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Original Articles: General Thoracic

Thoracoscopic and Anatomic Landmarks of Kuntz's Nerve: Implications for Sympathetic Surgery

^a Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
^b Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
^c Division of General Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria

Accepted for publication May 21, 2008.

^_* Address correspondence to Dr Neumayer, Division of General Surgery, AKH - E21.A, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria (Email: christoph.neumayer{at}meduniwien.ac.at).

Background: Kuntz's nerves (KN) have been blamed for surgical failures of endothoracic sympathectomy. The prevalence of these fibers, however, varies between the surgical (about 10%) and anatomic literature (about 80%). This clinically orientated cadaveric study was conducted to explain this discrepancy, to reveal possible reasons for the low thoracoscopic detection rate, and to define anatomic structures as possible landmarks of KNs.

Methods: Video-assisted thoracoscopy was performed in 33 thoracic cavities of fresh human cadavers within 48 hours postmortem, followed by anatomic dissection of the first intercostal space. Kuntz's nerves and concomitant blood vessels were of special interest. Statistical analysis included frequencies and ² tests.

Results: Kuntz's nerves were identified in 12.1% by thoracoscopy, whereas anatomic dissection revealed KNs in 66.7% (p = 0.003). Subpleural veins (mean diameter, 2.2 ± 0.9 mm) parallel to KNs were found in 81.8%. No collateral arteries were identified. Diameters of KNs were 1.4 ± 0.7 mm; distances between the first thoracic ganglion and the middle of KNs were 9.7 ± 3.0 mm. Thoracoscopic recognition of these Kuntz veins was higher than that of KNs (62.5% vs 18.2%, p < 0.005).

Conclusions: The low thoracoscopic detection rate of KNs may be due to the low color contrast of these small fibers. They have, however, most frequently concomitant subpleural veins that are easier to detect. These veins may serve as orientation landmarks of KNs and thus contribute to a more complete denervation improving the outcome of thoracoscopic sympathectomies.