CK 10-01-2011

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Phrenic Nerve : 

Phrenic Nerve By: Chaman Lal Karotia Clinical Neurophysiology Trainee Batch2010-2012 The Aga Khan University Hospital Karachi.

Study Outlines : 

Study Outlines Introduction to the Cervical Plexus Anatomy of Phrenic Nerve Anatomical Course of Phrenic Nerve Motor & Sensory Supply of Phrenic Nerve Clinical Importance of the Muscles innervated by Phrenic Nerve Injuries to Phrenic Nerve Phrenic Motor Nerve Conduction Study Techniques References 10-01-2011 2 Phrenic Nerve By: CK

Introduction to Cervical Plexus : 

Introduction to Cervical Plexus Cervical Plexus is formed by the contribution of anterior primary rami of first four cervical nerve roots (C1,C2,C3,C4) It is the looped plexus because four roots are joined to form three loops. 10-01-2011 3 Phrenic Nerve By: CK

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Branches of the Cervical Plexus : 

Branches of the Cervical Plexus Ansa Cervicalis: Superior (C1) & Inferior (C2,3) roots Lesser Occipital Nerve (C2) Greater Auricular Nerve (C2,3) Transverse Cervical Cut. Nerves\ (C2,3) Supraclavicular Nerve (C3,4) Deep branches Phrenic Nerve (C3,4,5) 10-01-2011 5 Phrenic Nerve By: CK

Origin of Phrenic Nerve : 

Origin of Phrenic Nerve Phrenic Nerve takes its origin from the Cervical Plexus roots. Phrenic nerve is derived from C3, C4 and C5 roots level1, and there is larger contribution of the anterior primary of C4 . 10-01-2011 6 Phrenic Nerve By: CK

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Subclavian v. Subclavian a. Phrenic nerve 10-01-2011 7 Phrenic Nerve By: CK

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Vertebral a. Phrenic nerve SCM muscle Anterior scalene m. Middle scalene m. Subclavian a. 10-01-2011 8 Phrenic Nerve By: CK

Phrenic Nerve Course : 

Phrenic Nerve Course It emerges at lateral and anterior border of the scalenus anterior muscle undercover the sternocleidomastoid muscle (SCM) Deep to the prevertebral fascia Leaves the neck through the thoracic outlet b/w subclavian artery and vein. Crossing in front the origin of the internal thoracic artery, where it joins the pericardiacophrenic branch of this artery . 10-01-2011 9 Phrenic Nerve By: CK

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Subclavian a-v Anterior and middle scalene 10-01-2011 10 Phrenic Nerve By: CK

Phrenic Nerve Course….Cont’d : 

Phrenic Nerve Course….Cont’d Both phrenic nerves runs from c3,c4 and c5 along the anterior scalene muscles. The right phrenic nerve passes over the brachiocephalic artery and then crosses the root of the right lung and then leaves the thorax by passing through the vena cava hiatus opening in the diaphragm at the level of T8. The right phrenic nerve passes over the right atrium. 10-01-2011 11 Phrenic Nerve By: CK

Phrenic Nerve Course : 

Phrenic Nerve Course 10-01-2011 12 Phrenic Nerve By: CK

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The left phrenic nerve passes over the left ventricle and pierces the diaphragm separately. Phrenic Nerve Course….Cont’d 10-01-2011 13 Phrenic Nerve By: CK

Innervations of the Phrenic Nerve : 

Innervations of the Phrenic Nerve Motor Supply:- Scaleni (elevation of upper thorax) Sole motor supply of the diaphragm Sensory Supply:- Pericardium Mediastinal Pleura Pleural and peritoneal And coverings of the central part of the diaphragm Phrenic Nerve By: CK 10-01-2011 14

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1- Motor innervations of the diaphragm 2- Sensory A-pericardium B- mediastinal pleura C- pleural and peritoneal And coverings of the central part of the diaphragm 10-01-2011 15 Phrenic Nerve By: CK

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Accessory Phrenic Nerve. Arises as a contribution of C5 to the phrenic nerve or a branch of the nerve to the subclavius C5 Descends lat. to the phrenic nerve Post. to the subclavian vein Joins the phrenic n below the first rib to supply the diaphragm. 10-01-2011 16 Phrenic Nerve By: CK

Clinical Importance Phrenic Innervations : 

Each phrenic nerve contributes predominantly motor fibers to ipsilateral hemidiaphragm muscle which helps in breathing process by pushing up beneath the lungs to control the contraction and expansion during respiration, or breathing. Clinical Importance Phrenic Innervations 10-01-2011 17 Phrenic Nerve By: CK

Clinical Importance of Diaphragm : 

18 Clinical Importance of Diaphragm With quite breathing, the diaphragm accounts about 75 to 80% of ventilation. The vertical movement of the diaphragm is 1 to 2 cm during quite breathing and 6 to 7 cm during deep breathing. Each cm of vertical movement contributes 300 to 400 ml of air during normal breathing. 10-01-2011 Phrenic Nerve By: CK

Diaphragm……cont’d : 

19 Diaphragm……cont’d The diaphragm comprise 2 parts: costal and crural portions. The costal portion is thinner and the crural portion is thicker. Both portions are innervated by the phrenic nerve. The costal portion flatten the diaphragm and lift the rib. The crural portion causes downward placement of the diaphragm( less effective in breathing.) 10-01-2011 Phrenic Nerve By: CK

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Clinical Importance of Diaphragm : 

During inhalation, the diaphragm contracts to expand the lungs and allow air to fill the space. During expiration, the diaphragm relaxes and expands against the lungs, causing the lungs to contract and push out the used air. The diaphragm may also exert pressure on the abdominal cavity, helping out process such as the excretion of vomit, feces, or urine2. Clinical Importance of Diaphragm 10-01-2011 21 Phrenic Nerve By: CK

Phrenic Nerve : 

Phrenic Nerve 10-01-2011 22 Phrenic Nerve By: CK

Injury To the Phrenic Nerve : 

Injury To the Phrenic Nerve Injury to the phrenic nerve may lead to paralysis of involved hemidiaphragm. Isolated phrenic neuropathy can occur, possibly as variant of acute brachial plexopathy and it is unilateral. Bilateral phrenic neuropathy may be caused by GBS4 and amyotrophic lateralized sclerosis, which causes respiratory failure and is a major cause of death in ALS 8. 10-01-2011 23 Phrenic Nerve By: CK

Injury To the Phrenic Nerve…..Cont’d : 

Injury To the Phrenic Nerve…..Cont’d Irritation of the phrenic sensory fibers tends to referred pain to the C4 dermatome territory and may present with hiccups. Phrenic nerve conduction techniques have been in use since number of years for evaluation of respiratory failure in neuromuscular disorder. 10-01-2011 24 Phrenic Nerve By: CK

PHRENIC MOTOR NERVE CONDUCTION STUDY : 

PHRENIC MOTOR NERVE CONDUCTION STUDY RECORDING SITE:- Diaphragm muscle G1 placed two fingerbreadths above the xiphoid process G2 placed over the anterior costal margin 16cm from G1 G3 in between recording and stimulating electrodes STIMULATION SITE:- Lateral neck: Posterior to the sternocleidomastoid muscle approximately 3cm above the clavicle. 10-01-2011 25 Phrenic Nerve By: CK

PHRENIC MOTOR NERVE CONDUCTION STUDY….cont’d : 

PHRENIC MOTOR NERVE CONDUCTION STUDY….cont’d 10-01-2011 26 Phrenic Nerve By: CK

Placement number 1 : 

Placement number 1 10-01-2011 Phrenic Nerve By: CK 27

Placement number 2 : 

10-01-2011 Phrenic Nerve By: CK 28 Placement number 2

Placement number 3 : 

10-01-2011 Phrenic Nerve By: CK 29 Placement number 3

PHRENIC MOTOR NERVE CONDUCTION STUDY….cont’d : 

Distal Distance:- Variable Key Points:- Firm pressure is needed when holding stimulator If stimulator is not in correct location , the spinal accessory or brachial plexus can be stimulated. In thin individuals the diaphragm contraction is often visualized with hiccups. Difficult study to perform in obese individuals. Avoid the co-stimulation PHRENIC MOTOR NERVE CONDUCTION STUDY….cont’d 10-01-2011 30 Phrenic Nerve By: CK

PHRENIC MOTOR NERVE CONDUCTION STUDY….cont’d : 

PHRENIC MOTOR NERVE CONDUCTION STUDY….cont’d Contraindication: Do not perform this study in the intensive care unit in patients who have external pacemaker (risk of current spread to heart) Caution if an internal jugular catheter, implanted cardiac pacemaker, or cardioverter-defibrillator is nearby. 10-01-2011 31 Phrenic Nerve By: CK

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References : 

References John Cunningham, Arthur Robinson. Cunningham’s text book of Anatomy. 5th Edition. William Wood and Company;1818:5: 699-701 Shin J. OH. Clinical Electromyography: Nerve conduction studies second edition; Nerve conduction in focal neuropathies 508. Shin J. OH. Clinical Electromyography: Nerve conduction studies second edition; Uncommon nerve conduction studies: techniques and normal values; 165-166; 10-01-2011 33 Phrenic Nerve By: CK

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Thanks 10-01-2011 Phrenic Nerve By: CK 34

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