The peripheral nervous system is a channel for the relay of sensory and motor impulses between the central nervous system on one hand and the body surface, skeletal muscles, and internal organs on the other hand. It is composed of (1) spinal nerves, (2) cranial nerves, and (3) certain parts of the autonomic nervous system. As in the central nervous system, peripheral nervous pathways are made up of neurons (that is, nerve cell bodies and their axons and dendrites) and synapses, the points at which one neuron communicates with the next. The structures commonly known as nerves (or by such names as roots, rami, trunks, and branches) are composed of orderly arrangements of the axonal and dendritic processes of many nerve cell bodies.
The cell bodies of peripheral neurons are often found grouped into clusters called ganglia. On the basis of the type of nerve cell bodies found in ganglia, they may be classified as either sensory or motor. Sensory ganglia are oval swellings located on the dorsal roots of spinal nerves and on the roots of certain cranial nerves. The sensory neurons making up these ganglia are unipolar. Shaped much like a golf ball on a tee, they have round or slightly oval cell bodies with concentrically located nuclei, and they give rise to a single fibre that undergoes a T-shaped bifurcation, one branch going to the periphery and the other entering the brain or spinal cord. There are no synaptic contacts between neurons in a sensory ganglion.
Motor ganglia are associated with neurons of the autonomic nervous system, the part of the nervous system that controls and regulates the internal organs. Many motor ganglia are located in the sympathetic trunks, two long chains of ganglia stretching along each side of the vertebral column from the base of the skull to the coccyx; these are referred to as paravertebral ganglia. Prevertebral motor ganglia are located near internal organs innervated by their projecting fibres, while terminal ganglia are found on the surfaces or within the walls of the target organs themselves. Motor ganglia have multipolar cell bodies, which have irregular shapes and eccentrically located nuclei and which project several dendritic and axonal processes. Preganglionic fibres originating from the brain or spinal cord enter motor ganglia, where they synapse on multipolar cell bodies. These postganglionic cells, in turn, send their processes to visceral structures.
SPINAL NERVE
The cell bodies of peripheral neurons are often found grouped into clusters called ganglia. On the basis of the type of nerve cell bodies found in ganglia, they may be classified as either sensory or motor. Sensory ganglia are oval swellings located on the dorsal roots of spinal nerves and on the roots of certain cranial nerves. The sensory neurons making up these ganglia are unipolar. Shaped much like a golf ball on a tee, they have round or slightly oval cell bodies with concentrically located nuclei, and they give rise to a single fibre that undergoes a T-shaped bifurcation, one branch going to the periphery and the other entering the brain or spinal cord. There are no synaptic contacts between neurons in a sensory ganglion.
Motor ganglia are associated with neurons of the autonomic nervous system, the part of the nervous system that controls and regulates the internal organs. Many motor ganglia are located in the sympathetic trunks, two long chains of ganglia stretching along each side of the vertebral column from the base of the skull to the coccyx; these are referred to as paravertebral ganglia. Prevertebral motor ganglia are located near internal organs innervated by their projecting fibres, while terminal ganglia are found on the surfaces or within the walls of the target organs themselves. Motor ganglia have multipolar cell bodies, which have irregular shapes and eccentrically located nuclei and which project several dendritic and axonal processes. Preganglionic fibres originating from the brain or spinal cord enter motor ganglia, where they synapse on multipolar cell bodies. These postganglionic cells, in turn, send their processes to visceral structures.
SPINAL NERVE
Sensory input from the body surface, from joint, tendon, and muscle receptors, and from internal organs passes centrally through the dorsal roots of the spinal cord. Fibres from motor cells in the spinal cord exit via the ventral roots and course to their peripheral targets (autonomic ganglia or skeletal muscle). Each spinal nerve is formed by the joining of a dorsal root and a ventral root, and it is the basic structural and functional unit of the peripheral nervous system.
STRUCTURAL COMPONENTS OF THE SPINAL NERVE
There are 31 pairs of spinal nerves; in descending order from the most rostral end of the spinal cord, there are 8 cervical (designated C1–C8), 12 thoracic (T1–T12), 5 lumbar (L1–L5), 5 sacral (S1–S5), and 1 coccygeal (Coc1). Each spinal nerve exits the vertebral canal through an opening called the intervertebral foramen. The first spinal nerve (C1) exits the vertebral canal between the skull and the first cervical vertebra; consequently, spinal nerves C1–C7 exit above the correspondingly numbered vertebrae. Spinal nerve C8, however, exits between the 7th cervical and first thoracic vertebrae, so that, beginning with T1, all other spinal nerves exit below their corresponding vertebrae.
There are 31 pairs of spinal nerves; in descending order from the most rostral end of the spinal cord, there are 8 cervical (designated C1–C8), 12 thoracic (T1–T12), 5 lumbar (L1–L5), 5 sacral (S1–S5), and 1 coccygeal (Coc1). Each spinal nerve exits the vertebral canal through an opening called the intervertebral foramen. The first spinal nerve (C1) exits the vertebral canal between the skull and the first cervical vertebra; consequently, spinal nerves C1–C7 exit above the correspondingly numbered vertebrae. Spinal nerve C8, however, exits between the 7th cervical and first thoracic vertebrae, so that, beginning with T1, all other spinal nerves exit below their corresponding vertebrae.
Just outside the intervertebral foramen, two branches, known as the gray and white rami communicantes, connect each spinal nerve with the sympathetic trunk. These rami, along with the sympathetic trunk and more distal ganglia, are involved with the innervation of visceral structures. In addition, small meningeal branches leave each spinal nerve and gray ramus and reenter the vertebral canal, where they innervate the dura mater (the outermost of the meninges) and blood vessels.More peripherally, each spinal nerve divides into ventral and dorsal rami. All dorsal rami (with the exception of those from C1, S4, S5, and Coc1) have medial and lateral branches, which innervate deep back muscles and overlying skin. The medial and lateral branches of the dorsal rami of spinal nerves C2–C8 supply both the muscles and the skin of the neck. Those of T1–T6 are mostly cutaneous (that is, supplying only the skin), while those from T7–T12 are mainly muscular. Dorsal rami from L1–L3 have both sensory and motor fibres, while those from L4–L5 are only muscular. Dorsal rami of S1–S3 may also be divided into medial and lateral branches, serving deep muscles of the lower back as well as cutaneous areas of the lower buttocks and perianal area. Undivided dorsal rami from S4, S5, and Coc1 also send cutaneous branches to the gluteal and perianal regions.Ventral rami of the spinal nerves carry sensory and motor fibres for the innervation of the muscles, joints, and skin of the lateral and ventral body walls and the extremities. Both dorsal and ventral rami also contain autonomic fibres.
FUNCTIONAL TYPES OF SPINAL NERVES
Because spinal nerves contain both sensory fibres (from the dorsal roots) and motor fibres (from the ventral roots), they are known as mixed nerves. When individual fibres of a spinal nerve are identified by their specific function, they may be categorized as one of four types: (1) general somatic afferent, (2) general visceral afferent, (3) general somatic efferent, and (4) general visceral efferent. The term somatic refers to the body wall (broadly defined to include skeletal muscles as well as the surface of the skin), and visceral refers to structures composed of smooth muscle, cardiac muscle, glandular epithelium, or a combination of these. Efferent fibres carry motor information to skeletal muscle and to autonomic ganglia (and then to visceral structures), and afferent fibres carry sensory information from them.
Because spinal nerves contain both sensory fibres (from the dorsal roots) and motor fibres (from the ventral roots), they are known as mixed nerves. When individual fibres of a spinal nerve are identified by their specific function, they may be categorized as one of four types: (1) general somatic afferent, (2) general visceral afferent, (3) general somatic efferent, and (4) general visceral efferent. The term somatic refers to the body wall (broadly defined to include skeletal muscles as well as the surface of the skin), and visceral refers to structures composed of smooth muscle, cardiac muscle, glandular epithelium, or a combination of these. Efferent fibres carry motor information to skeletal muscle and to autonomic ganglia (and then to visceral structures), and afferent fibres carry sensory information from them.
General somatic afferent receptors are sensitive to pain, thermal sensation, touch and pressure, and changes in the position of the body. (Pain and temperature sensation coming from the surface of the body is called exteroceptive, while sensory information arising from tendons, muscles, or joint capsules is called proprioceptive.) General visceral afferent receptors are found in organs of the thorax, abdomen, and pelvis; their fibres convey, for example, pain information from the digestive tract. Both types of afferent fibre project centrally from cell bodies in dorsal-root ganglia.
General somatic efferent fibres originate from large ventral-horn cells and distribute to skeletal muscles in the body wall and in the extremities. General visceral efferent fibres also arise from cell bodies located within the spinal cord, but they exit only at thoracic and upper lumbar levels or at sacral levels (more specifically, at levels T1–L2 and S2–S4). Fibres from T1–L2 enter the sympathetic trunk, where they either form synaptic contacts within a ganglion, ascend or descend within the trunk, or exit the trunk and proceed to ganglia situated closer to their target organs. Fibres from S2–S4, on the other hand, leave the cord as the pelvic nerve and proceed to terminal ganglia located in the target organs. Postganglionic fibres arising from ganglia in the sympathetic trunk rejoin the spinal nerves and distribute to blood vessels, sweat glands, and the arrector pili muscles of the skin, while postganglionic fibres arising from prevertebral and terminal ganglia innervate viscera of the thorax, abdomen, and pelvis.
CERVICAL PLEXUS
Cervical levels C1–C4 are the main contributors to the group of nerves called the cervical plexus; in addition, small branches of the plexus link C1 and C2 with the vagus nerve, C1 and C2 with the hypoglossal nerve, and C2–C4 with the accessory nerve. Sensory branches of the cervical plexus are the lesser occipital nerve (to the scalp behind the ear), the great auricular nerve (to the ear and to the skin over the mastoid and parotid areas), transverse cervical cutaneous nerves (to the lateral and ventral neck surfaces), and supraclavicular nerves (along the clavicle, shoulder, and upper chest). Motor branches of the plexus serve muscles that stabilize and flex the neck, muscles that stabilize the hyoid bone (to assist in actions like swallowing), and muscles that elevate the upper ribs.
CERVICAL PLEXUS
Cervical levels C1–C4 are the main contributors to the group of nerves called the cervical plexus; in addition, small branches of the plexus link C1 and C2 with the vagus nerve, C1 and C2 with the hypoglossal nerve, and C2–C4 with the accessory nerve. Sensory branches of the cervical plexus are the lesser occipital nerve (to the scalp behind the ear), the great auricular nerve (to the ear and to the skin over the mastoid and parotid areas), transverse cervical cutaneous nerves (to the lateral and ventral neck surfaces), and supraclavicular nerves (along the clavicle, shoulder, and upper chest). Motor branches of the plexus serve muscles that stabilize and flex the neck, muscles that stabilize the hyoid bone (to assist in actions like swallowing), and muscles that elevate the upper ribs.
Originating from C4, with small contributions from C3 and C5, are the phrenic nerves, which carry sensory information from parts of the pleura of the lungs and pericardium of the heart as well as motor impulses to muscles of the diaphragm.
BRACHIAL PLEXUS
Cervical levels C5–C8 and thoracic level T1 contribute to the formation of the brachial plexus; small nerve bundles also arrive from C4 and T2. Spinal nerves from these levels converge to form superior (C5 and C6), middle (C7), and inferior (C8 and T1) trunks, which in turn split into anterior and posterior divisions. The divisions then form cords (posterior, lateral, and medial), which provide motor, sensory, and autonomic fibres to the shoulder and upper extremity.
BRACHIAL PLEXUS
Cervical levels C5–C8 and thoracic level T1 contribute to the formation of the brachial plexus; small nerve bundles also arrive from C4 and T2. Spinal nerves from these levels converge to form superior (C5 and C6), middle (C7), and inferior (C8 and T1) trunks, which in turn split into anterior and posterior divisions. The divisions then form cords (posterior, lateral, and medial), which provide motor, sensory, and autonomic fibres to the shoulder and upper extremity.
Nerves to shoulder and pectoral muscles include the dorsal scapular (to the rhomboid muscles), suprascapular (to supraspinatus and infraspinatus), medial and lateral pectoral (to pectoralis minor and major), long thoracic (to serratus anterior), thoracodorsal (to latissimus dorsi), and subscapular (to teres major and subscapular). The axillary nerve carries motor fibres to the deltoid and teres minor muscles as well as sensory fibres to the lateral surface of the shoulder and upper arm. The biceps, brachialis, and coracobrachialis muscles, as well as the lateral surface of the forearm, are served by the musculocutaneous nerve.
The three major nerves of the arm, forearm, and hand are the radial, median, and ulnar. The radial nerve innervates the triceps, anconeus, and brachioradialis muscles, eight extensors of the wrist and digits, and one abductor of the hand; it is also sensory to part of the hand. The median nerve branches in the forearm to serve the palmaris longus, two pronator muscles, four flexor muscles, thenar muscles, and lumbrical muscles; most of these serve the wrist and hand. The ulnar nerve serves two flexor muscles and a variety of small muscles of the wrist and hand.
Cutaneous innervation of the upper extremity originates, via the brachial plexus, from spinal cord levels C3–T2. The shoulder is served by supraclavicular branches (C3, C4) of the cervical plexus, while the anterior and lateral aspects of the arm and forearm have sensory innervation via the axillary (C5, C6) nerve as well as the dorsal (C5, C6), lateral (C5, C6), and medial (C8, T1) antebrachial cutaneous nerves. These same nerves have branches that wrap around to serve portions of the posterior and medial surfaces of the extremity. The palm of the hand is served by the median (C6–C8) and ulnar (C8, T1) nerves. The ulnar nerve also wraps around to serve medial areas of the dorsum, or back, of the hand. An imaginary line drawn down the midline of the ring finger represents the junction of the ulnar-radial distribution on the back of the hand and the ulnar-median distribution on the palm. A small part of the thumb and the distal thirds of the index, middle, and lateral surface of the ring finger are served by the median nerve. The inner arm and the armpit is served by the intercostobrachial and the posterior and medial brachial cutaneous nerves (T1–T2).
LUMBAR PLEXUS
Spinal nerves from lumbar levels L1–L4 contribute to the formation of the lumbar plexus, which, along with the sacral plexus, provides motor, sensory, and autonomic fibres to gluteal and inguinal regions and to the lower extremities. Lumbar roots are organized into dorsal and ventral divisions.
LUMBAR PLEXUS
Spinal nerves from lumbar levels L1–L4 contribute to the formation of the lumbar plexus, which, along with the sacral plexus, provides motor, sensory, and autonomic fibres to gluteal and inguinal regions and to the lower extremities. Lumbar roots are organized into dorsal and ventral divisions.
Minor cutaneous and muscular branches of the lumbar plexus include the iliohypogastric, genitofemoral, and ilioinguinal (projecting to the lower abdomen and to inguinal and genital regions) and the lateral femoral cutaneous nerve (to skin on the lateral thigh). Two major branches of the lumbar plexus are the obturator and femoral nerves. The obturator enters the thigh through the obturator foramen; motor branches proceed to the obturator internus and gracilis muscles as well as the adductor muscles, while sensory branches supply the articular capsule of the knee joint. An accessory obturator nerve supplies the pectineus muscle of the thigh and is sensory to the hip joint. The sartorius muscle and medial and anterior surfaces of the thigh are served by branches of the anterior division of the femoral nerve. The posterior division of the femoral nerve provides sensory fibres to the inner surface of the leg (saphenous nerve), to the quadriceps muscles (muscular branches), to the hip and knee joints, and to the articularis genu muscle.
SACRAL PLEXUS
The ventral rami of L5 and S1–S3 form the sacral plexus, with contributions from L4 and S4. Branches from this plexus innervate gluteal muscles, muscles forming the internal surface of the pelvic basin (including those forming the levator ani), and muscles that run between the femur and pelvis to stabilize the hip joint (such as the obturator, piriformis, and quadratus femoris muscles). These muscles lend their names to the nerves that innervate them. Cutaneous branches from the plexus serve the buttocks, perineum, and posterior surface of the thigh.
The major nerve of the sacral plexus, and the largest nerve in the body, is the sciatic. Formed by the joining of ventral and dorsal divisions of the plexus, it passes through the greater sciatic foramen and descends in back of the thigh. There, sciatic branches innervate the biceps femoris, semitendinosus and semimembranosus muscles, and part of the adductor magnus muscle. In the popliteal fossa (just above the knee), the sciatic nerve divides into the tibial nerve and the
common fibular (or peroneal) nerve. The tibial nerve (from the dorsal division) continues distally in the calf and innervates the gastrocnemius muscle, deep leg muscles such as the popliteus, soleus, and tibialis posterior, and the flexor muscles, lumbrical muscles, and other muscles of the ankle and plantar aspects of the foot. The peroneal nerve, from the ventral division, travels to the anterior surface of the leg and innervates the tibialis anterior, the fibularis muscles, and extensor muscles that elevate the foot and fan the toes. Cutaneous branches from the tibial and common fibular nerves serve the outer sides of the leg and the top and bottom of the foot and toes.COCCYGEAL PLEXUS
The ventral rami of S4, S5, and Coc1 form the coccygeal plexus, from which small anococcygeal nerves arise to innervate the skin over the coccyx (tailbone) and around the anus.
CRANIAL NERVES
Cranial nerves can be thought of as modified spinal nerves, since the general functional fibre types found in spinal nerves are also found in cranial nerves but are supplemented by special afferent or efferent fibres. Fibres conveying olfaction (in cranial nerve I) and taste (in cranial nerves VII, IX, and X) are classified as special visceral afferent, while the designation of special somatic afferent is applied to fibres conveying vision (cranial nerve II) and equilibrium and hearing (cranial nerve VIII). Skeletal muscles that arise from the branchial arches are innervated by fibres of cranial nerves V, VII, IX, and X; these are classified as special visceral efferent fibres.The 12 pairs of cranial nerves are identified either by name or by Roman or Arabic numeral.
Olfactory nerve (CN I or 1): Bipolar cells in the nasal mucosa give rise to axons that enter the cranial cavity through foramina in the cribriform plate of the ethmoid bone. These cells and their axons, totaling about 20 to 24 in number, make up the olfactory nerve. Once in the cranial cavity, the fibres terminate in a small oval structure resting on the cribriform plate called the olfactory bulb. As stated above, the functional component of olfactory fibres is special visceral afferent. Injury or disease of the olfactory nerve may result in anosmia, an inability to detect odours; it may also dull the sense of taste.
Optic nerve (CN II or 2): Rods and cones in the retina of the eye receive information from the visual fields and, through intermediary cells, convey this input to retinal ganglion cells. Ganglion cell axons converge at the optic disc, pass through the sclera, and form the optic nerve. A branch from each eye enters the skull via the optic foramen, and they join to form the optic chiasm. At the chiasm, fibres from the nasal halves of each retina cross, while those from the temporal halves remain uncrossed. In this way the optic tracts, which extend from the chiasm to the thalamus, contain fibres conveying information from both eyes. Injury to one optic nerve therefore results in total blindness of that eye, while damage to the optic tract on one side results in partial blindness in both eyes.
Optic fibres also participate in accommodation of the lens and in the pupillary light reflex. Since the subarachnoid space around the brain is continuous with that around the optic nerve, increases in intracranial pressure can result in papilledema, or damage to the optic nerve, as it exits the bulb of the eye.
Optic fibres also participate in accommodation of the lens and in the pupillary light reflex. Since the subarachnoid space around the brain is continuous with that around the optic nerve, increases in intracranial pressure can result in papilledema, or damage to the optic nerve, as it exits the bulb of the eye.
Oculomotor nerve (CN III or 3): The oculomotor nerve arises from two nuclei in the rostral midbrain. These are (1) the oculomotor nucleus, the source of general somatic efferent fibres to superior, medial, and inferior recti muscles, to the inferior oblique muscle, and to the levator palpebrae superious muscle, and (2) the Edinger-Westphal nucleus, which projects general visceral efferent preganglionic fibres to the ciliary ganglion.
The oculomotor nerve exits the ventral midbrain, pierces the dura mater, courses through the lateral wall of the cavernous sinus, and exits the cranial cavity via the superior orbital fissure. Within the orbit it branches into a superior ramus (to the superior rectus and levator muscles) and an inferior ramus (to the medial and inferior rectus muscles, the inferior oblique muscles, and the ciliary ganglion). Postganglionic fibres from the ciliary ganglion innervate the sphincter pupillae muscle of the iris as well as the ciliary muscle.
Oculomotor neurons project primarily to orbital muscles on the same side of the head. A lesion of the oculomotor nerve will result in paralysis of the three rectus muscles and the inferior oblique muscle (causing the eye to rotate downward and slightly outward), paralysis of the levator palpebrae superious muscle (drooping of the eyelids), and paralysis of the sphincter pupillae and ciliary muscles (so that the iris will remain dilated and the lens will not accommodate).
The oculomotor nerve exits the ventral midbrain, pierces the dura mater, courses through the lateral wall of the cavernous sinus, and exits the cranial cavity via the superior orbital fissure. Within the orbit it branches into a superior ramus (to the superior rectus and levator muscles) and an inferior ramus (to the medial and inferior rectus muscles, the inferior oblique muscles, and the ciliary ganglion). Postganglionic fibres from the ciliary ganglion innervate the sphincter pupillae muscle of the iris as well as the ciliary muscle.
Oculomotor neurons project primarily to orbital muscles on the same side of the head. A lesion of the oculomotor nerve will result in paralysis of the three rectus muscles and the inferior oblique muscle (causing the eye to rotate downward and slightly outward), paralysis of the levator palpebrae superious muscle (drooping of the eyelids), and paralysis of the sphincter pupillae and ciliary muscles (so that the iris will remain dilated and the lens will not accommodate).
Trochlear nerve (CN IV or 4): The fourth cranial nerve is unique for three reasons. First, it is the only cranial nerve to exit the dorsal side of the brainstem. Second, fibres from the trochlear nucleus cross in the midbrain before they exit, so that trochlear neurons innervate the contralateral (opposite side) superior oblique muscle of the eye. Third, trochlear fibres have a long intracranial course before piercing the dura mater.
The trochlear nucleus is located in the caudal midbrain; the functional component of these cells is general somatic efferent. After exiting at the dorsal side of the midbrain, the trochlear nerve loops around the midbrain, pierces the dura mater, and passes through the lateral wall of the cavernous sinus. It then enters the orbit through the superior orbital fissure and innervates only the superior oblique muscle, which rotates the eye downward and slightly outward. Damage to the trochlear nerve will result in a loss of this eye movement and may produce double vision (diplopia).
The trochlear nucleus is located in the caudal midbrain; the functional component of these cells is general somatic efferent. After exiting at the dorsal side of the midbrain, the trochlear nerve loops around the midbrain, pierces the dura mater, and passes through the lateral wall of the cavernous sinus. It then enters the orbit through the superior orbital fissure and innervates only the superior oblique muscle, which rotates the eye downward and slightly outward. Damage to the trochlear nerve will result in a loss of this eye movement and may produce double vision (diplopia).
Trigeminal nerve (CN V or 5): The trigeminal nerve is the largest of the cranial nerves. It has both motor and sensory components, the sensory fibres being general somatic afferent and the motor fibres being special visceral efferent. Most of the cell bodies of sensory fibres are located in the trigeminal ganglion, which is attached to the pons by the trigeminal root. These fibres convey pain and thermal sensations from the face, oral and nasal cavities, and parts of the dura mater and nasal sinuses, sensations of deep pressure, and information from sensory endings in muscles. Trigeminal motor fibres, projecting from nuclei in the pons, serve the muscles of mastication (chewing). Lesions of the trigeminal nerve result in sensory losses over the face or in the oral cavity. Damage to the motor fibres results in paralysis of the masticatory muscles; as a result, the jaw may hang open or deviate toward the injured side when opened. Trigeminal neuralgia, or tic douloureux, is an intense pain originating mainly from areas supplied by sensory fibres of the maxillary and mandibular branches of this nerve.
The trigeminal ganglion gives rise to three large nerves: the ophthalmic, maxillary, and mandibular.
1.Ophthalmic nerve: The ophthalmic nerve passes through the wall of the cavernous sinus and enters the orbit via the superior orbital fissure. Branches in the orbit are (1) the lacrimal nerve, serving the lacrimal gland, part of the upper eyelid, and the conjunctiva, (2) the nasociliary nerve, serving the mucosal lining of part of the nasal cavity, the tentorium cerebelli and some of the dura mater of the anterior cranial fossa, and skin on the dorsum and tip of the nose, and (3) the frontal nerve, serving the skin on the upper eyelid, the forehead, and the scalp above the eyes up to the v ertex of the head.
2.Maxillary nerve: The maxillary nerve courses through the cavernous sinus below the ophthalmic nerve and passes through the foramen rotundum into the orbital cavity. Branches of the maxillary nerve are (1) the meningeal branches, which serve the dura mater of the middle cranial fossa, (2) the alveolar nerves, serving the upper teeth and gingiva and the lining of the maxillary sinus, (3) the nasal and palatine nerves, which serve portions of the nasal cavity and the mucosa of the hard and soft palate, and (4) the infraorbital, zygomaticotemporal, and zygomaticofacial nerves, serving the upper lip, the lateral surfaces of the nose, the lower eyelid and conjunctiva, and the skin on the cheek and the side of the head behind the eye.
3.Mandibular nerve: The mandibular nerve exits the cranial cavity via the foramen ovale and serves (1) the meninges and parts of the anterior cranial fossae (meningeal branches), (2) the temporomandibular joint, skin over part of the ear, and skin over the sides of the head above the ears (auriculotemporal nerve), (3) oral mucosa, the anterior two-thirds of the tongue, gingiva adjacent to the tongue, and the floor of the mouth (lingual nerve), and (4) the mandibular teeth (inferior alveolar nerve). Skin over the lateral and anterior surfaces of the mandible and the lower lip is served by cutaneous branches of the mandibular nerve.
Trigeminal motor fibres exit the cranial cavity via the foramen ovale along with the mandibular nerve. They serve the muscles of mastication (temporalis, masseter, medial and lateral pterygoid), three muscles involved in swallowing (anterior portions of the digastric muscle, the mylohyoid muscle, and the tensor veli palatini), and the tensor tympani, a muscle that has a damping effect on loud noises by stabilizing the tympanic membrane.
The trigeminal ganglion gives rise to three large nerves: the ophthalmic, maxillary, and mandibular.
1.Ophthalmic nerve: The ophthalmic nerve passes through the wall of the cavernous sinus and enters the orbit via the superior orbital fissure. Branches in the orbit are (1) the lacrimal nerve, serving the lacrimal gland, part of the upper eyelid, and the conjunctiva, (2) the nasociliary nerve, serving the mucosal lining of part of the nasal cavity, the tentorium cerebelli and some of the dura mater of the anterior cranial fossa, and skin on the dorsum and tip of the nose, and (3) the frontal nerve, serving the skin on the upper eyelid, the forehead, and the scalp above the eyes up to the v ertex of the head.
2.Maxillary nerve: The maxillary nerve courses through the cavernous sinus below the ophthalmic nerve and passes through the foramen rotundum into the orbital cavity. Branches of the maxillary nerve are (1) the meningeal branches, which serve the dura mater of the middle cranial fossa, (2) the alveolar nerves, serving the upper teeth and gingiva and the lining of the maxillary sinus, (3) the nasal and palatine nerves, which serve portions of the nasal cavity and the mucosa of the hard and soft palate, and (4) the infraorbital, zygomaticotemporal, and zygomaticofacial nerves, serving the upper lip, the lateral surfaces of the nose, the lower eyelid and conjunctiva, and the skin on the cheek and the side of the head behind the eye.
3.Mandibular nerve: The mandibular nerve exits the cranial cavity via the foramen ovale and serves (1) the meninges and parts of the anterior cranial fossae (meningeal branches), (2) the temporomandibular joint, skin over part of the ear, and skin over the sides of the head above the ears (auriculotemporal nerve), (3) oral mucosa, the anterior two-thirds of the tongue, gingiva adjacent to the tongue, and the floor of the mouth (lingual nerve), and (4) the mandibular teeth (inferior alveolar nerve). Skin over the lateral and anterior surfaces of the mandible and the lower lip is served by cutaneous branches of the mandibular nerve.
Trigeminal motor fibres exit the cranial cavity via the foramen ovale along with the mandibular nerve. They serve the muscles of mastication (temporalis, masseter, medial and lateral pterygoid), three muscles involved in swallowing (anterior portions of the digastric muscle, the mylohyoid muscle, and the tensor veli palatini), and the tensor tympani, a muscle that has a damping effect on loud noises by stabilizing the tympanic membrane.
Abducens nerve (CN VI or 6): From its nucleus in the caudal pons, the abducens nerve exits the brainstem at the pons-medulla junction, pierces the dura mater, passes through the cavernous sinus close to the internal carotid artery, and exits the cranial vault via the superior orbital fissure. In the orbit the abducens nerve innervates the lateral rectus muscle, which turns the eye outward. Damage to the abducens nerve results in a tendency for the eye to deviate medially, or cross. Double vision may result on attempted lateral gaze. The nerve often is affected by increased intracranial pressure.
Facial nerve (CN VII or 7): The facial nerve is composed of a large root that innervates facial muscles and a small root (known as the intermediate nerve) that contains sensory and autonomic fibres.
From the facial nucleus in the pons, facial motor fibres enter the internal auditory meatus, pass through the temporal bone, exit the skull via the stylomastoid foramen, and fan out over each side of the face in front of the ear. Fibres of the facial nerve are special visceral efferent; they innervate the small muscles of the external ear, the superficial muscles of the face, neck, and scalp, and the muscles of facial expression.
The intermediate nerve contains autonomic (parasympathetic) as well as general and special sensory fibres. Preganglionic autonomic fibres, classified as general visceral efferent, project from the superior salivatory nucleus in the pons. Exiting with the facial nerve, they pass to the pterygopalatine ganglion via the greater petrosal nerve (a branch of the facial nerve) and to the submandibular ganglion by way of the chorda tympani nerve (another branch of the facial nerve, which joins the lingual branch of the mandibular nerve). Postganglionic fibres from the pterygopalatine ganglion innervate the nasal and palatine glands and the lacrimal gland, while those from the submandibular ganglion serve the submandibular and sublingual salivary glands. Among the sensory components of the intermediate nerve, general somatic afferent fibres relay sensation from the caudal surface of the ear, while special visceral afferent fibres originate from taste buds in the anterior two-thirds of the tongue, course in the lingual branch of the mandibular nerve, and then join the facial nerve via the chorda tympani branch. Both somatic and visceral afferent fibres have cell bodies in the geniculate ganglion, which is located on the facial nerve as it passes through the facial canal in the temporal bone.
Injury to the facial nerve at the brainstem produces a paralysis of facial muscles known as Bell palsy as well as a loss of taste sensation from the anterior two-thirds of the tongue. If damage occurs at the stylomastoid foramen, facial muscles will be paralyzed but taste will be intact.
Vestibulocochlear nerve or Auditory nerve (CN VIII or 8): This cranial nerve has a vestibular part, which functions in balance, equilibrium, and orientation in three-dimensional space, and a cochlear part, which functions in hearing. The functional component of these fibres is special somatic afferent; they originate from receptors located in the temporal bone.
Vestibular receptors are located in the semicircular canals of the ear, which provide input on rotatory movements (angular acceleration), and in the utricle and saccule, which generate information on linear acceleration and the influence of gravitational pull. This information is relayed by the vestibular fibres, whose bipolar cell bodies are located in the vestibular (Scarpa) ganglion. The central processes of these neurons exit the temporal bone via the internal acoustic meatus and enter the brainstem alongside the facial nerve.
Auditory receptors of the cochlear division are located in the organ of Corti and follow the spiral shape (about 2.5 turns) of the cochlea. Air movement against the eardrum initiates action of the ossicles of the ear, which, in turn, causes movement of fluid in the spiral cochlea. This fluid movement is converted by the organ of Corti into nerve impulses that are interpreted as auditory information. The bipolar cells of the spiral, or Corti, ganglion branch into central processes that course with the vestibular nerve. At the brainstem, cochlear fibres separate from vestibular fibres to end in the dorsal and ventral cochlear nuclei.
Lesions of the vestibular root result in eye movement disorders (nystagmus), unsteady gait with a tendency to fall toward the side of the lesion, nausea, and vertigo. Damage to the cochlea or cochlear nerve results in complete deafness, ringing in the ear (tinnitus), or both.
Glossopharyngeal nerve (CN IX or 9): The ninth cranial nerve, which exits the skull through the jugular foramen, has both motor and sensory components. Cell bodies of motor neurons, located in the nucleus ambiguus in the medulla oblongata, project as special visceral efferent fibres to the stylopharyngeal muscle. The action of the stylopharyngeus is to elevate the pharynx, as in gagging or swallowing. In addition, the inferior salivatory nucleus of the medulla sends general visceral efferent fibres to the otic ganglion via the lesser petrosal branch of the ninth nerve; postganglionic otic fibres innervate the parotid salivary gland.
Among the sensory components of the glossopharyngeal nerve, special visceral afferent fibres convey taste sensation from the back third of the tongue via lingual branches of the nerve. General visceral afferent fibres from the pharynx, the back of the tongue, parts of the soft palate and eustachian tube, and the carotid body and carotid sinus have their cell bodies in the superior and inferior ganglia, which are situated, respectively, within the jugular foramen and just outside the cranium. Sensory fibres in the carotid branch detect increased blood pressure in the carotid sinus and send impulses into the medulla that ultimately reduce heart rate and arterial pressure; this is known as the carotid sinus reflex.
Among the sensory components of the glossopharyngeal nerve, special visceral afferent fibres convey taste sensation from the back third of the tongue via lingual branches of the nerve. General visceral afferent fibres from the pharynx, the back of the tongue, parts of the soft palate and eustachian tube, and the carotid body and carotid sinus have their cell bodies in the superior and inferior ganglia, which are situated, respectively, within the jugular foramen and just outside the cranium. Sensory fibres in the carotid branch detect increased blood pressure in the carotid sinus and send impulses into the medulla that ultimately reduce heart rate and arterial pressure; this is known as the carotid sinus reflex.
Vagus nerve (CN X or 10): The vagus nerve has the most extensive distribution in the body of all the cranial nerves, innervating structures as diverse as the external surface of the eardrum and internal abdominal organs. The root of the nerve exits the cranial cavity via the jugular foramen. Within the foramen is the superior ganglion, containing cell bodies of general somatic afferent fibres, and just external to the foramen is the inferior ganglion, containing visceral afferent cells.
Pain and temperature sensations from the eardrum and external auditory canal and pain fibres from the dura mater of the posterior cranial fossa are conveyed on general somatic afferent fibres in the auricular and meningeal branches of the nerve. Taste buds on the root of the tongue and on the epiglottis contribute special visceral afferent fibres to the superior laryngeal branch. General visceral afferent fibres conveying sensation from the lower pharynx, larynx, trachea, esophagus, and organs of the thorax and abdomen to the left (splenic) flexure of the colon converge to form the posterior (right) and anterior (left) vagal nerves. Right and left vagal nerves are joined in the thorax by cardiac, pulmonary, and esophageal branches. In addition, general visceral afferent fibres from the larynx below the vocal folds join the vagus via the recurrent laryngeal nerves, while comparable input from the upper larynx and pharynx is relayed by the superior laryngeal nerves and by pharyngeal branches of the vagus. A vagal branch to the carotid body usually arises from the inferior ganglion.
Motor fibres of the vagus nerve include special visceral efferent fibres arising from the nucleus ambiguus of the medulla oblongata and innervating pharyngeal constrictor muscles and palatine muscles via pharyngeal branches of the vagus as well as the superior laryngeal nerve. All laryngeal musculature (excluding the cricothyroid but including the muscles of the vocal folds) are innervated by fibres arising in the nucleus ambiguus. Cells of the dorsal motor nucleus in the medulla distribute general visceral efferent fibres to plexuses or ganglia serving the pharynx, larynx, esophagus, and lungs. In addition, cardiac branches arise from plexuses in the lower neck and upper thorax, and, once in the abdomen, the vagus gives rise to gastric, celiac, hepatic, renal, intestinal, and splenic branches or plexuses.
Damage to one vagus nerve results in hoarseness and difficulty in swallowing or speaking. Injury to both nerves results in increased heart rate, paralysis of pharyngeal and laryngeal musculature, atonia of the esophagus and intestinal musculature, vomiting, and loss of visceral reflexes. Such a lesion is usually life-threatening, as paralysis of laryngeal muscles may result in asphyxiation.
Pain and temperature sensations from the eardrum and external auditory canal and pain fibres from the dura mater of the posterior cranial fossa are conveyed on general somatic afferent fibres in the auricular and meningeal branches of the nerve. Taste buds on the root of the tongue and on the epiglottis contribute special visceral afferent fibres to the superior laryngeal branch. General visceral afferent fibres conveying sensation from the lower pharynx, larynx, trachea, esophagus, and organs of the thorax and abdomen to the left (splenic) flexure of the colon converge to form the posterior (right) and anterior (left) vagal nerves. Right and left vagal nerves are joined in the thorax by cardiac, pulmonary, and esophageal branches. In addition, general visceral afferent fibres from the larynx below the vocal folds join the vagus via the recurrent laryngeal nerves, while comparable input from the upper larynx and pharynx is relayed by the superior laryngeal nerves and by pharyngeal branches of the vagus. A vagal branch to the carotid body usually arises from the inferior ganglion.
Motor fibres of the vagus nerve include special visceral efferent fibres arising from the nucleus ambiguus of the medulla oblongata and innervating pharyngeal constrictor muscles and palatine muscles via pharyngeal branches of the vagus as well as the superior laryngeal nerve. All laryngeal musculature (excluding the cricothyroid but including the muscles of the vocal folds) are innervated by fibres arising in the nucleus ambiguus. Cells of the dorsal motor nucleus in the medulla distribute general visceral efferent fibres to plexuses or ganglia serving the pharynx, larynx, esophagus, and lungs. In addition, cardiac branches arise from plexuses in the lower neck and upper thorax, and, once in the abdomen, the vagus gives rise to gastric, celiac, hepatic, renal, intestinal, and splenic branches or plexuses.
Damage to one vagus nerve results in hoarseness and difficulty in swallowing or speaking. Injury to both nerves results in increased heart rate, paralysis of pharyngeal and laryngeal musculature, atonia of the esophagus and intestinal musculature, vomiting, and loss of visceral reflexes. Such a lesion is usually life-threatening, as paralysis of laryngeal muscles may result in asphyxiation.
Accessory nerve (CN XI or 11): The accessory nerve is formed by fibres from the medulla oblongata (known as the cranial root) and by fibres from cervical levels C1–C4 (known as the spinal root). The cranial root originates from the nucleus ambiguus and exits the medulla below the vagus nerve. Its fibres join the vagus and distribute to some muscles of the pharynx and larynx via pharyngeal and recurrent laryngeal branches of that nerve. For this reason, the cranial part of the accessory nerve is, for all practical purposes, part of the vagus nerve.
Fibres that arise from spinal levels exit the cord, coalesce and ascend as the spinal root of the accessory nerve, enter the cranial cavity through the foramen magnum, and then immediately leave through the jugular foramen. The accessory nerve then branches into the sternocleidomastoid muscle, which tilts the head toward one shoulder with an upward rotation of the face to the opposite side, and the trapezius muscle, which stabilizes and shrugs the shoulder.
Fibres that arise from spinal levels exit the cord, coalesce and ascend as the spinal root of the accessory nerve, enter the cranial cavity through the foramen magnum, and then immediately leave through the jugular foramen. The accessory nerve then branches into the sternocleidomastoid muscle, which tilts the head toward one shoulder with an upward rotation of the face to the opposite side, and the trapezius muscle, which stabilizes and shrugs the shoulder.
Hypoglossal nerve (CN XII or 12): The hypoglossal nerve innervates certain muscles that control movement of the tongue. From the hypoglossal nucleus in the medulla oblongata, general somatic efferent fibres exit the cranial cavity through the hypoglossal canal and enter the neck in close proximity to the accessory and vagus nerves and the internal carotid artery. The nerve then loops down and forward into the floor of the mouth and branches into the tongue musculature from underneath. Hypoglossal fibres end in intrinsic tongue muscles, which modify the shape of the tongue (as in rolling the edges), as well as in extrinsic muscles that are responsible for changing its position in the mouth.
A lesion of the hypoglossal nerve on the same side of the head results in paralysis of the intrinsic and extrinsic musculature on the same side. The tongue atrophies and, on attempted protrusion, deviates toward the side of the lesion.
A lesion of the hypoglossal nerve on the same side of the head results in paralysis of the intrinsic and extrinsic musculature on the same side. The tongue atrophies and, on attempted protrusion, deviates toward the side of the lesion.