Eric Holland OMS-I · ex-software engineer

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Viscerosomatic levels

The autonomic innervation chart from OPP-05: which sympathetic cord segments each organ facilitates and where its parasympathetics come from. Name the levels, name the organs at a level, click the segments on the spine, and work the referred-pain cases (appendicitis at T10–11, cholecystitis in the right shoulder…). Every answer lights the segments on the column.

Region
CranialCranial parasympathetic outflow (vagus, CN III/VII/IX) CN (vagus)CervicalC1 C1C2 C2C3 C3C4 C4C5 C5C6 C6C7 C7C8 C8ThoracicT1: Head and neck, Heart T1T2: Head and neck, Heart, Lung, Upper extremities T2T3: Head and neck, Heart, Lung, Esophagus, Upper extremities T3T4: Head and neck, Heart, Lung, Esophagus, Upper extremities T4T5: Heart, Lung, Esophagus, Stomach, Liver, Gallbladder, Spleen, Pancreas, Duodenum (before the ligament of Treitz), Upper extremities T5T6: Lung, Esophagus, Stomach, Liver, Gallbladder, Spleen, Pancreas, Duodenum (before the ligament of Treitz), Upper extremities T6T7: Lung, Stomach, Liver, Gallbladder, Spleen, Pancreas, Duodenum (before the ligament of Treitz), Upper extremities T7T8: Stomach, Liver, Gallbladder, Spleen, Pancreas, Duodenum (before the ligament of Treitz) T8T9: Stomach, Liver, Gallbladder, Spleen, Pancreas, Duodenum (before the ligament of Treitz) T9T10: Jejunum, Ileum, Ascending colon, proximal ⅔ of transverse colon & appendix, Kidneys, Adrenal medulla, Upper ureters, Gonads, Uterus and cervix, Lower extremities T10T11: Jejunum, Ileum, Ascending colon, proximal ⅔ of transverse colon & appendix, Kidneys, Adrenal medulla, Upper ureters, Bladder, Gonads, Uterus and cervix, Erectile tissue of penis and clitoris, Prostate, Lower extremities T11T12: Distal ⅓ of transverse colon, Descending & sigmoid colon (after the splenic flexure), Rectum, Kidneys, Lower ureters, Bladder, Uterus and cervix, Erectile tissue of penis and clitoris, Prostate, Lower extremities T12LumbarL1: Distal ⅓ of transverse colon, Descending & sigmoid colon (after the splenic flexure), Rectum, Kidneys, Lower ureters, Bladder, Uterus and cervix, Erectile tissue of penis and clitoris, Prostate, Lower extremities L1L2: Distal ⅓ of transverse colon, Descending & sigmoid colon (after the splenic flexure), Rectum, Bladder, Uterus and cervix, Erectile tissue of penis and clitoris, Prostate, Lower extremities L2L3 L3L4 L4L5 L5SacralS1 S1S2 S2S3 S3S4 S4S5 S5

■ sympathetic segments   ■ parasympathetic outflow (CN box = vagus / cranial nerves; S2–4 = pelvic splanchnics)

Click a row to light its levels on the column.

Head, neck & thorax 4

ViscusSympathetic (cord levels)Parasympathetic
Head and neck
Parasympathetics ride the cranial nerves (III, VII, IX, X); sympathetics climb from T1–4 via the cervical ganglia.
 T1–4 CN III, VII, IX, X
Heart
MI refers to the left arm/shoulder and produces tissue-texture changes at left T(1)2–4(5). Sustained sympathetic tone → tachyarrhythmias, coronary vasoconstriction.
 T1–5 Vagus (CN X)
Lung T2–7 Vagus (CN X)
Esophagus T3–6 Vagus (CN X)

Foregut (T5–9) 6

ViscusSympathetic (cord levels)Parasympathetic
Stomach T5–9 Vagus (CN X)
Liver
Hepatic/gallbladder dysfunction refers to the right shoulder and scapula.
 T5–9 Vagus (CN X)
Gallbladder
Cholecystitis → right shoulder / right scapular pain via T5–9; laparoscopic pneumoperitoneum mimics it.
 T5–9 Vagus (CN X)
Spleen T5–9 Vagus (CN X)
Pancreas
Pancreatitis is a classic 'spinal masquerader' — mid-back pain from T5–9.
 T5–9 Vagus (CN X)
Duodenum (before the ligament of Treitz)
Everything up to the ligament of Treitz is foregut — T5–9.
 T5–9 Vagus (CN X)

Midgut (T10–11) 3

ViscusSympathetic (cord levels)Parasympathetic
Jejunum
Small-bowel obstruction (distention) → T10–11.
 T10–11 Vagus (CN X)
Ileum T10–11 Vagus (CN X)
Ascending colon, proximal ⅔ of transverse colon & appendix
Ligament of Treitz to splenic flexure. Appendicitis → tenderness and bogginess at T10–11.
 T10–11 Vagus (CN X)

Hindgut (T12–L2) 3

ViscusSympathetic (cord levels)Parasympathetic
Distal ⅓ of transverse colon T12–L2 Pelvic splanchnics (S2–4)
Descending & sigmoid colon (after the splenic flexure) T12–L2 Pelvic splanchnics (S2–4)
Rectum T12–L2 Pelvic splanchnics (S2–4)

Kidneys, ureters & bladder 5

ViscusSympathetic (cord levels)Parasympathetic
Kidneys
Kidney stone → pain in the middle of the back (a spinal masquerader).
 T10–L1 Vagus (CN X)
Adrenal medulla
The medulla is itself a sympathetic ganglion — preganglionic fibres synapse directly on the chromaffin cells.
 T10–11 Vagus (CN X)
Upper ureters T10–11 Vagus (CN X)
Lower ureters T12–L1 Pelvic splanchnics (S2–4)
Bladder
Bladder distention → T11–L2.
 T11–L2 Pelvic splanchnics (S2–4)

Reproductive 4

ViscusSympathetic (cord levels)Parasympathetic
Gonads
Testes and ovaries keep their embryonic T10–11 supply even after descending.
 T10–11 Pelvic splanchnics (S2–4)
Uterus and cervix T10–L2 Pelvic splanchnics (S2–4)
Erectile tissue of penis and clitoris
Point (erection) is parasympathetic S2–4; shoot (emission) is sympathetic T11–L2.
 T11–L2 Pelvic splanchnics (S2–4)
Prostate T11–L2 Pelvic splanchnics (S2–4)

Extremities 2

ViscusSympathetic (cord levels)Parasympathetic
Upper extremities
No parasympathetic supply to the limbs. Sympathetic facilitation from the upper extremity lateralises to the right in the upper thoracics (T1–4 in the somato-somatic example).
 T2–7 None
Lower extremities
No parasympathetic supply to the limbs.
 T10–L2 None

The four osteopathic reflexes

  • Somato-somatic — Stimulus in one somatic structure triggers a reflex in another somatic structure.
  • Viscero-visceral — Sensory input from one viscus causes a motor or functional change in another viscus.
  • Viscero-somatic — A visceral stimulus produces an effect on somatic (musculoskeletal) structures — referred pain and tissue-texture change at the shared cord segment.
  • Somato-visceral — A somatic stimulus produces an effect on a visceral organ.

Source: OPP-05 Spine palpation 3 & the autonomic nervous system, slides 27–43 (chart after DiGiovanna 2020 and Willard, Foundations of Osteopathic Medicine 4e).

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