Phrenic nerve dog

Phrenic nerve dog DEFAULT

The canine phrenic-to-intercostal reflex


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Phrenic nerve

"Phrenectomy" redirects here. It is not to be confused with frenectomy, removal of a frenulum.

The phrenic nerve is a mixed motor/sensory nerve which originates from the C3-C5 spinal nerves in the neck. The nerve is important for breathing because it provides exclusive motor control of the diaphragm, the primary muscle of respiration. In humans, the right and left phrenic nerves are primarily supplied by the C4 spinal nerve, but there is also contribution from the C3 and C5 spinal nerves. From its origin in the neck, the nerve travels downward into the chest to pass between the heart and lungs towards the diaphragm.

In addition to motor fibers, the phrenic nerve contains sensory fibers, which receive input from the central tendon of the diaphragm and the mediastinal pleura, as well as some sympathetic nerve fibers. Although the nerve receives contributions from nerves roots of the cervical plexus and the brachial plexus, it is usually considered separate from either plexus.

The nerve is named from the Ancient Greekphren, meaning diaphragm.[1]


The phrenic nerve originates in the phrenic motor nucleus in the ventral horn of the cervical spinal cord. It descends obliquely with the internal jugular vein across the anterior scalene, deep to the prevertebral layer of deep cervical fascia and the transverse cervical and suprascapular arteries. On the left, the phrenic nerve crosses anterior to the first part of the subclavian artery. On the right, it lies on the anterior scalene muscle and crosses anterior to the 2nd part of the subclavian artery. On both sides, the phrenic nerve usually runs posterior to the subclavian vein as it enters the thorax where it runs anterior to the root of the lung and between the fibrous pericardium and mediastinal parietal pleura.[2]

The pericardiacophrenic arteries and veins travel with their respective phrenic nerves.

The phrenic nerve can be marked by a line connecting these two points:

  1. 1st point can be labelled 3.5 cm at the level of the thyroid cartilage from the midsagittal plane.
  2. 2nd point is at the medial end of the clavicle.


As with most nerves in the neck, multiple anatomic variants have been described. Notably, there may be variability in the course of the phrenic nerve in the retroclavicular region such that the nerve courses anterior to the subclavian vein, rather than its typical position posterior to the vein (between the subclavian vein and artery).[3] This variant may predispose the phrenic nerve to injury during subclavian vascular cannulation.

In addition, an accessory phrenic nerve is commonly identified, present in up to 75% of a cadaveric study.[3]

In canines the phrenic nerve arises from C5-C7 with occasional small contributions from C4.[4] In the cat, horse, ox, and small ruminant the phrenic nerve arises variably from C4-C7.


Both of these nerves supply motor fibers to the diaphragm and sensory fibers to the fibrous pericardium, mediastinal pleura, and diaphragmatic peritoneum.

Some sources describe the right phrenic nerve as innervating the gallbladder, other sources make no such mention.[5] The right phrenic nerve may also supply the capsule of the liver.[6]

Clinical significance[edit]

Left phrenic nerve palsy (right image side) in fluoroscopy: forced inspiration with closed mouth leads to paradox elevation of the paralytic left diaphragm while the healthy right side moves down.

Pain arising from structures supplied by the phrenic nerve is often "referred" to other somatic regions served by spinal nerves C3-C5. For example, a subphrenic abscess beneath the right diaphragm might cause a patient to feel pain in the right shoulder.

Irritation of the phrenic nerve (or the tissues it supplies) leads to the hiccup reflex. A hiccup is a spasmodic contraction of the diaphragm, which pulls air against the closed folds of the larynx.

The phrenic nerve must be identified during thoracic surgery and preserved. To confirm the identity of the phrenic nerve, a doctor may gently manipulate it to elicit a dartle (diaphragmatic startle) response.[7] The right phrenic nerve may be crushed by the vena cava clamp during liver transplantation.[8] Severing the phrenic nerve, or a phrenectomy,[9] will paralyse that half of the diaphragm. Bilateral diaphragmatic paralysis or BDP can also be caused by spinal cord injury, motor neuron disease, infection, pneumonia, sarcoidosis, multiple sclerosis, polyneuropathy, myopathy and amyotrophy, cardiac surgery, lung transplantation, or mediastinal tumors.[10][11] Diaphragm paralysis is best demonstrated by sonography.[8] Breathing will be made more difficult but will continue provided the other nerve is intact.

The phrenic nerve arises from the neck (C3-C5) and innervates the diaphragm, which is much lower. Hence, patients suffering spinal cord injuries below the neck are still able to breathe effectively, despite any paralysis of the lower limbs.

Brachial plexus injuries can cause paralysis to various regions in the arm, forearm, and hand depending on the severed nerves. The resulting palsy has been clinically treated using the phrenic nerve as a donor for neurotization of the musculocutaneous nerve and the median nerve.[12] This treatment has a high success rate (84.6%) in partial to full restoration of the innervation to the damaged nerve.[12] Furthermore, this procedure has resulted in restored function to nerves in the brachial plexus with minimal impact to respiratory function of the phrenic nerve. The instances where pulmonary vital capacity is reduced have typically been a result of use of the right phrenic as the donor for the neurotization whereas use of left phrenic nerve has not been significantly linked to reduced pulmonary vital capacity.[13]

See also[edit]

This article uses anatomical terminology.


  1. ^O'Rahilly, Ronan (2008). Basic Human Anatomy. Hanover, New Hampshire: Geisel School of Medicine. Retrieved 3 April 2019.
  2. ^Moore, Keith L. (1999). Clinically oriented anatomy. Philadelphia: Lippincott Williams & Wilkins. ISBN .[page needed]
  3. ^ abPrakash; Prabhu, L. V.; Madhyastha, S; Singh, G (2007). "A variation of the phrenic nerve: Case report and review"(PDF). Singapore Medical Journal. 48 (12): 1156–7. PMID 18043847.
  4. ^Evans, Howard (1979). Miller's Anatomy of the Dog. Philadelphia, PA: W. B. Saunders Company. p. 978. ISBN .
  5. ^Alexander, William (1940). "The innervation of the biliary system". Journal of Comparative Neurology. 72 (2): 357–370. doi:10.1002/cne.900720205.
  6. ^Lautt, W. Wayne (2009). "Hepatic Nerves". Morgan & Claypool Life Sciences.
  7. ^Dalman, Ronald; Thompson, Robert (2015). "7. Neurogenic Thoracic Outlet Syndrome Exposure and Decompression: Supraclavicular". Operative Techniques in Vascular Surgery. Philadelphia, PA: Wolters Kluwer Health. p. 50. ISBN .
  8. ^ abMcAlister, Vivian C.; Grant, David R.; Roy, Andre; Brown, William F.; Hutton, Linda C.; Leasa, David J.; Ghent, Cameron N.; Veitch, James E.; Wall, William J. (1993). "Right phrenic nerve injury in orthotopic liver transplantation". Transplantation. 55 (4): 826–30. doi:10.1097/00007890-199304000-00027. PMID 8475559.
  9. ^Hine, Maynard Kiplinger (1975). Review of dentistry: questions and answers (6th ed.). Mosby. p. 421. ISBN .
  10. ^Mizubuti, Glenio, MD, MSc, Wang, Louie, et al. Perioperative Management for Abdominal Surgery in Bilateral Diaphragmatic Paralysis: A Case Report and Literature Review. A&A Case Reports. 2017;9(10):280-282. doi:10.1213/XAA.0000000000000592.
  11. ^Chen HY, Chen HC, Lin MC, Liaw MYBilateral diaphragmatic paralysis in a patient with critical illness polyneuropathy: a case report. Medicine (Baltimore). 2015;94:e1288.
  12. ^ abYu-Dong, G., Min-Ming, W., Yi-Lu, Z., Jia-Ao, Z., Gao-Meng, Z., De-Song, C., Ji-Geng, Y. and Xiao-Ming, C. (1989), Phrenic nerve transfer for brachial plexus motor neurotization. Microsurgery, 10: 287–289. doi: 10.1002/micr.1920100407
  13. ^Luedemann, Wolf, Michael Hamm, Ulrike Blömer, Madjid Samii, and Marcos Tatagiba. "Brachial Plexus Neurotization with Donor Phrenic Nerves and Its Effect on Pulmonary Function." Journal of Neurosurgery 96.3 (2002): 523-26. Web.

External links[edit]

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Suspected bilateral phrenic nerve damage following a mediastinal mass removal in a 17-week-old pug


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Live stream review of ct scan in dog with adrenal gland tumour and rib mass

The Phrenic Nerve

The phrenic nerve is a bilateral, mixed nerve that originates from the cervical nerves in the neck and descends through the thorax to innervate the diaphragm.

It is the only source of motor innervation to the diaphragm and therefore plays a crucial role in breathing.

In this article, we shall look at the anatomy of the phrenic nerve – its anatomical course, motor and sensory functions.


  • Nerve roots - anterior rami of C3, C4 and C5.
  • Motor functions - innervates the diaphragm.
  • Sensory functions - innervates the central part of the diaphragm, the pericardium and the mediastinal part of the parietal pleura.

Anatomical Course

The phrenic nerve originates from cervical spinal roots C3, C4 and C5 . This can be remembered using the limerick “C3, 4 and 5 keep the diaphragm alive”.  Spinal root C4 provides the main contribution, with lesser contributions from C3 and C5 and some communicating fibres from the cervical plexus.

The nerve arises at the lateral border of the anterior scalene muscle. It then passes inferiorly over the anterior surface of anterior scalene, deep to the prevertebral layer of cervical fascia. On both sides, the nerve runs posterior to the subclavian vein. From here, the course of the phrenic nerve differs between the left and right:

Right Phrenic Nerve

  • Passes anteriorly over the lateral part of the right subclavian artery.
  • Enters the thorax via the superior thoracic aperture.
  • Descends anteriorly along the right lung root.
  • Courses along the pericardium of the right atrium of the heart.
  • Pierces the diaphragm at the inferior vena cava opening.
  • Innervates the inferior surface of the diaphragm.

Left Phrenic Nerve

  • Passes anteriorly over the medial part of the left subclavian artery.
  • Enters the thorax via the superior thoracic aperture.
  • Descends anterior to the left lung root.
  • Crosses the aortic arch and bypasses the vagus nerve.
  • Courses along the pericardium of the left ventricle.
  • Pierces and innervates the inferior surface of the diaphragm.
[caption id="attachment_11457" align="aligncenter" width="361"]Fig 1.1 - The branches of the cervical plexus. The smaller branches have been removed for simplicity.Fig 1 - The origin of the phrenic nerve from the anterior rami of C3,4 and 5.[/caption]

Motor Functions

The phrenic nerve provides motor innervation to the diaphragm; the main muscle of respiration.

As the phrenic nerve is a bilateral structure, each nerve supplies the ipsilateral side of the diaphragm (the hemi-diaphragm on the same side as itself).

Sensory Functions

Sensory fibres from the phrenic nerve supply the central part of the diaphragm, including the surrounding pleura and peritoneum. The nerve also supplies sensation to the mediastinal pleura and the pericardium.

[caption id="attachment_9124" align="aligncenter" width="888"]Fig 2 - The anatomical course of the phrenic nerves, which innervate the diaphragm.[/caption]


Clinical Relevance: Diaphragmatic Paralysis

The phrenic nerve provides motor innervation to the diaphragm. If the nerve becomes damaged, paralysis of the diaphragm can result. Causes of phrenic nerve palsy include:

  • Mechanical trauma – ligation or damage to the nerve during surgery.
  • Compression – due to a tumour within the chest cavity.
  • Neuropathies – such diabetic neuropathy.

Paralysis of the diaphragm produces a paradoxical movement. The affected side of the diaphragm moves upwards during inspiration, and downwards during expiration. A unilateral diaphragmatic paralysis is usually asymptomatic and is most often an incidental finding on x-ray. If both sides are paralysed, the patient may experience poor exercise tolerance, orthopnoea and fatigue. Lung function tests will show a restrictive deficit.

Management of diaphragmatic paralysis is two-fold. Firstly, the underlying cause must be identified and treated (if possible). The second part of treatment deals with symptomatic relief. This is usually via non-invasive ventilation, such as a CPAP (continuous positive airway pressure).

[caption id="attachment_10740" align="aligncenter" width="418"]Fig 3 - Chest x-ray, showing paralysis of the right hemidiaphragm.[/caption]




Nerve dog phrenic


Cervical Plexus - Anatomy Tutorial


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