The cervical sympathetic trunk is the superior continuation of the thoracic sympathetic chain, ascending on the prevertebral fascia deep to the carotid sheath. It bears three ganglia: the superior cervical ganglion (opposite C1-C3, the largest sympathetic ganglion in the body), the middle cervical ganglion (opposite C6, variable), and the inferior cervical ganglion (which fuses with the T1 ganglion to form the stellate ganglion at C7-T1). The chain supplies all sympathetic innervation to the head, neck, and upper limb.
| Origin | Upward continuation of the thoracic sympathetic trunk (preganglionic fibres from T1-T4 spinal segments) |
|---|---|
| Course | Ascends on the prevertebral fascia over longus colli and longus capitis, posterior to the carotid sheath, from the neck of the first rib to the base of the skull |
| Sensory |
|
The cervical sympathetic trunk lies on the prevertebral fascia just behind the carotid sheath and is vulnerable during carotid endarterectomy, anterior cervical spine surgery, radical neck dissection and thyroid surgery, and to carotid dissection and apical lung (Pancoast) tumours. Injury produces Horner syndrome: ptosis, miosis and, depending on the level, anhidrosis. Central and preganglionic lesions (in the trunk below the superior cervical ganglion) usually cause anhidrosis of the whole side of the face, while postganglionic lesions along the internal carotid artery spare most facial sweating because the sudomotor fibres to the face travel with the external carotid artery. Pharmacological eye drop tests (cocaine or apraclonidine to confirm Horner syndrome, hydroxyamphetamine to separate pre- from postganglionic lesions) help localise the lesion.
Injury to the trunk behind the carotid artery during endarterectomy or neck dissection produces Horner syndrome with ptosis, miosis and facial anhidrosis; many cases improve over weeks but some are permanent.
Facial anhidrosis points to a central or preganglionic lesion, whereas a postganglionic lesion (for example internal carotid dissection) causes ptosis and miosis with little or no loss of facial sweating.
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