What Is the Intercostal Space?

Intercostal space is a medical term that refers to the space between ribs and ribs in the chest cavity. There are many important organs and tissues in the space. There are intercostal muscles, blood vessels, nerves and connective tissues, membranes and other structures in the gap. The width of the intercostal space varies, the upper intercostal space is wider, and the lower intercostal space is narrower; the intercostal space is wider at the front and narrower at the rear, but can vary with body position. The ribs are curved and elastic, and the 5th to 8th ribs have a large curvature and are prone to fractures. If the fracture end is shifted inward, it can puncture the pleura and intercostal vessels and nerves, and even puncture the lungs, causing hemothorax, pneumothorax, or atelectasis.

Chinese name: Intercostal space
Implied: Ribs to ribs

Subject: Medicine, biology
Nature: A specific space within the human body

1 Anatomical basis of intercostal space through 1st intercostal space for thoracic puncture and drainage

A large number of clinical practices have proven that the 2nd and 3rd intercostal space outside the midline of the clavicle is selected as the high thoracic drainage point, which is not only effective, but also safe and reliable. For the treatment of pleural effusion, in principle, based on X-ray or other imaging positioning, the literature rarely refers to the treatment of wrapped lesions higher than the second intercostal space, especially the treatment of the first intercostal space. The relevant issues of puncture and drainage of the thorax at this site are described based on autopsy data, and 10 successful experiments of the first intercostal thoracentesis and drainage from October 1990 to October 2001 are summarized to explore its clinical significance.

Intercostal space anatomy

The chest and neck roots were dissected on 26 cadavers (male 16, female 10), and the direction of the blood vessels adjacent to the top of the chest and their relationship with the first and second ribs were observed. The subclavian arteries, veins, innominate veins, and intrathoracic blood vessels that were closer to the 1st and 2nd intercostal space from the midline of the clavicle were selected as the main research objects. The closest distances from the blood vessels at the top of the chest to the upper edge of the third rib of the midline of the clavicle (ie, the second intercostal drainage point) are all greater than 40mm, so they are omitted. Only the closest distance from the observed vessel to the midline of the clavicle on the upper edge of the second rib (ie, the first intercostal drainage point) is recorded.

Intercostal subclavian artery

The left starts directly from the aortic arch and the right starts from the innominate artery. Both sides go up the medial side of the lung apex, exit the upper thorax to the base of the neck, obliquely over the front of the chest, pass through the space above the 1st rib through the oblique muscle space to the outer edge of the 1st rib. The nearest distances of the drainage points were (32.2 ± 1.6) mm and (31.6 ± 1.8) mm.

Intercostal subclavian vein

The axillary vein continues from the outer edge of the first costal rib to the back of the sternoclavicular joint, and an innominate vein is formed with the ipsilateral internal jugular vein. The shortest distances from the left and right sides to the drainage point are (290 ± 1.9) mm and (28.6 ± 1.5) mm.

Intercostal space innominate vein

The closest distances from the left and right sides to the drainage point formed by the confluence of the ipsilateral internal jugular vein and subclavian vein were (34.0 ± 1.6) mitt and (33.8 ± 1.5) mm, respectively.

Intercostal internal thoracic artery

It is emitted from the subclavian artery and descends behind the medial end of the clavicle and enters the chest cavity. Down the outer edge of the sternum.

Intercostal space clinical application

Ten patients who underwent the first intercostal puncture and drainage were aged 23-73 years, with an average of 52 years. Before operation, chest X-ray examinations confirmed that there were 8 cases of lesions or pus, and pneumothorax wrapped in the second intercostal space, and 2 cases had lung tissue conglutination in the second and third intercostal space.

During the operation, the patient was supine, with the upper limb of the affected side abducted, raised, and extended. Place the affected hand behind the pillow, and take the first rib close to the upper edge of the second rib on the midline of the clavicle. In 9 cases, incision was made layer by layer or a new anal canal was directly placed in No. 24; or a plastic tube with a diameter of 5 mm was placed through a trocar and other operations were the same as conventional closed chest drainage.

All the 10 patients in the group achieved clinical cure. The shortest drainage time was 3d and the longest was 32d. Four cases of thoracic and thoracotomy infection after upper lobectomy, 3 cases of left lung swelled after drainage, completely eliminated the residual cavity, the drainage time was 10, 18, 32 days, leaving a small sterile residual cavity and chest top Localized pleural hypertrophy. In 3 cases of emphysema, ruptured pulmonary bullae, and infection of the residual chest cavity, the infection was completely controlled after drainage, but because of the poor elasticity of the lung tissue and local adhesions, there was a sterile residual cavity wrapped around the chest chest. Drainage time is 10, 12, 20d. Two cases had pneumothorax with anterior intercostal pleural adhesions 2 and 3, and 1 case had empyema that was wrapped around the top of the chest. After drainage, the lung tissues were completely expanded and the residual cavity disappeared. The drainage time was 3, 7, 10 days. .

Intercostal discussion

2 Thoracic drainage through the intercostal space through the second intercostal space is safe and reliable

Clinically, the second intercostal space outside the midline of the clavicle is emphasized as a high pleural drainage point, mainly for safety reasons. The anatomical data of this study also confirmed that the distance between the blood vessels at the top of the chest is more than 40mm, so in general, the operation of draining the chest in this part will not damage the large blood vessels. Moreover, after thoracic drainage at this point, as the lung tissue expands, the gas (such as the top of the chest) and / or the fluid (such as the costal sacral sinus) at the corresponding site are easily extracted, so as to achieve the purpose of treatment. Therefore, it is still worth highlighting the drainage location.

1 Indications of intercostal space through first intercostal thoracentesis

When there is pleural adhesion between the 2nd and 3rd intercostal space, the conventional drainage site is still mechanically emphasized, which will cause damage to the lung tissue at that site, destroy the established pleural adhesion, cause larger and new trauma, and even worsen the primary lesion . But if lower drainage is chosen. Especially for the drainage of pneumothorax, it is difficult to achieve the desired therapeutic effect. In this case, the first intercostal puncture and drainage of the thoracic cavity should be considered in order to achieve better results. When there is a clear indication of drainage for empyema or residual cavities (including postoperative residual cavities) wrapped above the level of the second intercostal space, puncture and drainage through the first intercostal space Surgical treatment.

1 Safety of intercostal space drainage through the first intercostal space and key points of surgery

The anatomical data of this study have confirmed that the distance between the first intercostal drainage point and the blood vessels in and out of the thorax is closer than the corresponding distance between the second intercostals, so it cannot be used as a conventional site. However, it also shows that there is still a certain safety distance between the midline of the first intercostal clavicle and the blood vessels; in addition, the axillary blood vessels move with the position of the upper limbs. Therefore, in absolute indications, the first intercostal space should still be regarded as a safe and reliable drainage site. In order to prevent possible accidental injury during surgery, the upper limbs of the affected side should be raised, abducted, and extended backward during the operation, and the hand should be placed behind the pillow to ensure that the axillary blood vessels are separated from the anterior chest wall and protected from injury. At the same time, instruments and drainage tubes with thinner outer diameters should be selected (the rubber anal canal of the 24th type with better elasticity is used in this group) to prevent the chest wall incision from becoming too large beyond the full limit. In addition, during surgery, the instrument should be close to the upper edge of the second rib and enter the chest cavity in a direction perpendicular to it to prevent the skin incision and the intercostal incision from accidentally damaging the blood vessels. In short, as long as you are familiar with the normal anatomy of the blood vessels in the first intercostal space and the top of the chest, and proficient in the main points of the operation, the first intercostal space is still one of the high positions of the puncture and drainage of the thorax, especially for the packages that are higher than the first The treatment of draining lesions in the intercostal thoracic apex and the pneumothorax treatment with adhesion in the second and third intercostal gyrus have certain clinical application value.