Neuroanatomy, Sympathetic Nervous System


Article Author:
Mark Alshak


Article Editor:
Joe M Das


Editors In Chief:
James Beauchamp
Mark Pellegrini
Nicole Hale-Crutch


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
5/13/2019 11:08:20 PM

Introduction

The sympathetic nervous system (SNS) is one of the two divisions of the autonomic nervous system (ANS), the other being the parasympathetic nervous system (PNS), These systems largely work unconsciously in opposite ways to regulate many functions and parts of the body. Colloquially, the SNS governs the "fight or flight" response while the PNS controls the "rest and digest" response. The main overall end effect of the SNS is to prepare the body for physical activity, a whole-body response affecting many organ systems throughout the body to redirect oxygen-rich blood to areas of the body needed during intense physical demand.[1]

Structure and Function

The sympathetic nervous system is composed of many pathways that perform a variety of functions on various organ systems. The preganglionic neurons of the SNS arise from the thoracic and lumbar regions of the spinal cord (T1 to L2) with the cell bodies distributed in four regions of the gray matter in the spinal cord bilaterally and symmetrically.[1][2] As opposed to the parasympathetic nervous system, the first order neurons of the SNS are short before synapsing on postsynaptic neurons found within sympathetic ganglia. Similar to the PNS, the neurotransmitter used at this junction is acetylcholine. This acetylcholine activates nicotinic receptors. These postganglionic neurons then travel to their effector sites and release the neurotransmitters epinephrine or norepinephrine, except for sympathetic innervation of sweat glands and the arrectores pili muscles, the small muscles attached to hair follicles, which use acetylcholine as their postganglionic neurotransmitter.[3] These neurotransmitters act on adrenergic receptors. Among the adrenergic receptors are alpha-1 (coupled to a Gq and works through the IP3/Ca2+ pathway), alpha-2 (coupled to Gi and works through decreasing the cAMP pathway), and beta-1 and beta-2 (coupled to Gs and works through increasing the cAMP pathway).[4] Whether beta-1 and beta-2 are excitatory or inhibitory depends on the tissue it is located on. These receptors are located on various parts of the body and regulate the actions of the SNS.

The functions of the sympathetic nervous system are expansive and involve many organ systems and various types of adrenergic receptors.

The effects in which SNS acts in direct contrast to the PNS function include the following:

  • In the eye, sympathetic activation causes the radial muscle of the iris (alpha-1) to contract which leads to mydriasis, allowing more light to enter. Furthermore, the ciliary muscle (beta-2) relaxes, allowing for far vision to improve.
  • In the heart (beta-1, beta-2), sympathetic activation causes an increased heart rate, force of contraction, and rate of conduction, allowing for increased cardiac output to supply the body with oxygenated blood.
  • In the lungs, bronchodilation (beta-2) and decreased pulmonary secretions (alpha-1, beta-2) occur to allow more airflow through the lungs.
  • In the stomach and intestines, decreased motility (alpha-1, beta-2) and sphincter contraction (alpha-1), as well as contraction of the gallbladder (beta-2), occur to slow down digestion in order to divert energy to other parts of the body.
  • The exocrine and endocrine pancreas (alpha-1, alpha-2) decreases both enzyme and insulin secretion.
  • In the urinary bladder, there is relaxation of the detrusor muscle and contraction of the urethral sphincter (beta-22) to help stop urine output during sympathetic activation.
  • The kidney (beta-1) increases renin secretion to increase intravascular volume.
  • The salivary glands (alpha-1, beta-2) work through small volume potassium and water secretion. 

Actions of SNS which do not oppose those of the PNS include the following:

  • There is strong constriction through the alpha-1 receptor in arterioles of the skin, abdominal viscera, and kidney, and weak constriction through the alpha-1 and beta-2 receptors in the skeletal muscle.
  • In the liver, increased glycogenolysis and gluconeogenesis (alpha-1, beta-2) occur to allow for glucose to be available for energy throughout the body.
  • In the spleen, there is contraction (alpha-1).
  • Sweat glands and arrector pili muscles (muscarinic) work to increase sweating and erection of hair to help cool down the body.
  • Lastly, the adrenal medulla (nicotinic receptor) increases the release of epinephrine and norepinephrine to act elsewhere in the body.[1]

Embryology

Neurons of the peripheral autonomic nervous system, which includes both the sympathetic nervous system and parasympathetic nervous system, arise from neural crest cells that originate from between the neural and non-neural ectoderm. They form the dorsal neural folds as the folds themselves are forming the neural tube.[5] 

Physiologic Variants

Aging has various effects on the sympathetic nervous system. Research has demonstrated that with increased age that baroreceptors of the heart decrease and become less sensitive; there is a compensatory increase in cardiovascular SNS activity and a reduction in PNS activity. However, both sympathetic and parasympathetic nervous activity to the iris decreases with aging, which is consistent with the general decline of peripheral somatic nerve function.[6] It has also been shown that baseline levels of noradrenaline levels increase with age resulting in an elevated basal SNS activation, while the reactivity is reduced with aging.[7] This increase in activation plays a role, among other disease processes, in both age-related hypertension and heart failure.[8]

Surgical Considerations

Horner syndrome is a complication born from interruption of the sympathetic innervation to the eye and adnexa at varying levels, most commonly of the neck, resulting in increased parasympathetic input. It presents with the classic triad of ipsilateral ptosis, pupillary miosis, and facial anhidrosis. It can be a complication of neck surgeries that damage the sympathetic input.[9] There are even reports after minimally invasive thyroidectomy.[10] For more information on Horner syndrome, please refer to our accompanying article.[11]

Hyperhidrosis, otherwise known as excessive sweating, is a common indication for minimally invasive thoracic sympathectomy. Hyperhidrosis is excessive sweating beyond the organism’s physiological need to sweat to have a temperature within an adequate range. Removing the sympathetic input to the part of the body affected by hyperhidrosis is an acceptable and well-tolerated treatment.[12] Thorascoposic sympathectomy can also be used to treat severe Raynaud syndrome, defined as episodic vascular spasms and digital ischemia secondary to cold or emotional stimuli.[[13]

Clinical Significance

The clinical significance of the sympathetic nervous system is vast as it affects many organ systems. Of the many physiological and pathological processes, pheochromocytoma, erections and priapism, diabetic neuropathy, and orthostatic hypotension are described below.

Pheochromocytomas are tumors that arise from chromaffin cells present in the adrenal medulla or paraganglion cells that secrete excess amounts of catecholamines (norepinephrine, epinephrine). Because of this catecholamine release, the symptoms are largely that of sympathetic activation, such as hypertension, tachycardia/palpitations, hyperglycemia, and diaphoresis.[14]

Erections are a product of parasympathetic activity. At resting state, the SNS predominates, and the penis remains flaccid. However, if the sympathetic fibers to the penis are damaged or compromised, a sustained erection of over 4 hours, called priapism, can occur and result in devastating consequences to the penis. This condition can be caused by spinal cord or cauda equina injury as the sympathetic input is damaged and the parasympathetic tone dominates.[15] Nevertheless, SNS also contributes to the normal sexual function of a man. Sympathetic stimulation of the male genitals causes sperm emission which is sensed by the hypogastric nerve.[16]

Diabetic autonomic neuropathy is one of the most common causes of sympathetic nerve neuropathy. This sympathetic denervation can lead to impaired myocardial coronary blood flow and reduced myocardial contractility.[17] Diabetic neuropathy plays a crucial role in morbidity and mortality in patients with both type 1 and type 2 diabetes mellitus and causes dysfunction of many systems, including the heart, the Gastroenterol tract, the and genitourinary system, and sexuality. As it is well established that hyperglycemia is the primary driver of this diabetic complication, it is imperative for the clinician to establish early and sustained intensive glycemic control to prevent or delay the onset and slow the progression of autonomic dysfunction. However, this strategy seems to be more effective in type 1 versus type 2 diabetic patients.[18] 

Lastly, orthostatic hypotension is a common problem caused by the failure of noradrenergic neurotransmission. It is defined as a drop of systolic blood pressure by at least 20 mmHg or diastolic by 10 mmHg.[19] It is caused by a wide variety of disease processes, including but not limited to pure autonomic failure, multiple system atrophy, and autonomic neuropathies that damage the SNS.[20]


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Neuroanatomy, Sympathetic Nervous System - Questions

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A patient with diabetes is starting to develop diabetic neuropathy due to poor glucose control. He has noticed reduced sweating in the area under his armpits. Axons of these fibers exit the spinal cord via which of the following?



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A teenager sustains a bicycle accident and sustains injuries to multiple thoracic and upper lumbar vertebrae. Which of the following outflow tract is most likely to be injured?

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    Contributed by Henry Gray (1918): Anatomy of the Human Body
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A man is stabbed in the back and sympathetic stimulation near the lumbar spine is damaged. What is the most likely location of the stab wound?



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A patient has an injury to the neck and develops ptosis and miosis of the eye. Damage to which spinal nerve is causing these eye symptoms?



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A man presents to the emergency department with acute intoxication of cocaine. His heart rate is 122 beats per minute, respiratory rate is 25 per minute, and his pupils are 8 mm bilaterally and are poorly reactive to light. Which of the following neurotransmitters is likely to be increased the postganglionic nerve terminal?



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A man presents complaining about dizziness and lightheadedness, most prominent when he changes position or gets out of bed in the morning. His blood pressure sitting down is 117/79 mmHg and standing up is 90/60 mmHg. A reduction in which neurotransmitter is likely to be involved with the development of his symptoms?



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A man is running away from a wild animal that is trying to attack him. As he runs, his heart rate increases and he begins to sweat. Through which neurotransmitter is causing his increased sweating?



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A 67-year-old man presents with vasodilation and dryness of the skin of the face. On examination, he is found to have hypertension, an enlarged liver, and an external otitis infection. In addition, readily apparent is ptosis and miosis of the left eye. Which of the following is likely causing the facial findings?



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A 32-year-old male patient ran a 5 kilometer (5K) race. When he crossed the finish line, his friends noticed that only half of his face was red and sweaty and that his pupils "did not match." Which system is most likely involved?



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A patient is involved in a motor vehicle collision without wearing a seatbelt. He is rushed to the hospital with an inability to move either of his legs. After emergency surgery, he has regained motor function but is unable to retain his urine. Damage to what pathway is most likely?



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A 58-year-old male presents to the clinic with complaints of a persistent cough. He has smoked two packs per day for the past 20 years. On physical exam, ptosis of his left eyelid is noted. Additionally, anisocoria is present, with his left pupil measuring 2 mm and his right pupil measuring 5 mm. After an x-ray reveals a lung nodule, a biopsy confirms the diagnosis of squamous cell carcinoma of the lung. Which of the following is the most likely mechanism of the patient's facial findings?



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A patient is injured in a motor vehicle accident. If the sympathetic stimulation of the male genitals is injured, which of the following deficits is most likely to occur?



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Neuroanatomy, Sympathetic Nervous System - References

References

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Freccero C,Svensson H,Bornmyr S,Wollmer P,Sundkvist G, Sympathetic and parasympathetic neuropathy are frequent in both type 1 and type 2 diabetic patients. Diabetes care. 2004 Dec;     [PubMed]
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