REVIEW Neuroanatomy of the Female Abdominopelvic Region: A Review With Application to Pelvic Pain Syndromes MOHAMMADALI M. SHOJA, 1,2 AMIT SHARMA, 3 NADINE MIRZAYAN, 3 CHRIS GROAT, 3 KOICHI WATANABE, 1 MARIOS LOUKAS, 3 AND R. SHANE TUBBS 1 * 1 Department of Pediatric Neurosurgery, Children’s Hospital, Birmingham, Alabama 2 Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran 3 Department of Anatomical Sciences, St. George’s University, Grenada, West Indies Pelvic pain can be a life altering disease. Multiple pathologies can affect this region resulting in neurologic issues. Therefore, a thorough understanding of the nerve supply to this region is important for the clinician who treats such patients. The current review outlines the anatomy of the nervous system of the abdominopelvic region with special attention to this anatomy in the female. Clin. Anat. 26:66–76, 2013. V V C 2012 Wiley Periodicals, Inc. Key words: anatomy; female; pelvis; abdomen; nerves; plexus; autonomics SYMPATHETIC PATHWAYS Both the sympathetic and parasympathetic nerv- ous systems are governed by upper motor neurons (i.e., neurons superior to the spinal cord) which are derived from the hypothalamus. These fibers descend into the brainstem and spinal cord as the hypothalamospinal tracts. These tracts are derived from the anterior and posterior hypothalamus for the parasympathetic and sympathetic systems, respec- tively. For the sympathetic nervous system, the hypothalamospinal tracts travel in the white matter posterolateral to the dorsal horn of the spinal cord to end on neuronal cell bodies within the intermediolat- eral horns between the first thoracic and first or sec- ond lumbar segments. Axons from these spinal cord nuclei travel laterally through the ventral rootlets and enter the sympathetic trunk via a white ramus communicans. Once these axons have entered the sympathetic trunk, they may choose to synapse in a sympathetic ganglion at their entrance level or supe- rior or inferior to this level. Following synapse, post- ganglionic (postsynaptic) fibers may leave the sym- pathetic trunk and travel to their target organs pri- marily along blood vessels within the body cavities or into the head. These postganglionic fibers may not be distributed to the viscera but instead reenter a spinal nerve segment via a gray ramus communi- cans to be disseminated to smooth muscle (arrector pili), blood vessels, and glands in the skin of the extremities and walls of the body cavities. As the source neurons for the sympathetic system lie pri- marily within the thoracic spinal cord, it is only here that one finds white rami communicans (T1-L2). In contrast, gray rami communicans (Fig. 1) are found at all spinal levels and therefore postganglionic fibers that are destined for the somatic body superior or in- ferior to the thoracic spinal cord must ascend or descend within the sympathetic trunk. Topographi- cally, the white rami communicans are found slightly lateral to the gray ramus communicans and these former rami are generally larger in size due to the preponderance of myelinated fibers. Additionally, white ramus communicans will carry visceral afferent fibers from the body cavities. Moreover, in the upper lumbar region the white rami usually ascend obliquely from a given ganglion since they typically originate from a nerve from the next more superior level (Hollinshead, 1956). Gray rami tend to run hor- izontally or travel inferiorly only slightly from a gan- glion to their corresponding nerve segment. *Correspondence to: Dr. R. Shane Tubbs, Children’s Hospital, 1600 7th Avenue South, ACC 400, Birmingham, AL 35233. E-mail: shane.tubbs@chsys.org Received 8 August 2012; Revised 10 October 2012; Accepted 15 October 2012 Published online 23 November 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/ca.22200 V V C 2012 Wiley Periodicals, Inc. Clinical Anatomy 26:66–76 (2013)