Lumbar and Sacral Plexus with Clinical Cases
by Annie Burke-Doe, PT, MPT, PhD
Practicing physical therapist and associate professor at the University of St. Augustine
for Health Sciences in San Diego, California
Slide 1: Lumbar and Sacral Plexus with Clinical Cases
Welcome to Neuroanatomy in Physical Therapy. I am Dr. Annie Burke-Doe, a practicing
physical therapist and an associate professor at the University of St. Augustine
for Health Sciences in San Diego, California.
This lecture series has been developed for physical therapists embarking on the
study of neurology. In this lecture we will focus on the lumbar and sacral plexus,
which provides nervous innervation to the lower limb.
Slide 2: Lumbar Plexus
The lumbar plexus is a nervous plexus in the lumbar region of the body, which forms
part of the lumbosacral plexus. As with the brachial plexus, the spinal nerves contributing
to the lumbar plexus have both anterior and posterior divisions (anterior on this
slide is shaded yellow and posterior is shaded blue). The lumbar portion of the
plexus is formed by the ventral divisions of the first four lumbar nerves (L1 through
L4) and from contributions of the last thoracic nerve (T12). Additionally, the ventral
rami of the fourth lumbar nerve passes communicating branches to the sacral plexus.
The nerves of the lumbar plexus pass in front of the hip joint and mainly support
the anterior portion of the thigh. So, when you think about this ventral aspect,
you should think about it supporting the anterior portion of the thigh.
The plexus is formed lateral to the intervertebral foramina (which are not pictured
here) and pass through psoas major. Its smaller motor branches are distributed directly
to the psoas major, while larger branches leave the muscle at various sites to run
obliquely downward through the pelvic area and leave the pelvis under the inguinal
ligament, with the exception of the obturator nerve, which exits the pelvis through
the obturator foramen.
Slide 3: Femoral and Obturator Nerves
It is most clinically important to be familiar with the functions of the femoral,
obturator, sciatic, tibial, and peroneal nerves in the lower extremity. Let’s start
with the motor functions of the femoral and obturator nerves (pictured here).
I would like you to begin by tracing the largest and longest nerve in the plexus,
the femoral nerve, with your finger. That way you can follow its pathway. You can
see that it gives motor innervation to iliopsoas (which refers to both the psoas
and iliacus at their inferior ends), pectineus, sartorius, and the quadriceps muscle
group. Motor functions of the femoral nerve include hip flexion at L2-3 (lift my
knee) and knee extension at L3-4 (kick the door).
Next, trace the obturator nerve with your finger as it leaves the lumbar plexus
and descends behind the psoas major on its medial side, then travels into the lesser
pelvis, and finally leaves the pelvic area through the obturator canal. In the thigh,
it sends motor branches to obturator externus before dividing into an anterior and
posterior branch, both of which will continue distally. These branches are separated
by adductor brevis and supply all the thigh adductors with motor innervation, including
pectineus, adductor longus, adductor brevis, adductor magnus, adductor minimus,
and gracilis.
Slide 4: Femoral and Obturator Nerves
Here on the right we can see the sensory distribution of the femoral nerve, which
provides sensory innervation to the anterior thigh, posterior lower leg, and hindfoot.
In the thigh, it divides into numerous sensory and motor branches and the saphenous
nerve, which is its long, sensory, terminal branch that continues down to the foot.
The obturator nerve (pictured in darker blue) has an anterior branch that supplies
the skin on the medial, distal part of the thigh.
When testing sensation clinically, it is also important to link the dermatomes (which
are pictured on the left) to provide the clinician information related to the spinal
level involved.
Slide 5: The Sacral Plexus
The sacral plexus (pictured here) arises from L4 through S3 and S4 at the lumbosacral
enlargement. Some authors do not differentiate between the lumbar and the sacral
plexus and describe them together. The sacral plexus provides motor and sensory
nerves for the posterior thigh, most of the lower leg, the entire foot, as well
as part of the pelvis. The most clinically important branches arising from the plexus
are the sciatic, tibial, and peroneal nerves. Branches from the posterior division
are in blue, and branches from the anterior division are in yellow.
Trace your finger beginning at L4-5 to see that the posterior division leads to
the superior gluteal nerve, which innervates the gluteus medius, minimus, and tensor
fasciae latae, whose actions are abducting and medial rotation of your thigh. As
you continue to travel down with your finger, you will find the inferior gluteal
nerve, which innervates the gluteus maximus, and whose actions are to extend and
laterally rotate the thigh, as well as to extend the lower trunk. You will now descend
down to the sciatic and common peroneal nerve. Now follow the anterior division
of the tibial nerve that innervates the lower extremity, which will be discussed
further as we go forward.
Slide 6: The Sciatic Nerve
Here on slide 6, we are looking at the sciatic nerve. The sciatic nerve is the largest
peripheral nerve in the body. It is comprised of the tibial and common peroneal
nerve and exits the pelvis inferior to the piriformis muscle, between the ischial
tuberosity and the greater trochanter of the femur. Motor functions include thigh
adduction, medial rotation, and hip extension, as well as knee flexion.
Clinically, in sciatic neuropathy, there is weakness of all foot and ankle muscles,
of knee flexion, loss of Achilles tendon reflexes, and sensory loss in the foot
and lateral leg below the knee. The term “sciatica” is a vague term and refers to
all disorders causing painful paresthesias in a sciatic distribution.
Slide 7: The Tibial Nerve
The tibial nerve (pictured here) is the larger, medial and terminal branch of the
sciatic nerve. Trace the tibial nerve with your finger as it continues the line
of the sciatic nerve through the popliteal fossa and into the leg. In the popliteal
fossa, the nerve gives off branches to gastrocnemius, popliteus, plantaris, and
soleus muscles. The tibial nerve also provides an articular branch to the knee joint
and a cutaneous branch that will become the sural nerve. The sural nerve will supply
the lateral side of the foot.
Below the soleus muscle, the nerve lies close to the tibia and supplies tibialis
posterior, the flexor digitorum longus, and flexor hallucis longus. The nerve passes
into the foot running posterior to the medial malleolus. Here it is bound down by
the flexor retinaculum in company with the posterior tibial artery.
In the foot, the nerve divides into medial and lateral plantar branches. Motor functions
of the tibial nerve include foot plantar flexion and inversion and toe flexion.
Slide 8: The Tibial Nerve
In the foot, the tibial nerve divides into medial and lateral plantar branches.
Cutaneous distribution of the medial plantar nerve is to the medial sole and the
medial three-and-a-half toes, including the nail beds on the dorsum, like the median
nerve in the hand.
The lateral plantar nerve cutaneous innervation is to the lateral sole and lateral
one-and-a-half toes, like the ulnar nerve.
Slide 9: The Common Peroneal Nerve
Now, let’s trace the common peroneal nerve in its pathway as it descends obliquely
along the lateral side of the popliteal fossa to the head of the fibula. Where the
nerve winds around the head of the fibula, it is palpable.
The common peroneal nerve divides into the superficial peroneal nerve and the deep
peroneal nerve.
The superficial peroneal nerve supplies the muscles of the lateral compartment of
the leg, including peroneus longus and peroneus brevis. These two muscles help in
eversion and plantar flexion of the foot. The deep peroneal nerve innervates the
muscles of the anterior compartment of the leg, which are tibialis anterior, extensor
hallucis longus, extensor digitorum longus, and peroneus tertius. Together these
muscles are responsible for dorsiflexion of the foot and extension of the toes.
Clinically, peroneal nerve palsy can cause drop foot with weakness of foot dorsiflexion
and eversion and sensory loss over the dorsolateral foot and shin. An ankle foot
orthotic may improve function if the foot drop is significant.
Slide 10: The Common Peroneal Nerve with Superficial and Deep Peroneal Sensory Distribution
Depicted here on slide 10, the common peroneal nerve supplies sensation to the lateral
and anterior surfaces of the upper part of the leg. The superficial peroneal nerve
supplies sensation to the distal third of the leg and the dorsum of the foot, while
the deep peroneal nerve supplies contiguous sides of the first and second toes.
Slide 11: Regions of Sensory Innervation Supplied by Cutaneous Nerve Branches
Here on slide 11, we see regions of sensory innervation supplied by the lateral
cutaneous nerve of the thigh and the obturator nerve (both depicted in gray).
Slide 12: Case 1: Lower Extremity Weakness
The following interactive cases are designed for you to read and answer the questions
in preparation for your coursework in neurology, as well as for your licensure preparation.
Please proceed through each of the cases and determine the answers to the questions.
Slide 13: Case 1: Jane Has Lower Extremity Weakness
A 68-year-old female was admitted to the hospital due to an acute chest pain. She
underwent cardiac catheterization and angioplasty through the right femoral artery.
She was referred to physical therapy one month later for evaluation of her right
lower extremity weakness and numbness in her thigh. She described her pain as moderate
in her groin and anterior thigh.
Slide 14: Case 1: Jane’s History
Her Medical History:
- One month ago, the patient underwent femoral catheterization and angioplasty with
resulting lower extremity weakness, sensory changes, and groin pain.
- On the third day after her admission, a neurologic examination and a CT scan of
her pelvis identified a right retroperitoneal hematoma involving the iliacus muscle
extending to the iliac crest with surgical evacuation.
Social History:
- She is employed as an administrative assistant.
- She is divorced; has one daughter and two grandchildren.
- She enjoys entertaining and spending time with her grandchildren.
Medication:
- Her medications include Lovenox, Lipitor, and Metoprolol.
Family History:
- Her family history includes hypertension, cardiac disease, and diabetes.
Please stop and review the following:
- What are the key findings from the history?
- What is the anatomy and innervation of the iliacus?
- Look up the medications involved and what they do in the body.
- Describe why social history is important to the physical therapist.
Slide 15: Case 1: Jane’s Neurologist Report
Jane’s neurologic examination during her acute stay revealed complete paralysis
of the right quadriceps and iliopsoas. Thigh adductors and ankle dorsiflexion were
normal. The right knee jerk was absent. There was loss of touch and pain sensation
over the anterior thigh and medial leg.
Please review the following before proceeding:
- What nerves innervate the quadriceps and iliopsoas?
- What nerves innervate the thigh adductors and ankle dorsiflexors?
- What spinal cord level is responsible for the knee jerk?
- What spinal cord levels provide sensation to the anterior thigh and medial leg?
Slide 16: Case 1: Jane’s PT Examination
Jane presents for her physical therapy examination with the following findings:
Vital Signs:
- Her blood pressure was 140/90.
- Heart rate, 80 beats per minute.
- Her skin was dry and had scales bilaterally on the lower extremities.
- Her endurance, she demonstrated shortness of breath with activity.
- Passive range of motion was within normal limits.
- Her mental status, she was alert and oriented and provided good history.
- Her cranial nerves were intact.
- Her tone was normal.
- Strength in the bilateral upper extremities was within normal limits.
- The right lower extremity, quadriceps, and iliopsoas were 3-/5.
- Right adductors and dorsiflexors were 5/5.
- Her reflexes, she was hyperreflexive at the right knee jerk.
- Coordination of the right lower extremity was impaired.
Slide 17: Case 1: Examination, Continued
Further physical therapy examination found:
- Balance, sitting statically and dynamically within normal limits.
- Good standing static balance and fair standing dynamic balance.
- Jane ambulates with some loss of balance noted with self-recovery at community level
distances on even surfaces.
- Sensation was diminished, touch and pain, over the anterior thigh and medial leg.
Slide 18: Case 1: Jane's Goals
Jane’s goals were to return to independent ambulation on all surfaces and return
to recreational activities including taking care of her grandchildren.
Slide 19: Case 1: Questions
Please answer the following question.
Which of the following nerves are responsible for this patient’s weakness in the
quadriceps musculature?
- Sciatic
- Obturator
- Femoral
- Tibial
Slide 20: Case 1: Questions
Which of the following key signs in the right lower extremity indicate femoral neuropathy
versus L4 radiculopathy?
- Sparing of the right foot dorsiflexion
- Sparing of right thigh adduction
- Sparing of right foot plantar flexion
- Sparing of right knee flexion
Slide 21: Case 1: Questions
Which nerve is responsible for the following pattern of weakness and sensory impairment?
- 0/5 left tibialis anterior and extensor hallucis longus, 3/5 left foot evertors
- Decreased pinprick sensation on the dorsum of the right foot especially pronounced
in the web space between the second toes
When looking at this pattern of weakness and sensory impairment, is it:
- Common peroneal nerve
- Obturator nerve
- Femoral nerve
- Tibial nerve
Slide 22: Case 1: Questions
Which nerve is responsible for the following pattern of weakness and sensory impairment?
- Diminished tone and S1 DTR, the right foot
- 0/5 right tibialis anterior and extensor hallucis longus, right foot evertors, invertors
and gastrocnemius, 3/5 power right hamstrings
- Decreased light touch, pinprick, vibration, and joint proprioception in the right
lateral calf and entire foot
Is it:
- Tibial nerve
- Obturator nerve
- Femoral nerve
- Sciatic nerve
Slide 23: Case 2: Sally Has Numbness and Pain with Pregnancy
Slide 24: Case 2: Sally’s Case Presentation
Sally is a 25-year-old female, who, one day after giving birth, developed a burning
pain and numbness in her left lateral thigh, which increased when ambulating.
She was referred to physical therapy for evaluation of her left lower extremity
pain and numbness in her thigh.
Slide 25: Case 2: Sally’s History
Sally’s medical history includes that she is a healthy 25-year-old female, who,
one day after giving birth, developed a burning pain and numbness in her left lateral
thigh, which increased when ambulating.
Her social history includes the fact that she’s married, and she plans to stay at
home and care for her newborn.
The only medication she is currently taking is ibuprofen, and she has a family history
of diabetes.
Please stop and review the following:
- What are the key findings from the history?
- Please look up the medications involved and what they do in the body.
- What types of activities do you think will be required to care for a newborn?
Slide 26: Case 2: Sally’s PT Examination
Sally’s physical therapy examination findings are as follows:
Her vitals:
- Blood pressure 115/75.
- Heart rate, 65 beats per minute.
- Her skin was unremarkable.
- No endurance or fatigue was noted during the evaluation.
- Range of motion was within normal limits.
- She is alert and oriented with intact cranial nerves, normal muscle tone.
- Her strength, reflexes, and coordination were all within normal limits.
Slide 27: Case 2: Examination, Continued
Additional examination findings include normal balance, gait, but diminished sensation
to light touch and pinprick, and cold on the right lateral thigh. Pain was initially
described as burning, rated 3/10 at rest and 6/10 with ambulation.
Slide 28: Case 2: Patient Goals
Sally’s physical therapy goal is to have her leg feel normal and have no pain in
her right thigh in order to care for her child.
Slide 29: Case 2: Questions
Please answer the following question:
Which of the following nerve roots should be considered in the differential diagnosis
as a source of the patient’s key signs and symptoms?
- L1 myotome
- L2 myotome
- L3 myotome
- L4 myotome
- Both B and C myotomes
Slide 30: References
- Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science. 4th ed.
New York: McGraw-Hill; 2000.
- Schuenke M, Schulte E, Shumaker U. Thieme Atlas of Anatomy. New York, NY:
Thieme; 2006: 470-471.
- Seigal A, Sapru HN. Essential Neuroscience. New York: Lippincott Williams
& Wilkins; 2006.
- Blumenfeld, H. Neuroanatomy through Clinical Cases. Sunderland, MA: Sinauer
Associates; 2002.
- Goodman C, Fuller K, et al. Pathology Implications for the Physical Therapist.
3rd ed. St. Louis, MO: Saunders; 2008.
- Hoppenfeld S. Physical Examination of the Spine and Extremities. New Jersey:
Prentice-Hall; 1976.
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