The phrenic nerve is a mixed

nerve A nerve is an enclosed, cable-like bundle of nerve fibers (called axons). Nerves have historically been considered the basic units of the peripheral nervous system. A nerve provides a common pathway for the Electrochemistry, electrochemical nerv ...

that originates from the C3–C5 spinal nerves in the neck. The nerve is important for

breathing Breathing (spiration or ventilation) is the rhythmical process of moving air into ( inhalation) and out of ( exhalation) the lungs to facilitate gas exchange with the internal environment, mostly to flush out carbon dioxide and bring in oxy ...

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 a 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 A sensory nerve, or afferent nerve, is a nerve that contains exclusively afferent nerve fibers. Nerves containing also motor fibers are called mixed. Afferent nerve fibers in a sensory nerve carry sensory information toward the central nervous ...

, 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 nerve roots of the

cervical plexus The cervical plexus is a nerve plexus of the anterior rami of the first (i.e. upper-most) four cervical spinal nerves C1-C4. The cervical plexus provides motor innervation to some muscles of the neck, and the diaphragm; it provides sensory inne ...

and the

brachial plexus The brachial plexus is a network of nerves (nerve plexus) formed by the anterior rami of the lower four Spinal nerve#Cervical nerves, cervical nerves and first Spinal nerve#Thoracic nerves, thoracic nerve (cervical spinal nerve 5, C5, Cervical spi ...

, it is usually considered separate from either plexus. The name of the nerve comes from

Ancient Greek Ancient Greek (, ; ) includes the forms of the Greek language used in ancient Greece and the classical antiquity, ancient world from around 1500 BC to 300 BC. It is often roughly divided into the following periods: Mycenaean Greek (), Greek ...

''phren'' 'diaphragm'.

Structure

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 The internal jugular vein is a paired jugular vein that collects blood from the brain and the superficial parts of the face and neck. This vein runs in the carotid sheath with the common carotid artery and vagus nerve. It begins in the posteri ...

across the

anterior scalene The scalene muscles are a group of three muscles on each side of the neck, identified as the anterior, the middle, and the posterior. They are innervated by the third to the eighth cervical spinal nerves (C3-C8). The anterior and middle scale ...

, 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 In human anatomy, the subclavian arteries are paired major arteries of the upper thorax, below the clavicle. They receive blood from the aortic arch. The left subclavian artery supplies blood to the left arm and the right subclavian artery suppli ...

. 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 The pericardium (: pericardia), also called pericardial sac, is a double-walled sac containing the heart and the roots of the great vessels. It has two layers, an outer layer made of strong inelastic connective tissue (fibrous pericardium), a ...

and mediastinal

parietal pleura The pleurae (: pleura) are the two flattened closed sacs filled with pleural fluid, each ensheathing each lung and lining their surrounding tissues, locally appearing as two opposing layers of serous membrane separating the lungs from the medi ...

. * The right phrenic nerve passes over the

brachiocephalic artery The brachiocephalic artery, brachiocephalic trunk, or innominate artery is an artery of the mediastinum that supplies blood to the right arm, head, and neck. It is the first branch of the aortic arch. Soon after it emerges, the brachiocephalic ...

, posterior to the

subclavian vein The subclavian vein is a paired large vein, one on either side of the body, that is responsible for draining blood from the upper extremities, allowing this blood to return to the heart. The left subclavian vein plays a key role in the absorption ...

, and then crosses the root of the right

lung The lungs are the primary Organ (biology), organs of the respiratory system in many animals, including humans. In mammals and most other tetrapods, two lungs are located near the Vertebral column, backbone on either side of the heart. Their ...

anteriorly and then leaves the

thorax The thorax (: thoraces or thoraxes) or chest is a part of the anatomy of mammals and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main di ...

by passing through the vena caval foramen opening in the diaphragm at the level of T8. The right phrenic nerve passes over the

right atrium The atrium (; : atria) is one of the two upper chambers in the heart that receives blood from the circulatory system. The blood in the atria is pumped into the heart ventricles through the atrioventricular mitral and tricuspid heart valves. ...

. * The left phrenic nerve passes over the pericardium of the

left ventricle A ventricle is one of two large chambers located toward the bottom of the heart that collect and expel blood towards the peripheral beds within the body and lungs. The blood pumped by a ventricle is supplied by an atrium, an adjacent chamber in t ...

and pierces the diaphragm separately. The pericardiacophrenic arteries and veins travel with their respective phrenic nerves. The phrenic nerve can be marked by a line connecting these two points: # 1st point can be labelled 3.5 cm at the level of the thyroid cartilage from the midsagittal plane. # 2nd point is at the medial end of the clavicle.

Variation

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 retro-clavicular 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). 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. In canines, the phrenic nerve arises from C5-C7 with occasional small contributions from C4. In the cat, horse, ox, and small ruminant the phrenic nerve arises variably from C4-C7.

Function

Both of these nerves supply motor fibers to the diaphragm and sensory fibers to the fibrous

pericardium The pericardium (: pericardia), also called pericardial sac, is a double-walled sac containing the heart and the roots of the great vessels. It has two layers, an outer layer made of strong inelastic connective tissue (fibrous pericardium), ...

, mediastinal pleura, and diaphragmatic

peritoneum The peritoneum is the serous membrane forming the lining of the abdominal cavity or coelom in amniotes and some invertebrates, such as annelids. It covers most of the intra-abdominal (or coelomic) organs, and is composed of a layer of mesotheli ...

. Some sources describe the right phrenic nerve as innervating the

gallbladder In vertebrates, the gallbladder, also known as the cholecyst, is a small hollow Organ (anatomy), organ where bile is stored and concentrated before it is released into the small intestine. In humans, the pear-shaped gallbladder lies beneath t ...

, other sources make no such mention. The right phrenic nerve may also supply the capsule of the

liver The liver is a major metabolic organ (anatomy), organ exclusively found in vertebrates, which performs many essential biological Function (biology), functions such as detoxification of the organism, and the Protein biosynthesis, synthesis of var ...

Clinical significance

Zwerchfellparese links - Sniff-Test - 001 - kleiner

Pain Pain is a distressing feeling often caused by intense or damaging Stimulus (physiology), stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sense, sensory and emotional experience associated with, or res ...

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 A hiccup (scientific name singultus, from Latin for "sob, hiccup"; also spelled hiccough) is an spasm, involuntary contraction (myoclonic jerk) of the diaphragm (anatomy), diaphragm that may repeat several times per minute. The hiccup is an in ...

is a spasmodic contraction of the diaphragm, which pulls air against the closed folds of the

larynx The larynx (), commonly called the voice box, is an organ (anatomy), organ in the top of the neck involved in breathing, producing sound and protecting the trachea against food aspiration. The opening of larynx into pharynx known as the laryngeal ...

. 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. The right phrenic nerve may be crushed by the

vena cava In anatomy, the ''venae cavae'' (; ''vena cava'' ; ) are two large veins ( great vessels) that return deoxygenated blood from the body into the heart. In humans they are the superior vena cava and the inferior vena cava, and both empty into t ...

clamp during

liver transplantation Liver transplantation or hepatic transplantation is the replacement of a diseased liver with the healthy liver from another person (allograft). Liver transplantation is a treatment option for end-stage liver disease and acute liver failure, al ...

. Severing the phrenic nerve will paralyse that half of the diaphragm. Bilateral paralysis can 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. Diaphragm paralysis is best demonstrated by

sonography Medical ultrasound includes diagnostic techniques (mainly imaging) using ultrasound, as well as therapeutic applications of ultrasound. In diagnosis, it is used to create an image of internal body structures such as tendons, muscles, joints ...

. 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 A spinal cord injury (SCI) is damage to the spinal cord that causes temporary or permanent changes in its function. It is a destructive neurological and pathological state that causes major motor, sensory and autonomic dysfunctions. Symptoms of ...

below the neck are still able to breathe effectively, despite any paralysis of the lower limbs. Brachial plexus injuries can cause paralysis in various regions in the arm, forearm, and hand depending on the severed nerves.

References

External links

* - "Left side of the

mediastinum The mediastinum (from ;: mediastina) is the central compartment of the thoracic cavity. Surrounded by loose connective tissue, it is a region that contains vital organs and structures within the thorax, mainly the heart and its vessels, the eso ...