Lower extremity neuroanatomy
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Wyndam M. Strodtbeck, MD Section Head, Acute Pain Dept of Anesthesiology and Pain Medicine Virginia Mason Medical Center [email protected] Lower extremity neuroanatomy. Disclosures. No financial disclosures No off-label use of medications or devices will be discussed

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Lower extremity neuroanatomy

Wyndam M. Strodtbeck, MD

Section Head, Acute Pain

Dept of Anesthesiology and Pain Medicine

Virginia Mason Medical Center

[email protected]

Lower extremity neuroanatomy


Disclosures
Disclosures

  • No financial disclosures

  • No off-label use of medications or devices will be discussed

  • Patient permission was explicitly granted for any pictures used


Objectives for our talk
Objectives for our talk

  • Describe the clinical anatomy of the innervation of the lower extremity

  • Identify surrounding structures and their implications for sonoanatomy and potential variation


Lumbosacral plexus
Lumbosacral plexus

L1-L4 form the lumbar plexus

Branches from L4 –S2 from the lateral trunk

Other branches from L3-S3 make up the medial trunk

S1-S5 make up the sacral plexus

Early branching of the lumbar plexus and thick musculature makes identifying a single compartment for lumbosacral blockade difficult


Early branches of the lumbar plexus
Early Branches of the Lumbar Plexus

  • Ilioinguinal and iliohypogastric nerves

    • From L1

    • Iliohypogastric supplies anterior and lateral cutaneous innervation in hypogastric and gluteal region

    • Ilioinguinal supplies cutaneous innervation of genital region

  • Genitofemoral nerve

    • From L1 and L2

    • Genital division supplies cremasteric muscle and sensory over genital region

    • Femoral branch supplies cutaneous innervation over femoral triangle


  • Early branches of the lumbar plexus1
    Early Branches of the Lumbar Plexus

    Gray, H. Anatomy of the human body, 1918.


    Femoral nerve
    Femoral Nerve

    Origin is dorsal divisions of L2-L4

    Divides into anterior and posterior division typically at level of profunda femoris artery

    Nader, Relationship Between Ultrasound Imaging and Eliciting Motor Response, J Ultrasound Med, 28(3):345-350, 2009


    Femoral nerve1
    Femoral Nerve

    Origin L2-L4

    Anterior division

    -Medial and intermediate cutaneous nerves

    -Muscular branches to sartorious

    -Articular branch to hip joint

    Posterior Division

    -Muscular branches to quads

    -Articular branches to knee joint

    -Saphenous nerve is terminal cutaneous branch and provides lower leg anteromedial sensation

    Nader, Relationship Between Ultrasound Imaging and Eliciting Motor Response, J Ultrasound Med, 28(3):345-350, 2009


    Femoral nerve2
    Femoral Nerve

    Nader, Relationship Between Ultrasound Imaging and Eliciting Motor Response, J Ultrasound Med, 28(3):345-350, 2009


    Femoral nerve3
    Femoral Nerve

    Ultrasound image shows anterior and posterior divisions

    Keep in mind the variations in location and appearance of the nerve

    Groups of authors have reported variable splits in the femoral nerve in 2.2-35% of subjects.

    Nader, Relationship Between Ultrasound Imaging and Eliciting Motor Response, J Ultrasound Med, 28(3):345-350, 2009


    Lateral femoral cutaneous nerve
    Lateral femoral cutaneous nerve

    Originates from dorsal divisions of L2 and L3

    May have a variable course as it emerges from psoas

    Passes under inguinal ligament and superficial to the sartorious muscle

    Located between fascia lata and fascia iliaca

    Responsible for pain transmission in meralgia paresthetica

    Hurdle, MF et al. Ultrasound-guided blockade of the lateral femoral cutaneous nerve. Arch Phys Med Rehab 88:1362-1364, 2007.


    Saphenous nerve
    Saphenous Nerve

    Terminal branch of posterior division of femoral nerve

    Provides cutaneous sensation around patella, anteromedial lower leg, and medial ankle

    Travels in adductor canal with femoral artery and vein

    In distal thigh, the saphenous nerve can be identified deep to the sartorious and between the vastus medialis and the adductor magnus


    Saphenous nerve1
    Saphenous Nerve

    Image courtesy of FV Salinas, MD



    Obturator nerve
    Obturator nerve

    Originates from ventral branches of L2-L4

    Supplies articular branches to hip and knee

    Adductors are supplied

    Similar to femoral nerve in having anterior and posterior divisions


    Obturator nerve1
    Obturator nerve

    Anterior division

    Motor innervation to pectineus (may be an accessory obturator nerve) , adductor longus and brevis, gracilis

    Articular branch of the hip

    Posterior division

    Motor inneravtion to adductor magnus and brevis as well as obturator externus

    Articular branches to hip and knee


    Nerves of the sacral plexus
    Nerves of theSacral Plexus

    Gray, H. Anatomy of the human body, 1918.


    Posterior femoral cutaneous nerve
    Posterior femoralcutaneous nerve

    Provides sensation for posterior thigh and leg, gluteal region, and perineum

    Originates from S1-S3


    Posterior femoral cutaneous nerve1
    Posterior femoralcutaneous nerve

    Gray, H. Anatomy of the human body, 1918.


    Sciatic nerve
    Sciatic Nerve

    Largest nerve in the body

    Joining of L4-S3

    Two parts:

    -Tibial (medial)

    (L4-S2)

    - Common Peroneal

    (L4-S3)

    Provides sensation for posterior leg and foot (except for saphenous distribution) as well as motor for posterior thigh, and all of leg and foot, and articular branches for hip and knee

    Wikipedia, Feb 10, 2012


    Sciatic nerve1
    Sciatic Nerve

    At gluteal level, Sciatic is deep to gluteus maximus and passes out below piriformis muscle, located lateral to ischial spine

    This level is useful due to the close proximity of the posterior femoral cutaneous nerve to the sciatic nerve


    Sciatic nerve2
    Sciatic Nerve

    At subgluteal level, the sciatic nerve is positioned between the gluteus maximus and the quadratus femoris


    Sciatic nerve3
    Sciatic Nerve

    Subgluteal ultrasound

    Image courtesy of FV Salinas, MD


    Sciatic nerve4
    Sciatic Nerve

    -Shared epineural sheath for tibial and common peroneal nerves separates above popliteal crease

    -Schwemmer et al (2005) demonstrated high variability for division of sciatic nerve above popliteal crease (1-15 cm with mean of 8 cm)

    Schwemmer et al. Sonographic imaging of the sciatic nerve division in the popliteal fossa. Ultraschall in Der Medizin, 2005.

    Wikipedia, Feb 10, 2012


    Nerves of the ankle and foot
    Nerves of the ankle and foot

    Primarily consists of terminal branches from the sciatic

    Exception is the saphenous branch of the femoral nerve

    NYSORA.com, accessed 2-10-2012

    Gray, H. Anatomy of the human body, 1918.


    Special thanks
    Special Thanks

    • Francis V. Salinas, MD


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