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Intercostal space

The intercostal spaces are the eleven anatomical gaps situated between the twelve pairs of ribs in the human thoracic cage, forming essential components of the chest wall that house muscles, nerves, and blood vessels critical for respiratory mechanics and organ protection.^[1]^[2] These spaces extend from the sternum anteriorly to the thoracic vertebrae posteriorly, bounded laterally by the ribs, and are lined internally by the endothoracic fascia and parietal pleura.^[2]^[3] Structurally, each intercostal space contains three layers of intercostal muscles arranged from superficial to deep: the external intercostal muscles, which run obliquely downward and forward to elevate the ribs during inspiration; the internal intercostal muscles, oriented downward and backward to depress the ribs during expiration; and the innermost intercostal muscles, a thinner layer parallel to the internal ones and separated by neurovascular structures.^[2]^[3] These muscles span the spaces, attaching to the inferior border of the rib above and the superior border of the rib below, with the external and internal layers present in all eleven spaces and the innermost layer more prominent in the lower spaces.^[1]^[3] The intercostal spaces also accommodate a neurovascular bundle running along the inferior margin of each rib within the costal groove, consisting—from superior to inferior—of the intercostal vein, intercostal artery, and intercostal nerve (mnemonic: VAN).^[2]^[3] The arteries include one posterior intercostal artery branching from the thoracic aorta (or subclavian for the first two spaces) and two anterior intercostal arteries arising from branches of the internal thoracic artery, while the veins drain into the azygos or hemiazygos systems posteriorly and the internal thoracic vein anteriorly; the nerves arise from the anterior rami of thoracic spinal nerves T1–T11, providing motor innervation to the intercostal muscles and sensory supply to the thoracic wall.^[2]^[3] Functionally, the intercostal spaces and their contents enable the expansion and contraction of the rib cage during breathing, with the external intercostals and diaphragm primarily facilitating inspiration and the internal and innermost intercostals aiding forced expiration, such as during coughing or exertion.^[1]^[3] These structures collectively maintain thoracic cage integrity, protect underlying organs like the lungs and heart, and allow flexibility for vital physiological processes.^[2] Clinically, the intercostal spaces serve as access points for procedures such as intercostal nerve blocks, thoracentesis, or chest tube insertion, though they carry risks of neurovascular injury if not approached carefully.^[2]

Overview

Definition

The intercostal space is the anatomical region situated between adjacent ribs in the thoracic wall, extending from the sternum anteriorly to the thoracic spine posteriorly, and containing various structures that facilitate respiration while contributing to the protection of underlying thoracic organs such as the heart and lungs.^[2] These spaces form part of the flexible thoracic cage, enabling coordinated movement during the respiratory cycle.^[4] Functionally, each intercostal space serves as a dynamic compartment that accommodates rib elevation and depression, essential for increasing thoracic volume during inspiration and aiding expiration.^[2] This adaptability supports efficient gas exchange by allowing the lungs to expand without constraint, underscoring the spaces' critical contribution to respiratory physiology.^[4]

Location and Boundaries

The thorax is formed by 12 pairs of ribs, resulting in 11 intercostal spaces on each side. These spaces are positioned between consecutive ribs and are numbered according to the rib forming their superior boundary, such that the first intercostal space lies between the first and second ribs, the second between the second and third ribs, and so on, up to the 11th space between the 11th and 12th ribs.^[2]^[5] Each intercostal space is bounded superiorly by the inferior aspect of the upper rib, including its costal groove, and inferiorly by the superior aspect of the lower rib. This configuration provides structural support while allowing flexibility for respiratory movements within the thoracic cage.^[2]^[5] Anteriorly, the intercostal spaces extend from the costochondral junctions, where the bony ribs articulate with their cartilaginous extensions, to the posterior extent at the vertebral column, specifically the heads and tubercles of the ribs attaching to the thoracic vertebrae and intervertebral discs. The spaces are functionally divided into three regions: an anterior part near the sternum (parasternal), a middle lateral part, and a posterior part adjacent to the spine (paravertebral), reflecting variations in width and accessibility along the thoracic wall.^[2]^[5] These spaces integrate seamlessly with the overall thoracic cage, incorporating the costal cartilages that connect the anterior ends of ribs 1 through 10 to the sternum (true and false ribs) or each other, while the 11th and 12th ribs remain floating posteriorly. In regions where muscular layers are absent, such as anteriorly between the costochondral junction and sternum or posteriorly between the rib angle and vertebra, thin intercostal membranes form the boundaries, maintaining continuity and protection of the thoracic cavity.^[2]^[5]

Anatomical Components

Muscles

The intercostal spaces contain three layers of skeletal muscles that contribute to the mechanics of respiration by stabilizing and moving the ribs. The most superficial layer consists of the external intercostal muscles, which originate from the inferior border of the rib above and insert onto the superior border of the rib below, with fibers oriented obliquely downward and forward (inferomedially). These muscles function primarily to elevate the ribs during inspiration, increasing the anteroposterior and transverse diameters of the thoracic cavity through a "bucket-handle" motion.^[6]^[7] The middle layer is formed by the internal intercostal muscles, which arise from the costal groove of the upper rib and insert onto the superior margin of the rib or costal cartilage below, with fibers running obliquely downward and backward (perpendicular to the external layer). These muscles are divided into two parts: the posterior interosseous part, which spans between the bony ribs and aids in depressing the ribs during forced expiration, and the anterior interchondral part, which connects adjacent costal cartilages and contributes to similar expiratory actions. The internal intercostal muscles are thinner than the external layer.^[6]^[8]^[9] The deepest layer comprises the innermost intercostal muscles, which are the thinnest of the three and have fibers oriented transversely, parallel to the costal groove, originating from the inner surface of the rib and inserting onto the inner surface of the adjacent rib below. These muscles assist the internal intercostals in forced expiration by depressing the ribs, though their precise role is less dominant. The neurovascular bundle of each intercostal space lies between the internal and innermost layers, protected within the costal groove.^[6]^[10] All intercostal muscles are innervated by the intercostal nerves (anterior rami of spinal nerves T1-T11), which provide motor supply to facilitate their respiratory functions. Their blood supply derives from the posterior intercostal arteries (branches of the thoracic aorta for T3-T11 and supreme intercostal artery for T1-T2) and anterior intercostal arteries (from the internal thoracic artery for upper spaces and musculophrenic artery for lower spaces). In the lower intercostal spaces, accessory muscles such as the subcostal muscles (fibers spanning two or three ribs posteriorly) and the transversus thoracis (fibers from the sternum to ribs 2-6 anteriorly) supplement the innermost layer, aiding in rib depression during forced expiration.^[6]^[6]

Vessels and Nerves

The neurovascular bundle within each intercostal space consists of an intercostal vein, intercostal artery, and intercostal nerve, arranged from superior to inferior in the order remembered by the mnemonic VAN.^[11]^[12] This bundle travels posteriorly to anteriorly along the inferior border of each rib within the costal groove, positioned between the internal intercostal and innermost intercostal muscles for protection.^[5]^[13] The posterior intercostal arteries, which form the arterial component of the bundle, originate from the thoracic aorta for spaces 3 through 11, while the first and second arise from the supreme intercostal artery, a branch of the costocervical trunk from the subclavian artery.^[14]^[15] Anterior intercostal arteries, which anastomose with the posterior ones, branch from the internal thoracic artery for the first six spaces and from the musculophrenic artery (a terminal branch of the internal thoracic) for the seventh through ninth spaces.^[16]^[17] Venous drainage parallels the arterial supply, with posterior intercostal veins from the right side (typically spaces 2 through 11) emptying into the azygos vein and those from the left side into the hemiazygos or accessory hemiazygos veins; the first posterior intercostal vein often drains directly into the brachiocephalic vein.^[18]^[19] Anterior intercostal veins drain into the internal thoracic vein.^[18] The intercostal nerves derive from the ventral rami of thoracic spinal nerves T1 through T11 and course within the neurovascular bundle to provide motor innervation to the intercostal muscles and sensory innervation to the parietal pleura, overlying skin, and (for lower nerves) abdominal peritoneum.^[20]^[21] Each nerve gives rise to collateral branches near the rib angles, which run superiorly along the inferior rib to supply additional motor and sensory fibers to the intercostal muscles and adjacent structures.^[20]^[22]

Clinical Relevance

Surgical Access

Intercostal spaces provide critical access points for thoracic procedures, allowing minimally invasive interventions into the pleural cavity while minimizing disruption to surrounding structures. These spaces are selected based on the underlying condition, with incisions or insertions typically positioned to avoid the intercostal neurovascular bundle, which runs along the inferior border of each rib.^[13] Surgeons enter above the superior rib margin to reduce injury risk to this bundle during procedures like thoracotomy.^[23] Needle thoracostomy, a life-saving emergency intervention for tension pneumothorax, involves inserting a large-bore needle (typically 14-16 gauge, 7-8 cm long) into the second intercostal space at the midclavicular line.^[24]^[25] This site facilitates rapid decompression by allowing air escape from the pleural space, guided by landmarks such as the second rib's superior border and the nipple line for orientation. Advanced Trauma Life Support protocols recommend this approach for its direct access to the anterior chest, though ultrasound confirmation of placement has improved success rates by identifying optimal depth and avoiding variations in chest wall thickness.^[26] Chest tube insertion, or tube thoracostomy, is commonly performed in the fourth or fifth intercostal space along the midaxillary line to drain air, blood, or fluid from the pleural cavity. The tube (usually 28-32 French for adults) is advanced posteriorly and superiorly after creating a subcutaneous tunnel and incising the intercostal muscles, with the patient positioned laterally to expose the site between the anterior and midaxillary lines.^[27] This location balances accessibility and efficacy, corresponding roughly to the nipple level in males, and is secured with sutures to prevent dislodgement.^[28] Thoracentesis, a diagnostic or therapeutic aspiration of pleural fluid, frequently utilizes the fifth intercostal space in the midaxillary or posterior axillary line, identified by percussion for dullness or ultrasound for fluid localization. A needle or catheter is inserted just superior to the rib to evade the neurovascular bundle, with real-time imaging reducing complications like pneumothorax to under 6%.^[29] Landmarks include the midscapular line for posterior approaches, ensuring the procedure remains above the diaphragm.^[30] For more extensive interventions, thoracotomy employs an intercostal incision, often in the fourth or fifth space via a posterolateral approach, where a rib spreader is inserted after dividing the intercostal muscles to expose the thoracic cavity. This technique, refined to limit rib retraction and nerve compression, provides wide access for lobectomies or repairs while preserving intercostal integrity.^[23] The use of intercostal spaces in thoracic surgery originated in the 19th century, with pioneers like French surgeon Chevalier Richerand advancing chest wall resections and drainage for empyema around 1821, evolving from earlier rudimentary incisions.^[31] By the late 1800s, procedures like thoracoplasty popularized intercostal access for tuberculosis treatment, but high infection rates prompted refinements. Modern techniques, integrated with ultrasound since the 1980s, have enhanced precision in landmark identification and reduced procedural risks.^[32]

Common Pathologies

Intercostal muscle strains represent a frequent injury to the intercostal spaces, often resulting from direct trauma such as blunt chest impacts or repetitive strain from severe coughing, leading to sharp pain exacerbated by breathing, coughing, or sneezing, along with tenderness and restricted respiratory movement.^[33] These strains disrupt the normal function of the intercostal muscles, causing localized swelling and potential bruising, which can impair overall chest expansion and contribute to shallow breathing patterns.^[34] In cases of rib fractures, which occur in 10-20% of blunt trauma incidents, intercostal muscle involvement is common, with complications like strain or associated neuropathy affecting up to 23% of patients in clinical studies.^[35]^[36] Infections affecting the intercostal spaces typically arise as extensions from adjacent pleural or pulmonary pathologies, such as empyema, which involves pus accumulation in the pleural cavity and can extend through the intercostal tissues in rare cases known as empyema necessitans, presenting with fever, chest wall swelling, and severe localized pain.^[37] Intercostal abscesses, though uncommon, may develop from hematogenous spread in conditions like infective endocarditis or as complications of penetrating injuries, manifesting as tender, fluctuant masses with overlying erythema and systemic signs of infection.^[38] Empyema, the most prevalent such infection, is primarily caused by bacterial pneumonia and leads to significant morbidity if untreated, including potential sepsis and chronic pleural fibrosis.^[39] Intercostal neuralgia, a neuropathic pain syndrome, frequently occurs as a sequela of herpes zoster (shingles) infection involving the intercostal nerves, resulting in a characteristic band-like, burning pain along the dermatomal distribution, often accompanied by hypersensitivity, itching, or numbness persisting beyond the rash resolution.^[40] This condition, a form of postherpetic neuralgia (PHN), affects approximately 10-18% of individuals following shingles outbreaks, with intercostal involvement contributing to thoracic pain that can severely limit daily activities and quality of life.^[40] Symptoms may include sharp, stabbing sensations triggered by light touch or movement, reflecting damage to the intercostal nerve's sensory fibers.^[41] Tumors in the intercostal spaces are rare, encompassing primary soft tissue sarcomas originating from intercostal muscles or connective tissues, which present as slowly enlarging, painless masses that may compress the neurovascular bundle, causing localized pain, neurological deficits, or respiratory compromise.^[42] Metastatic lesions, more common than primaries, often spread from distant sites like breast or lung carcinomas to the intercostal muscles, leading to similar compressive symptoms including radicular pain and weakness along the affected intercostal distribution.^[43] These tumors, accounting for a small fraction of chest wall malignancies, underscore the need for imaging and biopsy to differentiate them from benign masses or infectious processes.^[44]

Variations and Development

Anatomical Variations

Anatomical variations in the intercostal spaces are relatively common and can affect the ribs, muscles, and neurovascular structures, potentially altering the normal configuration and function of these regions. Rib anomalies represent one of the most notable variations. Cervical ribs, which are supernumerary ribs originating from the seventh cervical vertebra, occur in approximately 1% of the population and create additional upper intercostal spaces that may compress adjacent neurovascular elements.^[45] Lumbar ribs, transitional structures at the thoracolumbar junction, are found in about 1-2% of individuals and can modify the lower intercostal spaces by extending rib-like processes from the first lumbar vertebra, potentially impacting spinal nerve distribution.^[46]^[47] Variations in the intercostal muscles include the absence or incomplete development of the innermost intercostal layer, particularly in the upper spaces where this muscle is often rudimentary or absent.^[3] Neurovascular variants further contribute to diversity in intercostal anatomy. High takeoff or anomalous courses of the posterior intercostal arteries, such as those arising directly from the thoracic aorta in an atypical position, are observed in up to 14% of cases.^[48] These variations carry clinical implications, particularly in increasing procedural risks. For instance, aberrant intercostal vessels or nerves heighten the potential for hemorrhage or nerve injury during interventions like thoracentesis, where unrecognized anatomical differences may lead to complications such as hemothorax.^[49]^[50]

Embryological Origin

The intercostal spaces originate from the segmentation of the paraxial mesoderm into somites during the third and fourth weeks of embryonic development, with the thoracic somites (pairs 13 through 24) contributing specifically to the thoracic cage structures. These somites differentiate into sclerotome, myotome, and dermatome components; the sclerotome gives rise to the ribs through mesenchymal condensation and subsequent chondrification, while the myotome forms the intercostal muscles. By Carnegie stage 17 (approximately week 6), initial cartilage models of the ribs appear dorsally from sclerotomal cells surrounding the somites, creating preliminary separations that define the intercostal spaces as the ribs elongate ventrolaterally.^[51]^[52]^[53] The intercostal muscles derive from the hypaxial division of the thoracic myotomes, migrating into the body wall to occupy the emerging spaces between ribs. By Carnegie stage 18 (week 6.5), these myoblasts differentiate into distinct external and internal intercostal muscle layers, with the external layer originating from the dorsal lip of the dermomyotome and the internal from the ventral lip, establishing the layered muscular framework of the spaces by week 8. Concurrently, neurovascular elements develop: intercostal nerves arise from the ventral rami of thoracic spinal nerves (T1-T11), which form as neural crest and mesodermal cells organize around the neural tube starting in week 4, with rami extending segmentally into the spaces by weeks 5-6. Posterior intercostal arteries branch from the dorsal aorta during weeks 4-6, as segmental vessels supply the growing somites and body wall, running alongside the nerves and veins in the costal grooves.^[52]^[54]^[55]^[56] Key developmental milestones include the expansion of rib anlagen by week 7, forming defined intercostal spaces through chondrification of mesodermal condensations around the somites, with posterior attachment via membranous costovertebral ligaments. By the end of the embryonic period (week 8, Carnegie stage 23), the thoracic cage achieves a basic circular configuration, enclosing the pleural cavities and permitting initial lung bud expansion during the pseudoglandular phase. Further maturation occurs in the early fetal period, with the thoracic cage substantially complete by the third fetal month (week 12), supporting respiratory organogenesis and thoracic volume increase.^[53]^[57]

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