PowerPoint

Presentation
 Sacral Plexus

Presented By:
Amitinder Singh Dhaliwal
BPT IV, Roll No. 3171
Department Of Physiotherapy
Punjabi University, Patiala
 Spinal nerves and plexus

There are 31 pairs of spinal nerves.

2. 8 cervical
3. 12 thoracic
4. 5 lumbar
5. 5 sacral
6. 1 coccygeal
Formation of a Spinal nerve and subsequent division
Ø A spinal nerve exits the spinal cord and divides into a
dorsal ramus and a ventral ramus.

Ø The dorsal ramus of C1 is located in the suboccipital

region and is known as the suboccipital nerve. The
ventral rami of T1-T11 travel between the ribs and are
known as intercostal nerves. The ventral ramus of T12
travels inferiorly to the 12th rib and is known as the
subcostal nerve.
Ø The dorsal rami of spinal nerves stay independent
from one another and innervate structures that are
located approximately at their segmental level. The
ventral rami of spinal nerves in thoracic region act
in same manner.

However, cervical, lumbar, sacral and

coccygeal ventral rami are different in that they
combine with other spinal ventral rami to form
plexus.
 What is a Plexus?
Ø A plexus means a structure in the form of a
network, especially of nerves, blood vessels or
the lymphatics.

Ø A nerve plexus can be defined as an area where

nerves branch and rejoin.

Ø It is a ‘nerve net’ in which the processes of

neurons join together to form a plexus.
 Number of Nerve Plexus in
Human Body?
There are 4 primary nerve plexus in the
human body, namely
2. Cervical plexus: C1-C5
3. Brachial plexus: C5-T1
4. Lumbar plexus: T12-L5
5. Sacral plexus: L4-S4
 What is SACRAL PLEXUS?

A nerve network originating from the nerves

of the sacral spine and innervating large
areas of the lower trunk and legs esp. via
the sciatic nerve.
Composition of Sacral Plexus
The sacral plexus is formed by:

Ø The lumbosacral trunk,

Ø The ventral rami of the first to third sacral

nerves,

Ø And some portion of the fourth sacral nerve.

Ø The lumbosacral trunk is formed by the descending
branch of the ventral ramus of nerve L4 and the whole
L5.

Ø It appears at the medial margin of the Psoas major.

ØThe trunk descends over the ala of the sacrum,

crosses the pelvic brim in front of the sacroiliac joint
and joins the nerve S1.
 Location and associated
anatomical structures
Ø The sacral plexus lies on the back of the pelvis between
the Piriformis and the pelvic fascia in front of it are the
hypogastric vessels, the ureter and the sigmoid colon.

Ø The superior gluteal vessels run between the

lumbosacral trunk and the first sacral nerve.

Ø The inferior gluteal vessels between the second and

third sacral nerves.
Main terminal branches of the
sacral plexus
The LUMBOSACRAL TRUNK, SCIATIC NERVE and
PUDENDAL NERVE
 The Nerves

Taking origin from the sacral plexus

1. Superior gluteal nerve- L4,L5, S1
2. Inferior gluteal nerve- L5, S1, S2
3. Nerve to Piriformis- S1, S2
4. Nerve to Obturator internus- L5, S1, S2
5. Nerve to Quadratus femoris- L4, L5, S1
6. Perforating cutaneous nerve- S2, S3
7. Posterior cutaneous nerve of thigh- S1,
S2, S3
8. Sciatic nerve- L4, L5, S1, S2, S3
– Tibial portion
– Common peroneal portion
9. Pudendal nerve- S1, S2, S3
- Inferior anal nerves
-Perineal nerve
-Dorsal nerve of penis/Dorsal nerve of
clitoris
 Superior gluteal nerve

ØIt originates in the pelvis and supplies the gluteus

medius, the gluteus minimus, and the tensor
fasciae latae muscles.

ØIt arises from the dorsal divisions of the fourth and

fifth lumbar and first sacral nerves.
Ø It leaves the pelvis through the greater
sciatic foramen above the Piriformis,
accompanied by the superior gluteal artery
and the superior gluteal vein.

Ø It then divides into a superior and an

inferior branch.
ØThe superior branch accompanies the upper branch
of the deep division of the superior gluteal artery and
ends in the gluteus minimus.

ØThe inferior branch runs with the lower branch of

the deep division of the superior gluteal artery across the
gluteus minimus; it gives filaments to the gluteus medius
and minimus, and ends in the tensor fasciae latae.

ØThe superior gluteal nerve and vessels travel above the

Piriformis muscle through the greater sciatic foramen;
the inferior gluteal nerve and vessels travel below the
muscle.
 Pathology
Ø Damage to the nerve can lead to the gait disturbance
known as Trendelenburg gait.

Ø Patients with a lesion of superior gluteal nerve have

weakness of abducting the thigh at the hip. This type of
gait may also be seen in L5 radiculopathy and after
poliomyelitis.
 Inferior gluteal nerve
Ø innervates the gluteus maximus muscle.

Ø It arises from the dorsal divisions of the fifth

lumbar and first and second sacral nerves

Ø It leaves the pelvis through the greater sciatic

foramen, below the Piriformis, and divides into
branches which enter the deep surface of the
gluteus maximus.
 Nerve to Piriformis
Ø Innervates the Piriformis muscle.

Ø It arises from the dorsal division of the second

sacral nerve, or the dorsal divisions of the first
and second sacral nerves, and enters the
anterior surface of the Piriformis muscle; this
nerve may be double.
 Nerve to Quadratus Femoris
Ø The nerve to quadratus femoris is a nerve that
provides innervations to the quadratus femoris and
gemellus inferior muscles.

Ø It arises from the ventral divisions of the fourth and

fifth lumbar and first sacral nerves.
Ø It leaves the pelvis through the greater sciatic foramen,
below the piriformis muscle, and runs down in front of
the sciatic nerve, the gemelli, and the tendon of the
obturator internus, and enters the anterior surfaces of
the muscles; it gives an articular branch to the hip-
joint.
Nerve to Obturator Internus
Ø The Nerve to the Obturator Internus and Gemellus
Superior
Ø arises from the ventral divisions of the fifth lumbar and
first and second sacral nerves.

Ø It leaves the pelvis through the greater sciatic foramen

below the Piriformis, and gives off the branch to the
Gemellus superior, which enters the upper part of the
posterior surface of the muscle.

Ø It then crosses the ischial spine, re-enters the pelvis

through the lesser sciatic foramen, and pierces the pelvic
surface of the Obturator internus.
 The
nerves on
the back
of thigh
and leg
 Posterior cutaneous nerve
Ø It arises partly from the dorsal divisions of the first and second,
and from the ventral divisions of the second and third sacral
nerves.
Ø It issues from the pelvis through the greater sciatic foramen
below the Piriformis. It then descends beneath the Gluteus
maximus, and runs down the back of the thigh beneath the
fascia lata, and over the long head of the Biceps femoris to the
back of the knee; here it pierces the deep fascia and
accompanies the small saphenous vein to about the middle of
the back of the leg, its terminal twigs communicating with the
sural nerve.
Ø Its branches are all cutaneous, and are distributed to the gluteal
region, the perineum, and the back of the thigh and leg.
 Perforating Cutaneous Nerve
Ø The perforating cutaneous nerve arises from the 2nd
and 3rd sacral nerves.
Ø It is an inferior clunial (buttocks) nerve; it supplies the
skin covering the medial and lower parts of gluteus
maximus.

Ø The perforating cutaneous nerve may arise from the

pudendal nerve.
Ø It is absent in approximately one third of people; its
place may be taken by a branch from the posterior
cutaneous nerve of thigh or by a branch from the third
and fourth, or fourth and fifth, sacral nerves.
 Sciatic Nerve
Ø The Sciatic supplies nearly the whole of the skin of
the leg, the muscles of the back of the thigh, and those
of the leg and foot.
Ø It is the largest nerve in the body, measuring 2 cm. in
breadth, and is the continuation of the flattened band
of the sacral plexus.
Ø It passes out of the pelvis through the greater sciatic
foramen, below the Piriformis muscle. It descends
between the greater trochanter of the femur and the
tuberosity of the ischium, and along the back of the
thigh to about its lower third, where it divides into two
large branches, the tibial and common peroneal
nerves.
Ø In the upper part of its course the nerve rests upon the
posterior surface of the ischium, the nerve to the
Quadratus femoris, the Obturator internus and Gemelli,
and the Quadratus femoris; it is accompanied by the
posterior femoral cutaneous nerve and the inferior
gluteal artery, and is covered by the Gluteus maximus.

ØLower down, it lies upon the Adductor magnus, and is

crossed obliquely by the long head of the Biceps femoris.
ØThe nerve gives off articular and muscular branches.

Ø The articular branches arise from the upper part

of the nerve and supply the hip-joint, perforating the
posterior part of its capsule; they are sometimes derived
from the sacral plexus.

Ø The muscular branches are distributed to the

Biceps femoris, Semitendinosus, Semimembranosus,
and Adductor Magnus.

ØThe nerve to the short head of the Biceps femoris

comes from the common peroneal part of the sciatic,
while the other muscular branches arise from the tibial
portion.
Division of the sciatic nerve
 Pathology
Ø Sacral nerve is occasionally injured by
wounds, fractures or intramuscular
injection of drugs.

Ø The component nerves may be involved by

fracture, tumour or aneurysm.
 ØThe Tibial Nerve the larger of the two terminal
branches of the sciatic.

Øarises from the anterior branches of the fourth and

fifth lumbar and first, second, and third sacral nerves.

ØIt descends along the back of the thigh and through

the middle of the popliteal fossa, to the lower part of
the Popliteus muscle, where it passes with the
popliteal artery beneath the arch of the Soleus.

ØIt then runs along the back of the leg to the interval
between the medial malleolus and the heel, where it
divides beneath the laciniate ligament into the medial
and lateral plantar nerves.
 The
Plantar
Nerves
 The
nerves on
the front
of leg
 ØThe common peroneal nerve (common fibular
nerve; external popliteal nerve; peroneal nerve),
about one-half the size of the tibial nerve, is derived from
the dorsal branches of the fourth and fifth lumbar and
the first and second sacral nerves.

ØIt descends obliquely along the lateral side of the

popliteal fossa to the head of the fibula, close to the
medial margin of the Biceps femoris muscle.
ØIt gives off articular and lateral sural
cutaneous nerves.

ØThe articular branches are three in number:

•Two of these accompany the superior and
inferior lateral genicular arteries to the knee.
•The third articular nerve ascends with the
anterior recurrent tibial artery through the
Tibialis anterior to the front of the knee.

ØThe lateral sural cutaneous nerve supplies

the skin on the posterior and lateral surfaces of
the leg.
 The
Nerves of
the
dorsum of
foot
 Trauma to the nerve can result in a condition called foot drop,
where dorsiflexion of the foot is compromised and the foot drags
during walking, and sensory loss to the dorsal surface of the foot
and portions of the anterior, lower-lateral leg.
 Pudendal Nerve

ØIt originates from the ventral rami of the 2nd, 3rd

and 4th sacral nerves.

ØThe pudendal nerve innervates the penis and

clitoris, bulbospongiosus and ischiocavernosus
muscles, and areas around the scrotum, perineum,
and anus.
Pudendal Nerve and its branches
 Pathology
ØDifficult childbirth or bicycling can compress or
stretch the pudendal nerve, causing temporary
loss of function, but permanent injury is rare.

ØEntrapment of the nerve is very rare but can

happen.

ØA pelvic tumour (most notably a large

sacrococcygeal teratoma), or surgery to remove
the tumour, can damage this nerve permanently.
SENSORY SUPPLY
 Sensory Supply by the respective
nerve roots
Ø L4- medial aspect of the leg
Ø L5- dorsum of the foot and lateral aspect
of the leg.
Ø S1- sole and the posterior half of the lower
part of the leg.
Ø S2- posterior part of the thigh and the
upper part of the leg.

*Reference: Forester
 THE FOLLOWING
DIAGRAMS SHOW
CUTANEOUS NERVE
SUPPLY

BY THE NERVES OF THE SACRAL

PLEXUS
Anterior view
Posterior view
The
plantar
aspect of
foot
Thank You All!

Amitinder Singh Dhaliwal, BPT-IV, Punjabi University Patiala