Download Lumbar spinal nerves

Department of Human Anatomy KNMU
THE NERVES AND VESSELS
OF THE PELVIC GIRDLE AND
FREE LOWER LIMB
Slide-lecture for students of the
6 Faculty of Medicine
Lector – associate professor
Zharova Nataliya
2015
PLAN:
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LUMBAR, SACRAL, COCCYGEAL SPINAL NERVES
THE LUMBAR PLEXUS
THE SACRAL PLEXUS
THE COCCYGEAL PLEXUS
ARTERIES OF THE PELVIC GIRDLE
ARTERIES OF FREE LOWER LIMB
VEINS OF THE PELVIC GIRDLE
VEINS OF FREE LOWER LIMB
LUMBAR, SACRAL, COCCYGEAL SPINAL NERVES
• Each spinal nerve arise in the area of the intervertebral foramen as
the result of merging of the anterior and posterior roots of the
spinal cord. The principal trunk of spinal nerve escapes from the
intervertebral foramen and gives rise to 4 branches:
– anterior, posterior, meningeal, communicating.
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Lumbar spinal nerves:
anterior branches form lumbal plexus,
posterior branches
– medial – supply m. multifidus, m.interspinalis;
– lateral – supply m. sacrospinalis, mm. intertransversarii;
meningeal branches – returns to the vertebral canal to supply the
spinal meninges;
communicating branches – pass to the ganglia of sympathetic
trunk.
THE LUMBAR PLEXUS, PLEXUS
LUMBALIS (Тh12 — L4)
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The lumbar plexus is formed from the
anterior branches of three upper
lumbar spinal nerves and a part of the
anterior branches 12-th thoracic spinal
nerve and anterior branches 4-th
lumbar spinal nerve.
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It resides within the lumbar region in
between the transverse processes of
related lumbar vertebrae posterior
and in depth of the psoas major.
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Inferiorly, the lumbar plexus
communicates with the sacral plexus.
Most of the rami arise from behind
the lateral border of the psoas major;
one ramus traverses the muscle (the
genitofemoral nerve) and one branch
arises from behind the medial border
of the muscle (the obturator nerve).
The branches
of the lumbar plexus
1. muscular branches
2. iliohypogastric
nerve
3. ilioinguinal nerve
4. genitofemoral
nerve
5. lateral cutaneous
nerve
6. of thigh
7. obturator nerve
8. femoral nerve
The branches of the lumbar plexus
1. the muscular branches
2. the iliohypogastric nerve
3. the ilioinguinal nerve
4. the genitofemoral nerve
supply both psoas muscles, the quadratus lumborum,
the lumbar intertransversarii
supplies all abdominal muscles, the skin of
hypogastrium and the skin of the gluteal region (its
superolateral portion)
terminates within the skin of the pubic region and the
scrotum (the labia majora) and gives some branches to
both oblique muscles and the transversus abdominis
The genital branch enters the inguinal canal where runs
posterior to the spermatic cord (the round ligament of
uterus). It supplies the cremaster, the dartos muscle, the
skin of scrotum (the labia majora) and the skin of
superomedial surface of thigh.
The femoral branch passes through the vascular space
below the inguinal ligament to a small upper portion of
the femoral triangle
5. the lateral cutaneous nerve of
thigh
Skin of the lateral surface of thigh
6. the obturator nerve
It arises from behind of the medial border of the psoas
major and runs along the lesser pelvis wall to enter the
obturator canal that leads the nerve to the thigh.
Within the thigh, the nerve resides in between the
adductors and splits into the anterior and the posterior
branches.
The nerve supplies the neighboring adductors, the
pectineus, the gracilis, the obturator externus and the
joint capsule of the hip joint.
Is the greatest branch of the lumbar plexus
Topography
of
the
femoral
nerve
The nerve arises from behind the lateral border of the
psoas major and proceeds to the thigh region via the
muscular space. Within the thigh region, the nerve
resides in the femoral triangle laterally from the femoral
artery.
7. the femoral nerve
The branches of the femoral nerve
1. the
muscular
branches
2. the
anterior
cutaneous
branches
3. the
saphenous
nerve
supply the quadriceps femoris
and the pectineus
penetrate the fascia and
terminate in the skin of
anteromedial area of thigh
It enters the adductor canal
together with the femoral artery
and the femoral vein. In the
thigh are, the nerve gives no
branches; the first branch to
arise is the infrapatellar branch.
It supplies the skin of the medial
surface of knee joint and of the
patellar area. Apart from this,
the nerve supplies the skin of the
medial aspect of shin and foot
up to the great toe.
Clinical applications
Injury to the femoral nerve leads to paralysis of the quadriceps
femoris and thus to inability to extend the knee joint. When
walking, the victim is unable to with hold extension of leg and the
foot strikes against the ground with its entire surface. Injury to the
obturator nerve affects abduction of thigh and crossing of legs.
THE SACRAL PLEXUS
Topography of the sacral plexus
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The sacral plexus is the greatest of
all nervous plexuses in the human
body. It arises from merged upper
four sacral nerves, the fifth lumbar
nerve and a part of the fourth
lumbar nerve, the fourth and the
fifth lumbar nerves merge into a
single lumbosacral trunk, that
descends to the lesser pelvis cavity
and joins the sacral nerves. The
lowest portion of the sacral plexus
formed of the fifth sacral nerves
and the coccygeal nerve is the
coccygeal plexus.
The sacral plexus appears as a
thick triangular plate adherent to
the pelvic wall (namely to the
piriformis). The branches given
quit the lesser pelvis via the
suprapiriform and the
infrapiriform foramina as the short
and the long branches.
The greatest nerve of the plexus is
the sciatic nerve.
The short branches
1.the muscular
branches
2.the superior
gluteal nerve
supply the piriformis, the
obturator internus, both
gemelli and the
quadratus femoris
runs via the
suprapiriform foramen to
the gluteus medius, the
gluteus minimus and the
tensor fasciae latae
3.the inferior
gluteal nerve
runs via the infrapiriform
foramen to the gluteus
maximus and the joint
capsule of the hip joint
4.the pudendal
nerve
The nerve supplies the
external anal sphincter
and other perineal
muscles together with
related skin
The long branches
1.The posterior runs via the infrapiriform
cutaneous
foramen to skin of the
nerve of thigh posterior surface of thigh
2.The sciatic
nerve
The principal trunk of the nerve
gives off the muscular branches
to the posterior group of
muscles of thigh (to the
semitendinosus, the
semimembranosus and the
long head of biceps femoris).
Topography of the sciatic nerve
The nerve quits the lesser
pelvis cavity via the infrapiriform
foramen and runs on below the
gluteus maximus. Somewhat below
the escape point, the nerve enters in
between the ischial tuberosity and
the greater trochanter, proceeds
onto the quadratus lumborum
surface and finally becomes evident
within the thigh region, arising from
under the lower border of the
gluteus maximus. Within the thigh
region, the nerve runs deep in
between the neighboring muscles.
Clinical applications.
Chilling of the area related to
the nerve results in neuritis of the
sciatic nerve (sciatica). The state
features painful sensation within the
ischial area and the posterior portion
of the thigh. The condition may even
feature sensory and motor disorders.
On reaching the upper angle of the
popliteal fossa, the nerve splits
into the terminal branches:
- the tibial nerve and
- the common fibular nerve.
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Topography of the tibial nerve
The tibial nerve arises directly
from the sciatic nerve and runs
vertically down to the popliteal
fossa. Within the fossa, the nerve
occupies the most superficial
position with respect to
neighboring popliteal artery and
popliteal vein. From the popliteal
fossa, the nerve proceeds to the
cruropopliteal canal. On escaping
from the canal, the nerve loops
around the medial malleolus and
gives some branches to the ankle
joint.
Below the flexor retinaculum, the tibial nerve gives off its terminal branches
— the medial and the lateral plantar nerves.
1.muscular
supply all posterior muscles of shin (the
branches
igastrocnemius, the soleus, the plantaris,
the popliteus etc.)
2.medial sural
It runs laterally and merges with the lateral
cutaneous nerve sural cutaneous nerve (from the common
fibular nerve) to form the sural nerve
3.sural nerve
supplies skin of the posterolateral surface of
shin and the lateral aspect of foot up to the
little toe
4.medial plantar They supply the medial aspect of foot, the
nerve
toes 1 through 3 and a medial half of the
- common
fourth toe. The muscular branches of the
plantar digital
nerve supply the flexor digitorum brevis, all
nerves
muscles of great toe and two lumbricals
- proper plantar
(1 and 2).
digital nerves.
5.lateral plantar They supply the lateral aspect of foot, the
nerve
fifth toe and a lateral half of the fourth toe.
-superficial
The deep branch supplies all interossei, two
branch
lumbricals, the adductor hallucis, and the
-deep branch
lateral head of flexor hallucis brevis.
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Clinical applications
Injury to the tibial nerve
results in paralysis of
pertaining flexors. The
foot thus becomes
permanently extended
and the toes may
resemble the claws.
Topography
of the common fibular nerve
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From the arise point, the nerve runs
laterally to reach the head of fibula.
At that point, the nerve enters
between the heads of the fibularis
longus and slits into the superficial
and the deep fibular nerves.
Yet within the popliteal fossa, the
nerve gives the lateral sural
cutaneous nerve that merges with
the medial sural cutaneous nerve to
form the sural nerve. Very often,
the nerves merge at the lower third
of shin or even run separately.
Clinical applications
Injury to the fibular nerve leads to
inability to extend and to pronate
the foot. The foot in this case hangs
down and laterally.
The branches of the common fibular nerve
1.The
superficial
fibular
nerve
-medial
dorsal
cutaneous
nerve
-lateral
dorsal
cutaneous
nerve
Both nerves supply the
respective areas of the
dorsal surface of foot. It
also leaves some
muscular branches to
the fibulares muscles
while running within
the musculoperoneal
canal.
2.The deep Within the shin, the
fibular
nerve supplies the
nerve
anterior group of
muscles (the tibialis
anterior, the extensor
digitorum longus and
the extensor hallucis
longus) and the joint
capsule of ankle joint.
THE COCCYGEAL PLEXUS
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The coccygeal plexus is
composed of the anterior
branches of the fourth and
fifth sacral and the cocygeal
nerves. It gives rise to the
thin anococcygeal nerves
which join with the posterior
branch of the coccygeal
nerve and innervate the skin
at the top of the coccyx and
of the anus.
THE COMMON ILIAC ARTERY
The abdominal aorta diverges at sharp angle (60-70°) to give rise to the common iliac arteries. Each artery
descends laterally to reach the respective sacroiliac joint.
There, the arteries give rise to the external and internal iliac arteries.
THE INTERNAL
ILIAC ARTERY
Relations of the internal
iliac artery
• The internal iliac artery
arises from the
common iliac artery and
descends to the lesser
pelvis. The artery is the
principal nourishing
vessel for this region.
• The artery gives off
numerous branches,
both
• parietal and visceral.
The parietal
The visceral branches of the internal iliac artery:
1. the
1. the umbilical artery
iliolumbar
a)an opened part - the superior vesical arteries
artery
b)an obliterated part
2. the inferior vesical artery - In males, the artery gives branches to the seminal
glands and prostate; in females — to the vagina;
2. the lateral
3. the a. ductus deferentis (in male)
sacral
the uterine artery (in female)
arteries
- vaginal branch,
- ascending branch,
3. the
- ovarian branches,
obturator
- tubal branches;
artery:
4. the middle rectal artery. The middle rectal artery supplies the inferior part of
- acetabular
the rectum, anastomosing with the superior and inferior rectal arteries, supplying
branch,
the seminal glands and prostate (or the vagina);
- pubic
5.the internal pudendal artery
branch.
1) the inferior rectal artery, passes to the anus;
2) the artery of bulb of penis supplies the respective bulb of penis;
4. the superior
3) the dorsal artery of penis (clitoris) passes below skin (to the penis or
gluteal
clitoris respectively);
artery
4) the deep artery of penis (clitoris) take the same route as the latter
arteries yet deeper;
5. the inferior
5) the perineal artery supplies the perineal muscles and skin;
gluteal
6) the posterior labial branches and the posterior scrotal branches supply
artery
the spective external genitals.
THE EXTERNAL ILIAC ARTERY
The external iliac artery descends on the medial aspect of the psoas major and quits
the lesser pelvis via the vascular space. Within the femoral triangle, the artery
becomes continuous with the femoral artery. The external iliac artery gives the
branches as follows:
- the inferior epigastric artery arises from the main trunk above the inguinal
ligament and then ascends medially along the internal surface of the anterior
abdominal wall occupying the lateral umbilical ligament. Then the artery enters the
rectus sheath and ascends along its posterior surface to reach the umbilical ring.
Here it anastomoses with the superior hypogastric artery.
In the beginning, the artery gives off
- the pubic branch anastomoses with the same branch of the obturator artery;
-a. cremasterica (in male) or a. ligamentum teres uteri (in female);
- the deep circumflex iliac artery runs laterally along the inguinal ligament and the
iliac crest. It supplies the iliacus and the muscles of abdominal wall.
THE FEMORAL ARTERY, ARTERIA FEMORALIS
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The femoral artery arises directly
from the external iliac artery. The
arteries are delimited by the
inferior border of the inguinal
ligament.
On leaving the vascular space, the
artery appears within the femoral
triangle together with the femoral
nerve (found laterally) and the
femoral vein (found medially).
Pulsation of the artery is palpable
below the inguinal ligament in the
area related to the vascular space.
Within the femoral triangle, the
artery runs along the iliopectineal
groove and then along the femoral
groove. From the femoral groove,
the artery proceeds to the
adductor canal, which leads it to
the popliteal fossa. Here it
becomes continuous with the
popliteal artery.
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Clinical applications. The
deep artery of thigh is of
great importance for
collateral circulation.
Intrinsic anastomoses
and intersystem
anastomoses (with the
internal iliac and
popliteal arteries)
provide good conditions
for collateral circulation,
which is vital in
occlusions of femoral
artery.
The branches of the femoral artery:
1. The superficial epigastric artery arises
near the very beginning of the femoral
artery and passes in front of the inguinal
ligament under the skin to the region of
the navel.
2. The superficial circumflex artery runs
along the inguinal ligament to the skin in
the region of the superior anterior iliac
spine.
3. The external pudendal arteries usually
two in number, branch out in the region
of the hiatus saphenus and lead medially
to the skin of the external genital organs
and lower surface of the abdomen.
4. The descending artery of the knee
branches off from the femoral artery on
its way in the adductor canal and, exiting
through the anterior wall of this canal
with n. saphenus, supplies m. vastus
medialis with blood and participates in
the formation of the arterial network of
the knee joint.
5. The deep femoral artery is the main
vessel through which the thigh is
supplied with blood.
The branches of the deep femoral artery:
1) a. circumflexa femoris medialis passes
medially and upward and gives off the
branches to the m. pectineus, to the
adductor muscles, to the hip joint, to m.
iliopsoas, m. obturatorius externus, m.
piriformis, m. quadriceps femoris.
2) a. circumflexa femoris lateralis passes
laterally under m. rectus femoris and
gives off the branches to m.quadriceps,
m. sartorius and to the knee joint.
3) aa. perforantes (three in number) branch
off the posterior surface of the deep
femoral artery and supply posterior
muscles of the thigh.
Clinical applications. The deep artery of
thigh is of great importance for collateral
circulation. Intrinsic anastomoses and
intersystem anastomoses (with the
internal iliac and popliteal arteries)
provide good conditions for collateral
circulation, which is vital in occlusions of
femoral artery.
THE POPLITEAL ARTERY,
ARTERIA POPLITEA
The popliteal artery is a direct
continuation of the femoral artery.
It occupies the popliteal fossa
together with the vein of the
same name (it runs laterally and
posteriorly). Upon reaching the
leg region, the artery enters the
cruropopliteal canal and gives off
its two terminal branches
— the anterior and posterior
tibial arteries.
The popliteal artery gives off five
genicular arteries.
The popliteal artery gives off five genicular
arteries:
1. the superior (medial and lateral)
genicular arteries arise above the femoral
epicondyles. Each artery rounds the
respective epicondyle and passes to the
anterior surface of knee joint. Their
branches form the genicular anastomosis;
2. the middle genicular artery penetrates
the posterior wall of the joint capsule of
knee joint and terminates within the
cruciform ligaments;
3. the inferior (medial and lateral) genicular
arteries
arise
below
the
femoral
epicondyles. Each artery rounds the
respective epicondyle and passes to the
anterior surface of knee joint.
The genicular arteries supply the knee joint
and neighboring muscles. They form a wide
anastomosis around the knee joint — the
genicular anastomosis.
THE ANTERIOR TIBIAL ARTERY
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Relations of the anterior tibial artery
The anterior tibial artery arises from the
popliteal artery within the cruropopliteal canal.
It quits the canal via the anterior outlet (the
opening in the interosseous membrane) and
descends to the foot together with the deep
fibular nerve. Upon reaching the ankle joint, the
artery comes out from under the extensors
tendons. Then the artery proceeds to the dorsal
surface of foot to become continuous with the
dorsal artery of foot.
The branches of the anterior tibial artery:
the posterior tibial recurrent artery becomes
evident on the posterior surface of leg; it
ascends to join the genicular anastomosis;
the anterior tibial recurrent artery arises
opposite to the latter artery. It also joins the
genicular anastomosis;
the anterior (medial and lateral) malleolar
arteries descend to the respective ankles. They
participate in formation of the medial and
lateral malleolar networks.
muscular branches supply the anterior muscles
of the leg.
THE DORSAL ARTERY OF FOOT
Relations of the dorsal artery of foot
The dorsal artery of foot is a direct continuation
of the anterior tibial artery. It runs between the
tendons of the extensor hallucis longus and the
extensor digitorum longus.
The branches of the dorsal artery of foot:
1. the lateral and 2. medial tarsal arteries run to
the respective aspects of foot;
3. the arcuate artery arises at the bases of
metatarsals and runs laterally to anastomose
with the lateral tarsal artery.
The arch formed gives off the dorsal
metatarsal arteries (2 through 5), which split into
the dorsal digital arteries; the first dorsal
metatarsal artery arises directly from the dorsal
artery of foot. It gives off three dorsal digital
arteries to both aspects of the great toe and to
the medial aspect of the second toe;
4. the deep plantar artery is the 2nd terminal
branch of the dorsal artery of foot; there it
anastomoses with the lateral plantar artery to
form the deep plantar arch.
THE POSTERIOR TIBIAL ARTERY
Relations of the posterior tibial artery
The larger posterior tibial artery arises immediately
from the popliteal artery.
The artery occupies the cruropopliteal canal
together with the tibial nerve. Within the canal,
the artery runs along the deep muscles of leg
anterior to the soleus. The artery quits the canal
and passes medially from the calcaneal tendon
immediately below the skin and fascia. Here, one
can palpate pulsation of the artery.
The artery then rounds the medial malleolus,
passes under the flexor retinaculum and eventually
appears on the plantar surface of foot.
There it gives the lateral and medial plantar
arteries.
The branches of posterior tibial artery:
• muscular branches supply the posterior
muscles of the leg
• medial malleolar branches
• lateral malleolar branches
• calcaneal branch
• fibular artery
• perforating branch
THE PLANTAR ARTERIES
The posterior tibial artery gives rise to the lateral and
medial plantar arteries.
• The lateral plantar artery - it runs laterally to reach
the lateral plantar groove. On reaching the 5th
metatarsal bone, the artery declines medially and
anastomoses with the deep plantar artery to form the
deep plantar arch.
The arch gives off four plantar metatarsal arteries
which anastomose with the dorsal arteries by means of
the perforating branches. The plantar metatarsal
arteries become continuous with the common plantar
digital arteries which in turn split into the plantar
digital arteries proper. The latter arteries run along the
aspects of toes.
•The medial plantar artery is smaller than the lateral; it
runs along the medial plantar groove and reaches the
base of great toe to anastomose with the lateral plantar
artery. The plantar arch thus features anastomoses
related to both vertical and horizontal planes.
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Clinical applications The arteries of lower limb are often affected by atherosclerosis and obliterating
endarteritis, which feature pathological growth of connective tissue in the inner layer and lipid
infiltration of vascular wall. The pathologies result in occlusion of the vessel affected. Collateral
circulation may compensate slow progressing occlusion of the distal arteries yet occlusion of min trunks
results in severe ischemia and even gangrene. Gangrene requires amputation of the limb. Treatment of
the state nowadays includes various reconstructive and plastic surgeries.
THE VEINS OF LOWER LIMB
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The veins of the lower limb are
subdivided into the superficial and
deep. The double deep veins
accompany the arteries.
The superficial veins run below the
skin and outside the proper fascia. The
superficial veins give rise to the great
and small saphenous veins. They arise
from the dorsal and plantar venous
networks of foot.
The great saphenous vein, arises from
the medial portion of the dorsal venous
network of foot and ascend along the
medial aspect of the leg and thigh . In
the upper third of thigh, the vein runs
along its anterior surface to reach the
saphenous opening.
On passing the saphenous opening, the
vein joins the femoral vein. On the way
to destination point, the vein receives
numerous tributaries that anastomose
with each other and with the
tributaries of small saphenous vein and
deep veins of lower limb.
The small saphenous vein, arises
at the lateral aspect of foot. The
vein rounds the lateral malleolus
and ascends along the posterior
surface of leg in between the
heads of the gastrocnemius
muscle. At the popliteal fossa, the
muscle pierces the fascia and joins
the popliteal vein.
The small saphenous vein receives
numerous tributaries that
anastomose with the tributaries of
the great saphenous vein and with
the deep veins of thigh.
The deep veins accompany the
pertaining arteries
(two veins accompany one
artery):
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two anterior tibial veins,
two posterior tibial veins,
the anterior and
posterior tibial veins,
popliteal vein,
the femoral vein – resides
within the femoral triangle
medially from the femoral
artery. Upon passing through
the vascular space, it becomes
continuous with the external
iliac vein. The greatest tributary
of the femoral vein is the deep
vein of thigh, vena profunda
femoris.
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The deep veins anastomose
with each other and with the
superficial
veins.
Both
superficial and deep veins have
numerous valves.
Blood is continuously shunted from
the superficial veins in the subcutaneous
tissue to deep veins via the perforating
veins that penetrate the deep fascia.
Vein grafts obtained by surgically
harvesting parts of the great saphenous
vein are used to bypass obstructions in
blood vessels (e.g., an occlusion of a
coronary artery or its branches). When
part of the vein is used as a bypass, it is
reversed so that the valves do not
obstruct blood flow. Because there are
so many anastomosing leg veins,
removal of the great saphenous vein
rarely affects circulation seriously,
provided the deep veins are intact.
Muscular compression of deep veins
assists return of blood to the heart
against gravity.
Varicose veins form
when either the deep
fascia or the valves of
the perforating veins
are incompetent. This
allows the muscular
compression
that
normally
propels
blood toward the
heart to push blood
from the deep to
superficial
veins.
Consequently
superficial
veins
become enlarges and
tortuous.
THE END
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