The second intercostal space is between which ribs. Intercostal space. The use of massage for intercostal neuralgia

The intercostal spaces are filled with intercostal muscles, blood and lymph vessels, nerves, and lymph nodes (Fig. 4). Vessels and nerves pass through intermuscular spaces, sometimes called intercostal canals. The intercostal gap is formed due to the fact that the external intercostal muscle is connected to the lower edge of the rib, and the internal intercostal muscle is connected to that part of the rib that faces the thoracic cavity and is located above the costal groove (sulcus costalis).

Thus, the intercostal space is delimited from above by the costal groove, and from the outside and inside by the intercostal muscles.

The external intercostal muscles (mm.intercostales externi) do not fill the entire intercostal space: they do not reach the sternum. Along the costal cartilages they are replaced by dense shiny aponeurotic plates containing tendon fibers (ligg.intercostalia externa). The direction of the fibers of the external intercostal muscles and ligaments is from top to bottom and from back to front.

The neurovascular bundles pass deeper than the external intercostal muscles: usually the v.intercostalis is located above all, the n.intercostalis - below the artery.

An arterial ring is formed in each intercostal space due to anastomosis between the anterior and posterior intercostal arteries. According to the segmental structure of the walls of the thoracic cavity, there are segmental intercostal posterior arteries (10 pairs) extending from the thoracic aorta. The two upper pairs arise from the costocervical trunk. At the beginning of the intercostal spaces, each intercostal posterior artery gives off a posterior branch, ramus dorsalis, to the spinal cord and to the muscles and skin of the back. The continuation of the initial trunk of the posterior intercostal artery, constituting the intercostal artery itself, is directed along the costal groove. Up to the angle of the rib, it is adjacent directly to the pleura, then it is located between the external and internal intercostal muscles and its endings anastomose with the anterior intercostal branches extending from the internal thoracic artery. The three lower intercostal arteries anastomose with the superior epigastric artery. Along the way, the intercostal arteries give branches to the parietal pleura and to the parietal peritoneum, to the muscles, to the ribs, to the skin and, in women, to the mammary gland.

In the posterior part of the chest wall, to the mid-axillary line, the vessels pass in the costal groove, located near the lower edge of the rib, along its deep surface. Further anteriorly, the vessels are no longer protected by the rib. Therefore, it is preferable to make any punctures of the chest posterior to the mid-axillary line, or if the puncture is made along this line, then it must be along the upper edge of the rib.

Intercostal nerves usually pass outside the costal groove, as a result of which they are more susceptible to damage than blood vessels. Upon exiting the intervertebral foramina, the intercostal nerves communicate through rami communicantes with the trunk of the sympathetic nerve, then, having given off their dorsal branches, they are directed outward, adjoining for a short distance directly to the intrathoracic fascia and pleura (hence the possibility of their involvement in the process in diseases of the pleura). In the future the paths from the intercostal nerves are separated by perforating cutaneous branches.The lower 6 intercostal nerves innervate the prepalatal abdominal wall, as a result of which inflammation of the pleura and lungs often causes radiating pain in the abdomen.

Rice. 4. Topography of the intercostal space

1 - rib, 2 - innermost intercostal muscle, 3 - intercostal nerve, 4 - intercostal artery, 5 - intercostal vein, 6 - internal intercostal muscle, 7 - external intercostal muscle, 8 - collateral branch of the intercostal artery. (From: Ernest W. April. Clinical Anatomy, 1997.)

Deeper than the intercostal vessels and nerves lie the internal intercostal muscles (mm. intercostales interni). They also do not fill the entire intercostal space: in front they reach the sternum, and in the back they end at the costal angles. The direction of the fibers of the internal intercostal muscles is the opposite to the direction of the external intercostal muscles, i.e. from bottom to top and back to front.

The intercostal muscles, ribs and costal cartilages are lined from the inside with intrathoracic fascia (fascia endothoracica). It also covers the anterior surface of the thoracic vertebrae and the diaphragm.

Deeper than the intrathoracic fascia there is a layer of loose fiber that separates it from the parietal pleura along the entire length of the latter. The subpleural tissue is most developed near the spine, on the sides of it. This makes it possible to easily detach the pleura here and gain access to the organs of the posterior mediastinum without opening the pleural cavity.

In the clinic, the tissue between the fascia endothoracica and the pleura is often called parapleural, and the inflammatory process in it is parapleuritis. Most often, this disease is associated with tuberculosis of the lungs and pleura and is caused by inflammation of the lymph nodes embedded in the parapleural tissue. The lymphatic vessels of the mammary gland and intercostal spaces of the anterior chest wall flow into the anterior nodes (nodi lymphatici sternales), located along the vasa thoracica interna, into the posterior nodes (n.intercostales posteriores), located at the heads of the ribs, the vessels of the intercostal spaces of the posterior chest wall .

The bony basis of the segment is represented by the ribs, and the muscular basis is represented by the external and internal intercostal muscles, the neurovascular part consists of the intercostal nerve and intercostal vessels: from top to bottom - vein, artery. nerve. The chest segments are covered with soft tissue both inside and outside.

Topography: skin, subcutaneous fat, superficial fascia, pectoral fascia, muscles (pectoralis major or serratus anterior or latissimus dorsi), pectoral fascia, chest segment, intrathoracic fascia, tissue (prepleural, parapleural, pleural), costal pleura.

Treatment of purulent pleurisy:

Puncture of the pleural cavity.

Passive drainage according to Bulau.

Active aspiration.

Radical operations.

Puncture of the pleural cavity: in the 7-8 intercostal space. along the scapular or posterior axillary line along the upper edge of the rib, a puncture is made in the chest wall with a thick needle connected to a short rubber tube, which is clamped after removing each portion of pus.

Passive drainage, according to Bulau: a drainage tube connected to a jar from the Bobrov apparatus is inserted into the pleural cavity or a puncture in the 6-7 intercostal space (in adults with resection of the rib, but with preservation of the periosteum) along the midaxillary line using a thoracary, pus flows into the jar according to the law of communicating vessels.

Active aspiration: i.e., but a water jet pump is connected to a short tube, the pus flows out under the influence of negative pressure in the system, equal to 10-40 cm of water column.

46 Topography of the diaphragm

Along the right middle line, the dome of the diaphragm is located at the level of the 4th rib, and along the left middle line - at the 5th rib. The diaphragm is covered with serous membranes. On the side of the cavity, it is covered with the diaphragmatic pleura and partially with the pericardium. On the abdominal side, the diaphragm is covered by the parietal peritoneum. The central part of the diaphragm is represented by the tendon center. The muscular section of the diaphragm consists of 3 parts: sternal, costal, lumbar. The sternal part begins from the posterior part of the xiphoid process. To the left of the xiphoid process between the sternum and costal parts there is a gap (described by Larrey) - the left sternocostal triangulation. To the right of the xiphoid process, between the sternum and costal parts of the diaphragm, there is a similar gap (described by Morgagni) - the right costosternal triangulation. The internal mammary artery passes through each of the slits. The lumbar part of the diaphragm is represented by powerful muscle bundles, forming 3 pairs of legs: internal, intermediate, lateral. Inner legs starting from the anterolateral surface of the bodies of 1-4 lumbar vertebrae. Going up, the inner legs converge, forming 2 holes. The first is at the level of the 7th-1st vertebrae and is called the aortic. The second is at the level of 11 degrees pos. and is called esophageal. Intermediate legs shorter and starting from the lateral part of the body of the 2nd vertebral belt. Lateral crura even shorter, they can start from the lateral surface of the body of the first or second vertebral belt. The descending aorta passes through the aortic opening, and the thoracic duct passes posteriorly and to the right. Through the esophageal opening, the cavity leaves the esophagus with the vagus nerves. On the left, between the internal and intermediate legs, the hemizygos vein and splanchnic nerves pass. On the right, between similar legs, there is the azygos vein and celiac nerves. The sympathetic trunk passes between the intermediate and lateral crura on the left and right. Between the costal and waist sections of the diaphragm there are 2 triangles (described by Bokhdalik) - lumbocostal triangles. To the right of the midline in the tendon center of the diaphragm there is an opening through which the inferior vena cava passes. To the right of this opening, the branches of the right phrenic nerve pass through the tendinous center.

The skin of the anteromedial surface of the shoulder is innervated by the medial cutaneous nerve of the shoulder, which arises from: 2. Medial bundle of the brachial plexus

Skin incisions for felons of the fingers should not cross the line of the interphalangeal joints in order to: 2. The periarticular ligaments were not damaged

The knee joint has synovial volvulus in the following quantities: d) 9;

The number of segments in the left lung is often equal to: 3. 10

The number of segments in the right lung is: 3 . 10

The number of synovial torsions of the knee joint is equal to: 5. 13th

Collateral circulation is: 2. Blood flow through the lateral branches after the cessation of blood movement through the main vessel

The ends of the nerves are truncated during amputation: D To prevent the development of phantom pain

The root of the mesentery of the small intestine passes: 3. Obliquely from top to bottom, from left to right

The root of the right lung goes around from above: 4. Azygos vein

The crown of death is a variant of the origin of the artery: 4. Obturator

The crown of death in the area of the inner ring of the femoral canal usually passes through its border: d) medial;

The bony base of the pelvis is supplemented by the following ligaments: 1. Sacrotuberous 2. Sacrospinous

Anterior to the gluteus maximus muscle in the gluteal region are located directly d) deep layer of own fascia;

Anterior to which line is the intercostal neurovascular bundle not covered by the lower edge of the overlying rib?3. WITHmiddle axillary

Anterior to the neurovascular bundle of the posterior bed of the upper third of the leg is: e) tibialis posterior muscle;

The sacral plexus forms all nerves except: b) obturator;

The uterosacral ligaments belong to: 2. Fixation device

The blood supply to the scrotum comes from the artery basin: c) internal iliac;

The blood supply to the descending colon is provided by the artery: a) left colon;

The blood supply to the ileum is carried out by branches of the arteries : 2. Superior mesenteric

The blood supply to the pancreas is carried out by arteries arising from the following three of the listed vessels: 1. Superior mesenteric artery 2. Gastroduodenal artery 6. Splenic artery

The blood supply to the sigmoid colon comes from the artery basin: 4. Inferior mesenteric

The blood supply to the cecum comes from the artery basin: 1. Superior mesenteric

The blood supply to the jejunum of the small intestine is carried out through the branches of the arteries: b) superior mesenteric;

The blood supply to the jejunum is carried out by branches of arteries : 2. Superior mesenteric

Blood flow in the lower limb after blockage or ligation of the femoral artery in the middle third of the thigh is restored: 3. Along the deep artery of the thigh

The round opening of the base of the skull contains: maxillary branch of the V pair of cranial nerves;

The round ligaments of the uterus belong to: 1. Hanging apparatus

The orbicularis muscle lies in the anterior wall of the vestibule of the mouth between: mucous membrane and muscle that lifts the angle of the mouth;

Circular amputations are: 1 . Single-stage2. Two-stage3. Three-moment5. Guillotine

A circular incision at the first moment of cone-circular hip amputation according to N.I. Pirogov is dissected: Skin, subcutaneous tissue and superficial fascia

Where does the genital neurovascular bundle go after exiting the infrapiriform foramen? 3. Into the ischiorectal fossa through the lesser sciatic foramen

The dome of the diaphragm on the left along the midclavicular line is located at level: 3. V ribs

The dome of the diaphragm on the right along the midclavicular line is located at level: 2. IV ribs

The lateral umbilical fold of the peritoneum contains: 1. Inferior epigastric artery and vein

Laterally, the peri-rectal parietal tissue is limited to: a) sheath of the internal iliac artery;

The lateral border of the femoral triangle is: 2. Sartorial muscle

The lateral border of the right mesenteric sinus is : 3. Medial edge of the ascending colon

The lateral border of the carotid triangle of the neck is: sternocleidomastoid muscle;

The lateral wall of the axilla is: 4. Humerus with coracobrachialis and biceps brachii muscles

The lateral border of the lumbar Lesgaft-Grunfeld space is represented by:

The lateral border of Petit's lumbar triangle is represented by: d) external oblique abdominal muscle;

The lateral border of the lumbar region is the line: 3. Posterior axillary

The lateral wall of the femoral canal is: 5. Fascialfemoral vein vagina

The lateral wall of the adductor canal is made up of the muscle: a) medial wide;

The left gastric artery originates from: 2. Celiac trunk

The left gastroepiploic artery originates from: 4. Splenic artery

The left lung consists of lobes in the following numbers: b) two;

Left-sided chylous pleurisy occurs when the thoracic duct is damaged at the vertebral level: e) Th5 and higher;

The left vagus nerve enters the chest cavity between: b) left common carotid and subclavian arteries;

The left vagus nerve is located in relation to the wall of the esophagus: c) in front;

The left lateral canal of the abdominal cavity communicates with: 3. Pelvic cavity

The left lateral canal is delimited from the left subphrenic space: 3. Bunch

The left mesenteric sinus has a message : 1. With the small pelvis 2. With the right sinus

The left mesenteric sinus is demarcated from the pelvis : 1. Not delimited

The left recurrent laryngeal nerve usually arises from the left vagus nerve: 3. At the lower edge of the aortic arch

The left recurrent laryngeal nerve arises from the vagus nerve at the level of: Inferior edge of the aortic arch

The pulmonary artery at the hilum of the left lung in relation to the bronchus is located: c) from above;

Ligatures on the axillary artery should be applied: 2. Slightly above the level of origin of a.subscapularis

Lymphatic drainage from the vagina occurs in the lymph nodes: a) inguinal; b) sacral; c) internal iliac; d) para-aortic;

Lymphatic drainage from the uterus occurs in the lymph nodes: a) sacral; b) internal iliac; c) common iliac; d) inguinal;

Lymphatic drainage from the bladder occurs in the lymph nodes: a) anterior sacral; b) internal iliac; c) external iliac; d) deep inguinal;

Lymphatic drainage from the anal rectum is carried out to the lymph nodes: e) inguinal;

Lymphatic drainage from the lateral area of the face is carried out to the lymph nodes: parotid deep

Lymphatic drainage from the lower ampullary section of the rectum is carried out to the lymph nodes: c) sacral and internal iliacs;

Lymphatic drainage from the descending colon is carried out into the system: d) portal vein;

Lymphatic drainage from the transverse colon is carried out to all lymph nodes, except: e) upper rectum;

Lymphatic drainage from the rectosigmoid rectum is carried out primarily to the lymph nodes: b) inferior mesenteric;

Lymphatic drainage from the sigmoid colon is carried out to the lymph nodes along: d) inferior mesenteric vein;

Ken's line is a projection :d) femoral artery;

The line connecting the middle of the inguinal ligament with the medial epicondyle of the femur serves to determine the projection: c) femoral artery;

The facial nerve enters the thickness of the parotid. glands and is divided into: Temporal, zygomatic, buccal, marginal branch.inferior. people, cervical

The facial nerve exits the skull at its outer base through: Stylomastoid foramen

The facial nerve provides innervation to all formations, with the exception of: masticatory muscles;

The facial artery and vein lie on the face between: thin fascial plate and zygomatic muscles;

False insertion of a Luer cannula into the trachea during tracheostomy will likely result in increased asphyxia;

The scapulotracheal triangle is limited by: Medial-Midline of the neck, Superior and lateral Sternocleidomastoid muscle,Inferior and lateral superior belly of the omohyoid muscle

The scapular circulation consists of all arteries, except: ascending artery of the neck;

d) longitudinal arrangement of blood vessels;

The macroscopic difference between the rectum and other parts of the colon is: a) absence of shadows;

The lesser sciatic foramen of the small pelvis is formed by a ligament: a) sacrotuberous;

The small splanchnic nerve is formed by the roots of the thoracic ganglia of the sympathetic border trunk: d) Th10 - Th11;

The uterine artery is a branch of: 1. Internal iliac artery

The fallopian tube is located: 1. Along the upper edge of the broad ligament of the uterus

The fallopian tube is located: e) at the upper edge of the broad ligament of the uterus;

The medial inguinal fossa is limited by: 2. Medialumbilicalfold3. Lateralumbilicalfold

The medial umbilical fold of the peritoneum contains: 2. Obliterated umbilical artery

Medially, the pararectal parietal tissue of the pelvis is limited to: b) the visceral layer of the pelvic fascia of the ampulla of the rectum;

Medial to the femoral vein in the femoral canal lies d) fatty tissue and lymph nodes;

The medial border of the scalene-vertebral triangle of the neck is. longus colli muscle;

The medial wall of the axilla is: 2. Chest wall with serratus anterior muscle

The medial border of the internal ring of the femoral canal is: d) lacunar ligament;

The medial border of the parotid the masticatory region consists of: the styloid process of the temporal bone with outgoing muscles;

The medial border of the lumbar Lesgaft-Grunfeld space is represented by: e) back extensor muscle;

The medial border of Petit's lumbar triangle is represented by: a) latissimus dorsi muscle;

The medial wall of the femoral ring is: 4. Lacunar ligament

The medial wall of the internal femoral ring is: c) lacunar ligament (Zhimbernatova);

The medial wall of the adductor canal is made up of the muscle: b) adductor magnus;

The medial wall of the hepatic bursa is: 4. Falciform ligament

The medial wall of the axillary fossa consists of muscles: d) anterior serratus; sacIfinger into the synovial sacYfinger; b) into the cellular spaces of the elevationsIAndYfingers; c) into the middle cellular space of the palm; d) into the Pirogov-Paron space;

The medial wall of the right hepatic bursa is: e) falciform ligament of the liver;

The medial malleolar canal of the foot communicates proximally with: a) deep posterior bed of the lower leg;

The medial malleolar canal allows all elements of the lower leg to pass to the foot, except: 4. Peroneus longus tendons

The medial malleolar canal of the foot communicates proximally with: 1. Posterior bed of the tibia

Between what anatomical layers is the retromammary cellular space located?3. Psuperficial fascia4. Gore fascia

The interpterygoid tissue of the deep facial region communicates with all spaces except: temporal interaponeurotic;

The interpterygoid cellular space is deep. region faces sod..: mandibular nerve with branches; lingual nerve;

The interpterygoid cellular space of the deep facial region contains everything except: deep temporal artery;

The interstitial space is limited from below: First rib

The interscalene space is located between: Anterior and middle scalene muscles

Intercostal-lateral access to the lungs is carried out along the ribs: c) IV-V;

The intercostal vascular-nerve bundle is located: d ) along the lower edge of the rib;

The intercostal neurovascular bundle protrudes most from under the edge of the rib: 1. On the front wall of the chest

The intercostal neurovascular bundle is located between: d) external and internal intercostal muscles;

The exit point of the sensory branches of the cervical plexus is projected: Along the posterior edge of the middle thirdm. sternocleidomastoideus

The place of needle insertion for perinephric block is: 3. Apex of the angle between the 12th rib and the outer edge of the erector spinae muscle

Metastasis in breast cancer can occur in various groups of regional lymph nodes under the influence of a number of specific conditions, including the location of the tumor. Determine the most likely group of lymph nodes where metastasis can occur if the tumor is localized in the upper part of the mammary gland: 2. Subclavian lymph nodes

The urogenital diaphragm is enclosed bilaterally between the edges of the muscles: b) pubococcygeus;

The ureter is supplied by the artery: c) ovarian (testicular);

The ureter along its length has: 3. Three narrowings

The ureters are located in relation to the peritoneum: a) extraperitoneal;

The muscle lacuna is limited by: 1. FrontV.Inguinal ligament-2. Posterior and lateralA.Ilium -3. Mediallyb.Iliopectineal arch

The muscular and vascular lacunae of the thigh are separated by: 4. Iliopectineal arch

The muscle lacuna is formed posteriorly and laterally by: c) ilium;

The muscle lacuna in front is formed by: b) inguinal ligament;

Muscles of the lateral fascial bed 3. Adductor muscle thumb4. Interosseous muscles 6. Two lateral lumbrical muscles

The muscles of the anterolateral abdominal wall are innervated by: 2. Lateral and anterior branches of intercostal nerves from 7 to 12, 3. Branches of the lumbar plexus

The meatus of the scrotum is a derivative of the layer of the anterior abdominal wall :b) subcutaneous tissue;

At 5cm. Below the navel, the anterior wall of the fascial sheath of the rectus abdominis muscle is formed by: 1. Aponeurosis of the external oblique muscle of the abdomen2. Aponeurosis of the internal oblique abdominal muscle 3. Aponeurosis of the transverse abdominal muscle

On the posterior surface of the uterus, the peritoneum covers: 4. Body of the uterus, supravaginal part of the cervix and posterior vaginal fornix

What branches does the radial nerve divide into in the anterior lateral groove of the cubital fossa? 1. On the superficial and deep

What sections is the space under the inguinal ligament divided into?4 . For muscle and vascular lacunae

On what surface of the esophagus are the branches of the left vagus nerve located?1. Nand the front

The following are projected onto the skin of the subclavian region at the level of the thoracic triangle: b) medial and posterior bundles brachial plexus;

The following are projected onto the skin of the subclavian region at the level of the thoracic triangle: a) posterior bundle of the brachial plexus;

primary bundles of the brachial plexus;

The following are projected onto the skin of the subclavian region at the level of the clavipectoral triangle: a) suprascapular artery;

The following is projected onto the skin of the axillary region at the level of the inframammary triangle: d) median nerve;

The duodenum is projected onto the anterolateral abdominal wall in the following areas: 2. Umbilical and epigastric

The stomach is projected onto the anterolateral abdominal wall in the following areas: 2. In the left hypochondrium and proper epigastric

On the anterior surface of the uterus, the peritoneum covers: 1. Only the body of the uterus

On the anterior left surface of the aortic arch there are: 2. Left vagus nerve 3. Left phrenic nerve

The following three fascial beds are located on the forearm: 1. Anterior, posterior, lateral

At the level of the elbow joint, the ulnar nerve is located: 4. Posteriorly between the medial epicondyle and the olecranon

At the level of the elbow joint, the radial nerve is located: 1. Anteriorly in the lateral ulnar groove

At the level of the border line, the left ureter crosses: 1. Common iliac artery

At the level of the boundary line, the right ureter crosses: 3. External iliac artery

At the level of the cervical triangle of Pirogov between the posterior wall of the pharynx and the prevertebral fascia there is: retropharyngeal tissue;

The supramullary part of the rectum is covered with peritoneum: 1. From all sides

The supravaginal part of the cervix in relation to the peritoneum is located: c) intraperitoneal;

The supraorbital and frontal nerves of the cranial vault are final branches nerve: orbital;

The suprasternal interaponeurotic cellular space of the neck contains: venous jugular arch;

The suprasternal interaponeurotic cellular space of the neck communicates with: blind sac of the sternocleidomastoid muscle;

The suprascapular artery is one of the main arteries involved in the formation of the collateral circulation of the upper limb. The suprascapular artery is a branch of which artery? 5. Thyrocervical trunk

The supravesical fossa (fossa supravesicalis) is limited by: 1. Median umbilical fold 2. Medial umbilical fold

Name the anatomical formation passing through the tendon center of the diaphragm.3. Inferior vena cava

Name the arteries that supply blood to the uterus: 1. Uterine arteries 3. Arteries of the round uterine ligament 4. Ovarian arteries

Name the arteries that supply blood to the rectum: 1. Superior rectal artery 2. Middle rectal arteries 4. Inferior rectal arteries

Name the arteries that supply blood to the ovaries: 1. Uterine arteries 4. Ovarian arteries

Name the venous plexuses in the tissue of the prevesical space of the pelvis: 2. Vesicoprostatic (in men) 3. Cystic (in women)

Name the likely routes of spread of infected exudate from the parotid-masticatory area: 1. Temporopterygoid tissue2. Interpterygoid tissue3. Peripharyngeal tissue5. External auditory canal

Name all the anatomical structures passing through the supragiriform foramen: 1. Superior gluteal nerve 4. Superior gluteal artery and vein

Name all the anatomical structures passing through the infrapiriform foramen: 1. Sciatic nerve 2. Inferior gluteal neurovascular bundle 4. Posterior cutaneous nerve of the thigh 5. Genital neurovascular bundle

Name the suspensory apparatus of the uterus: 1. Broad ligaments of the uterus 2. Round ligaments of the uterus

Name the supporting apparatus of the uterus: 1. Pelvic diaphragm 4. Urogenital diaphragm

Name the ligaments between which the dorsal vein of the penis or clitoris passes into the prevesical cellular space: 1. Arcuate pubic ligament 2. Transverse perineal ligament

Name the walls of the prevesical cellular space of the pelvis: 1. Transverse fascia 2. Prevesical fascia 4. Fascial lateral flaps of the bladder 5. Pelvic diaphragm 6. Urogenital diaphragm

Name the fixing apparatus of the uterus: 1. Vesicouterine ligaments 2. Uterosacral ligaments 4. Cardinal ligaments

The most likely route of spread of purulent peritonitis from the left lateral canal is: 5. Peritoneal floor of the small pelvis

The most likely route of spread of purulent peritonitis from the right mesenteric sinus is: 2. Left mesenteric sinus

The most likely route of spread of purulent peritonitis from the right lateral canal is: 1. Hepatic bursa

The most likely routes of spread of purulent peritonitis from the left mesenteric sinus are two of the following: 3. Right mesenteric sinus 5. Peritoneal floor of the small pelvis

The most pronounced arterial and venous plexuses of the hollow organs of the abdominal cavity are located in: 3. Submucosa

The largest pericardial sinus is: b) anterior-inferior;

Most dangerous when tissue is damaged in the proximal thenar (“forbidden zone”): 3. Damage to the motor branch of the median nerve with disruption of the opposability of the thumb

The most typical location of blood clots during vascular embolism is: e) place of vascular bifurcation.

The most severe disorders are observed with pneumothorax: 3. Valve

The most physiological anastomosis to the small intestine is: 4. End to end

The most common position of the appendix in relation to the cecum is: 3. Medial 5. Descending

The most effective method of preventing scar formation after applying a tendon suture is: c) early execution of movements;

The external oblique abdominal muscle has the following fibers: 3. From top to bottom and from outside to inside

The external spermatic fascia of the scrotum is a derivative of the layer of the anterior abdominal wall: e) none of the options;

The external carotid artery in the neck gives off all branches except: inferior thyroid;

The outer quarter of the neck of the hip joint is not covered by the capsule: b) behind;

The outer ring of the femoral canal is formed: c) superficial layer of the fascia lata of the thigh;

The external pudendal vessels and nerves in the urogenital diaphragm are enclosed in a) subcutaneous tissue;

The external (derived) sphincter of the bladder covers the urethra: c) membranous (membranous);

The external sphincter of the rectum is located from the anus at a distance: b) 1-2 cm;

Located in the prevertebral tissue, the thoracic duct in the posterior mediastinum is located between: 2 . Thoracic aorta and azygos vein

The beginning of the trunk of the left gastric artery contains the gastric ligament: 4. Gastro-pancreas

The formation of the internal iliac artery begins at the level of: b) sacroiliac joint;

Neurolysis – release of the nerve from scar tissue

Neurolysis" or "neurolysis" is: Releasing the nerve from scar adhesions

The neuroma of the nerve segment is excised: in ) razor blade;

The disadvantage of using the femoral method of femoral hernia surgery is: 2. The possibility of increasing the inguinal space when the inguinal ligament is displaced downward

The need for urgent surgical intervention for purulent tenosynovitis of the finger flexor tendons is explained by: 3. Possibility of necrosis of tendons due to compression of their mesentery

The azygos vein of the posterior mediastinum drains into the vein: b) upper hollow;

The azygos vein receives venous blood from all veins except: e) transverse lumbar;

The azygos vein often flows into the wall of the superior cava: 2. To the back

The azygos and semi-gypsy veins pass through the diaphragm from the retroperitoneum into the mediastinum: 1. Between the medial and middle crura of the diaphragm

The unpaired splanchnic nerve is formed by the roots of the thoracic ganglia of the sympathetic border trunk: e) Th12;

Directly behind the collarbone is located: Subclavian vein

The non-permanent element of the pedicle of the lung segment is: a) segmental vein;

The Kis-Flyak nerve ganglion is located in the wall of the right atrium under: c) epicardium;

The lower border of the scapular-trapezoid triangle of the neck is the muscle: lower belly of the omohyoid;

The lower border of the pelvic rectum is: b) pelvic diaphragm;

The inferolateral border of the scapulotracheal triangle of the neck is the muscle: sternocleidomastoid;

The mandibular branch of the trigeminal nerve provides innervation to all anatomical structures except: muscle that lifts the upper lip; zygomaticus major;

The lower 2/3 of the thoracic lymphatic duct to the VII-VI thoracic vertebra are located in relation to the spine: a) front and right;

The lower edges of the internal oblique and transverse muscles form the wall of the inguinal canal: 1. Upper

The lower edge of the liver in the midline is located: 3. Midway between the base of the xiphoid process and the navel

The lower interpleural space is located below the costal cartilages: c) III-IV;

The lower nasal passage communicates with: nasolacrimal duct;

The lower border of the outer femoral ring is: d) inferior falx of the fascia lata;

The lower boundary of the subperitoneal floor of the pelvic cavity is: c) the inner layer of the pelvic fascia;

The lower boundary of the subcutaneous floor of the pelvic cavity is: d) skin of the perineum;

The inferior border of Petit's lumbar triangle is represented by: d) iliac wing crest;

The lower border of the lumbar region is: 2. Iliac crests and sacrum

The lower border of the neck consists of all formations except: superior nuchal line;

The lower border of the Pirogov cervical triangle is: digastric tendon;

The lower wall of the inguinal space is: b) inguinal ligament;

The lower wall of the omental bursa is: c) mesentery of the transverse colon;

The lower wall of the omental bursa is made up of : 3. Transverse colon and its mesentery

The lower 1/3 of the vagina is supplied with blood from the artery basin: a) internal shameful;

The lower ampullary part of the rectum in relation to the peritoneum is located extraperitoneal;

The inferior orbital fissure connects the orbit with: pterygopalatine, infratemporal and temporal fossae;

The lower horizontal line of the Kroenlein cranial topography diagram passes through: the lower edge of the orbit and the upper edge of the external auditory canal;

The inferior and superior epigastric arteries of the anterior abdominal wall are located: d) behind the rectus abdominis muscle;

The lower limb takes on the pathological “horse foot” position when damaged: b) common peroneal nerve;

The lower limb takes on the pathological “heel foot” position when damaged: a) tibial nerve;

The inferior adrenal artery originates from the artery: d) renal;

The inferior vena cava in relation to the peritoneum is located: extraperitoneal;

The lower wall of the inguinal canal is formed by: 2. Inguinal ligament

The lower part of the rectum is covered by the peritoneum: 3. Not covered with peritoneum at all

The inferior thyroid artery is a branch of the artery: subclavian;

The nasolacrimal duct connects the orbit to: lower nasal passage;

The area of projection of the gallbladder on the anterior abdominal wall is: 4. Epigastric region

The olfactory nerve provides sensitive specific innervation to the mucosa: upper nasal passage;

The formation located directly anterior to the soleus muscle in the upper third of the leg is: b) deep layer of own fascia;

The formation that makes up the posterior wall of the vagina m. rectus above the umbilical ring, is: d) aponeurosis of the internal oblique abdominal muscle;

The formation that makes up the posterior wall of the vagina m. rectus below the umbilical ring, is: a) transverse fascia;

Damage to the intercostal nerves, accompanied by acute pain. It is characterized by paroxysmal shooting or burning pain in one or more intercostal spaces, extending from the spinal column to the sternum. Diagnosis is based on complaints and an objective examination of the patient; to exclude/detect pathology of the spine and internal organs, additional examination is carried out using radiography, CT, and endoscopy of the gastrointestinal tract. The main directions of therapy are etiotropic, anti-inflammatory, neuroprotective and physiotherapeutic treatment.

General information

Intercostal neuralgia is a pain syndrome associated with damage to the intercostal nerves of any etiology (due to pinching, irritation, infection, intoxication, hypothermia, etc.). Intercostal neuralgia can occur in people of all ages, including children. Most often it is observed in adults. The most common is intercostal neuralgia, caused by osteochondrosis of the spine with radicular syndrome or intervertebral hernia of the thoracic region, and also caused by herpes zoster. In some cases, intercostal neuralgia acts as a “signaler” of serious diseases of the structures that form the chest, or organs located inside it (for example, pleurisy, tumors of the spinal cord, chest and mediastinum). In addition, left-sided intercostal neuralgia can mimic cardiac pathology. Due to the diversity of etiologies of intercostal neuralgia, patient management is not limited to clinical neurology, but often requires the participation of related specialists - vertebrologists, cardiologists, oncologists, pulmonologists.

Anatomy of intercostal nerves

Intercostal nerves are mixed, containing motor, sensory (sensitive) and sympathetic fibers. They originate from the anterior branches of the spinal roots of the thoracic segments of the spinal cord. There are a total of 12 pairs of intercostal nerves. Each nerve passes in the intercostal space below the edge of its corresponding rib. The nerves of the last pair (Th12) pass under the 12th ribs and are called subcostal. In the area from the exit from the spinal canal to the costal angles, the intercostal nerves are covered by the parietal pleura.

The intercostal nerves innervate the muscles and skin of the chest, the anterior wall of the abdomen, the mammary gland, the costophrenic part of the pleura, and the peritoneum lining the anterolateral surface of the abdominal cavity. The sensory branches of adjacent intercostal nerves branch and connect with each other, providing cross-innervation, in which an area of skin is innervated by one main intercostal nerve and partially by the superior and inferior lying nerve.

Causes of intercostal neuralgia

Damage to the intercostal nerves may be inflammatory in nature and be associated with previous hypothermia or an infectious disease. The most common neuralgia of infectious etiology is intercostal neuralgia due to herpetic infection, the so-called. herpes zoster. In some cases, damage to the nerves is associated with their injury due to bruises and fractures of the ribs, other injuries to the chest, and spinal injuries. Neuralgia can occur due to compression of nerves by intercostal muscles or back muscles with the development of muscular-tonic syndromes associated with excessive physical activity, working in an uncomfortable position, reflex impulses in the presence of pleurisy, chronic vertebrogenic pain syndrome.

Various diseases of the spine (thoracic spondylosis, osteochondrosis, intervertebral hernia) often cause irritation or compression of the intercostal nerves at the point of their exit from the spinal canal. In addition, the pathology of the intercostal nerves is associated with dysfunction of the costovertebral joints due to arthrosis or post-traumatic changes in the latter. Factors predisposing to the development of neuralgia of the intercostal nerves are deformations of the chest and curvature of the spine.

In some cases, intercostal neuralgia occurs as a result of compression of the nerves by a growing benign tumor of the pleura, a neoplasm of the chest wall (chondroma, osteoma, rhabdomyoma, lipoma, chondrosarcoma), aneurysm of the descending thoracic aorta. Like other nerve trunks, intercostal nerves can be affected when the body is exposed to toxic substances, hypovitaminosis with B vitamin deficiency.

Symptoms of intercostal neuralgia

The main symptom is a sudden one-sided piercing acute pain in the chest (thoracalgia), running along the intercostal space and encircling the patient’s torso. Patients often describe it as a “lumbago” or “passing electric current.” Moreover, they clearly indicate the spread of pain along the intercostal space from the spine to the sternum. At the beginning of the disease, thoracalgia may be less intense in the form of tingling, then the pain usually intensifies and becomes unbearable. Depending on the location of the affected nerve, pain can radiate to the scapula, heart, or epigastric region. The pain syndrome is often accompanied by other symptoms (hyperemia or pallor of the skin, local hyperhidrosis) caused by damage to the sympathetic fibers that make up the intercostal nerve.

Characterized by repeated pain paroxysms, lasting from a few seconds to 2-3 minutes. During an attack, the patient freezes and holds his breath while inhaling, since any movements, including respiratory excursion of the chest, cause increased pain. For fear of provoking a new painful paroxysm, during the interictal period patients try to avoid sharp turns of the body, deep sighs, laughter, coughing, etc. During the period between painful paroxysms along the intercostal space, paresthesia may be noted - subjective sensory sensations in the form of tickling, crawling.

With a herpetic infection, intercostal neuralgia is accompanied by skin rashes that appear on the 2-4th day of thoracalgia. The rash is localized on the skin of the intercostal space. It appears as small pink spots, which then transform into vesicles that dry out to form crusts. Itching is typical, occurring even before the first elements of the rash appear. After the disease resolves, temporary hyperpigmentation remains at the site of the rash.

Diagnosis of intercostal neuralgia

A neurologist can determine the presence of neuralgia of the intercostal nerves based on characteristic complaints and examination data. The patient's antalgic posture is noteworthy: in an effort to reduce pressure on the affected intercostal nerve, he tilts his torso to the healthy side. Palpation in the affected intercostal space provokes the appearance of a typical painful paroxysm; trigger points are identified at the lower edge of the corresponding rib. If several intercostal nerves are affected, during a neurological examination an area of decreased or loss of sensitivity in the corresponding area of the skin of the body can be determined.

Clinical differentiation of pain syndrome is important. Thus, when pain is localized in the cardiac region, it is necessary to differentiate it from the pain syndrome associated with cardiovascular diseases, primarily from angina pectoris. Unlike the latter, intercostal neuralgia is not relieved by taking nitroglycerin, but is provoked by movements in the chest and palpation of the intercostal spaces. With angina, a painful attack is of a compressive nature, provoked by physical activity and is not associated with turning the body, sneezing, etc. In order to clearly exclude coronary heart disease, the patient is given an ECG, and if necessary, a consultation with a cardiologist is indicated.

When the lower intercostal nerves are damaged, the pain syndrome can mimic diseases of the stomach (gastritis, gastric ulcer) and pancreas (acute pancreatitis). Stomach pathology is characterized by a longer and less intense pain paroxysm, usually associated with food intake. With pancreatitis, girdle pain is also observed, but they are usually bilateral in nature and associated with food. In order to exclude pathology of the gastrointestinal tract, additional examinations may be prescribed: determination of pancreatic enzymes in the blood, gastroscopy, etc. If intercostal neuralgia occurs as a symptom of thoracic radiculitis, then painful paroxysms occur against the background of constant dull pain in the back, which decreases when the spine is unloaded in a horizontal position. To analyze the condition of the spine, an X-ray of the thoracic region is performed, and if an intervertebral hernia is suspected, an MRI of the spine is performed.

Intercostal neuralgia can be observed in some lung diseases (atypical pneumonia, pleurisy, lung cancer). To exclude/detect such a pathology, a chest x-ray is performed, and if indicated, a computed tomography is performed.

Treatment of intercostal neuralgia

Complex therapy is carried out aimed at eliminating the causative pathology, relieving thoracalgia, and restoring the affected nerve. One of the main components is anti-inflammatory therapy (piroxicam, ibuprofen, diclofenac, nimesulide). In case of severe pain, drugs are administered intramuscularly, therapy is supplemented by therapeutic intercostal blockades with the administration of local anesthetics and glucocorticosteroids. An auxiliary means in relieving pain is the prescription of sedatives, which reduce pain by increasing the threshold of excitability of the nervous system.

Etiotropic therapy depends on the genesis of neuralgia. Thus, for herpes zoster, antiviral agents (famciclovir, acyclovir, etc.), antihistamine pharmaceuticals and local use of antiherpetic ointments are indicated. In the presence of muscular-tonic syndrome, muscle relaxants (tizanidine, tolperisone hydrochloride) are recommended. If there is compression of the intercostal nerve at the exit of the spinal canal due to osteochondrosis and displacement of the vertebrae, gentle manual therapy or spinal traction can be performed to relieve the compression. If nerve compression is caused by a tumor, surgical treatment is considered.

In parallel with etiotropic and anti-inflammatory therapy, neurotropic treatment is carried out. To improve the functioning of the affected nerve, intramuscular administration of B vitamins and ascorbic acid is prescribed. Drug therapy is successfully complemented by physiotherapeutic procedures: ultraphonophoresis, magnetotherapy, UHF, reflexology. For herpes zoster, local UV irradiation on the area of the rash is effective.

Forecast and prevention of intercostal neuralgia

In general, with adequate treatment, intercostal neuralgia has a favorable prognosis. Most patients experience complete recovery. In the case of herpetic etiology of neuralgia, relapses are possible. If intercostal neuralgia is persistent and cannot be treated, you should carefully reconsider its etiology and examine the patient for the presence of a herniated disc or tumor process.

Prevention measures include timely treatment of spinal diseases, prevention of spinal curvature, and adequate treatment of chest injuries. The best protection against herpes infection is a high level of immunity, which is achieved by a healthy lifestyle, hardening, moderate physical activity, and active recreation in nature.

Thus, the intercostal space is delimited from above by the costal groove, and from the outside and inside by the intercostal muscles.

The neurovascular bundles pass deeper than the external intercostal muscles: usually the v.intercostalis is located above all, the n.intercostalis - below the artery.

Rice. 4. Topography of the intercostal space