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V17N4 Anloague

V17N4 Anloague

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Published by rapannika
Descriptive anatomy study on anatomical variation of the lumbar plexus with possible clinical implications
Descriptive anatomy study on anatomical variation of the lumbar plexus with possible clinical implications

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Published by: rapannika on Dec 15, 2009
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01/13/2013

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 The Journal of Manual & ManipulaTive Therapy
n
voluMe 17
n
nuMber 4 [e
107]
1
Program Director, Doctor o Physical Terapy Program, University o Dayton
2
Assistant Proessor, Online Education, University o St. Augustine or Health SciencesAddress all correspondence and request or reprints to: Philip A. Anloague, anloague@udayton.edu
E
 vidence-based practice emphasizesthe examination and application o evidence rom clinical research intodiagnosis, prognosis, and outcomesbased on a ormal set o rules
1
. Onemethod o evaluating evidence is to as-sign levels o evidence
2
. In this evidencehierarchy, extrapolations rom basic sci-ence research are classied as the lowestlevel o evidence. However, especially insituations where higher-level researchevidence is insucient, such extrapola-tion based on a thorough knowledge o relevant anatomy oen still serves toguide clinical reasoning. Tis impor-tance o anatomy remains recognizedwithin physical therapy education in theUnited States, both as part o programentrance requirements
3
and as a part o the required basic sciences content inentry-level curricular content
4
. In thosecircumstances where clinical diagnosis issolely based on anatomical extrapola-tion, knowledge o anatomical deviationswith a potential impact on interpretationo test results becomes even moreimportant.Te lumbar plexus originates romthe ventral rami o the L1–L4 nerve rootsand projects laterally and caudally romthe intervertebral oramina, posterior tothe psoas major muscle. A
 
communicat-ing branch rom the 12, also known asthe subcostal nerve, oen joins the rstlumbar nerve
5-10
. Te L2–L4 ventral ramirst biurcate into an anterior and poste-rior primary division. Te 12 and L1nerves and the L2–L4 anterior primary divisions supply muscular branches tothe psoas major and quadratus lumbo-rum. Both primary divisions then enterthe lumbar plexus and give rise to six pe-ripheral nerves. Within this plexus, theL1 nerve splits into a cranial and caudalbranch. Te cranial branch biurcatesinto the iliohypogastric and ilioinguinalnerves, the ormer also ormed by thesubcostal nerve in people where thisnerve contributes to the lumbar plexus.Te caudal branch o the L1 nerve uniteswith the anterior division o the L2 nerveto orm the genitoemoral nerve. Te an-terior divisions o the L2–L4 roots ormthe obturator nerve. Te lateral emoralcutaneous nerve arises rom the posteriordivisions o the L2 and L3 roots; the pos-terior divisions o L2, L3, and L4 join tocreate the emoral nerve (Figure 1). able1 presents a summary o the normal pre-sentation o nerves o the lumbar plexusbased upon a review o several authorita-tive anatomical texts commonly used inphysical therapy education
 5-10
.Te purpose o this study was to de-scribe the anatomical variations in thelumbar plexus rom the origin at the ven-tral roots o (12) L1–L4 to the exit romthe pelvic cavity based on our descriptiveanatomy study o human cadavers ascompared to the above description o normal anatomy 
5-10
. Comparing our nd-ings to anatomical variation describedelsewhere in the literature, we will alsosuggest possible clinical implications
ABSTRACT:
 
Tis study used dissection o 34 lumbar plexes to look at the prevalence o anatomical variations in the lumbar plexus and the six peripheral branches rom the originat the ventral roots o (12) L1-L4 to the exit rom the pelvic cavity. Prevalence o anatomi-cal variation in the individual nerves ranged rom 8.8–47.1% with a mean prevalence o 20.1%. Anatomical variations included absence o the iliohypogastric nerve, an early split o the genitoemoral nerve into genital and emoral branches, an aberrant segmental origin orthe lateral emoral cutaneous nerve, biurcation o the lateral emoral nerve prior to exitingthe pelvic cavity, biurcation o the emoral nerve into two to three slips separated by psoasmajor muscle bers, the presence o a single anterior emoral cutaneous nerve rather thanthe normal presentation o two separate anterior emoral cutaneous branches, and the pres-ence o an accessory obturator nerve. Comparison with relevant research literature showeda wide variation in reported prevalence o the anatomical variations noted in this study.Clinical implications and directions or uture research are proposed.
KEYWORDS:
 
Anatomical Variation, Clinical Implications, Lumbar Plexus
Aaical Vaiais   La Pls:A Dscipiv Aa Sdi Ppsd Cliical Iplicais
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e108
 The Journal of Manual & ManipulaTive Therapy
n
voluMe 17
n
nuMber 4
AnAtomICAL VArIAtIonS of the LumbAr PLexuS: A DeSCrIPtIVe AnAtomy StuDy wIth ProPoSeD CLInICAL ImPLICAtIonS
tAbLe 1.
lm xs: nm tm.
Nerve Origin(Ventral Rami) Course and Function
Iliohypogastric L1 Emerges rom the superior aspect o the lateral margin o the psoas major
6
; enters the abdomenposterior to the medial arcuate ligaments and courses ineriolaterally along the anterior suraceo the quadratus lumborum
5-10
,
 
then pierces and innervates the posterior bers o the transverseabdominis near the iliac crest and traverses through the internal and external oblique abdominismuscles to which it supplies motor branches. Supercial innervation is supplied to the skin o the gluteal region posterior to the lateral cutaneous branch o 12 via a lateral cutaneous branch.Te anterior cutaneous branch o the iliohypogastric nerve innervates the skin o the hypogastricregion
5-10
.Ilioinguinal L1 Runs caudal to the iliohypogastric nerve; pierces and innervates the transverse abdominis nearthe anterior part o the iliac crest, communicates with the iliohypogastric, then supplies motorbranches to the internal oblique abdominis. Follows the spermatic cord through the supercialinguinal ring and terminates supercially over the proximal and medial aspect o the thigh, theroot o the penis and the scrotum, or mons pubis and labia majora
5-10
.Lateral Femoral Posterior ravels obliquely across the iliacus muscle in the direction o theCutaneous Division L2–L3 anterior superior iliac spine. Passes beneath the inguinal ligament and divides into an anteriorand posterior branch. Te anterior branch supplies the skin on the anterolateral aspect o thethigh. Te distal branches communicate with the anterior cutaneous laments o the emoralnerve and its inrapatellar branches o the saphenous nerve to orm the patellar plexus. Teposterior branch pierces the ascia lata and supplies the skin o the lateral thigh rom greatertrochanter to mid-thigh
5-10
Femoral Posterior Primary nerve innervating the anterior aspect o the thigh and the largest o the peripheralDivision L2–L4 branches o the lumbar plexus. It emerges through the psoas major bers and passes downbetween the psoas major and the iliacus, then passes underneath the inguinal ligament just lateral to the emoral artery as it enters the thigh. Within the abdomen, the emoral nervegives o muscular branches to the iliacus. Peripherally, there are two large anterior cutaneousbranches (intermediate and medial cutaneous nerves). Te intermediate cutaneous branchdescends along the anterior thigh to supply the skin and then contributes to the patellar plexus.Te medial cutaneous branch supplies the skin on the medial side o the thigh. Te emoralnerve sends several terminal branches including the nerve to pectineus, nerve to vastus medialisobliquus, nerve to sartorius, and the saphenous nerve
5-10
.Genitoemoral L1–L2 Penetrates the substance o the psoas major and runs ineriorly along the anterior aspect o themuscle belly beneath the transversalis ascia and the peritoneum, then biurcates into a genitaland emoral branch. Te genital branch passes through the transverse and spermatic ascia,traverses the internal inguinal ring and then reaches the spermatic cord. Lying on the dorsalaspect o the cord, this nerve supplies the cremaster muscle and the skin o the scrotum andthigh. In emales, the genital nerve accompanies the round ligament o the uterus. Te emoralbranch travels beneath the inguinal ligament alongside the external iliac artery. Aer enteringthe emoral sheath supercial and lateral to the emoral artery, the emoral branch exits thesheath and ascia lata to supply the skin o the proximal anterior thigh
5-10
.Obturator Anterior L2–L4 Emerging rom the medial border o the psoas major beneath the common iliac vessels,Division this nerve travels along the lateral wall o the lesser pelvis and enters the obturator oramen.Aer entering the thigh, it biurcates into an anterior and posterior branch. Te anterior branchpasses anterior to the obturator externus, deep to the pectineus and adductor longus, andsupercial to the adductor brevis. Muscular branches are supplied to the adductor longus,gracilis, and adductor brevis. Te posterior branch o the obturator nerve exits the anterioraspect o the obturator externus, travels beneath the adductor brevis anterior to the adductormagnus, and then gives o muscular and articular branches. Te muscular branches innervatethe obturator externus, adductor magnus, and the adductor brevis
5-10
.
 
 The Journal of Manual & ManipulaTive Therapy
n
voluMe 17
n
nuMber 4
e109
AnAtomICAL VArIAtIonS of the LumbAr PLexuS: A DeSCrIPtIVe AnAtomy StuDy wIth ProPoSeD CLInICAL ImPLICAtIonS
fIGure 1.
Lumbar plexus with surroundingmusculature: Normal anatom
fIGure 2.
Variation o the genitoemoral nerve.Te genitoemoral nerve has prematurely biurcatedinto two components, the genital branch(G) and emoral branch (F). Fibers o the psoasmajor lie between these branches.
fIGure 3.
Variation o the emoral nerve.
Cadaver 8 Lef.
Te psoas major is sectioned (PMS) to revealthe biurcation o the emoral nerve into medial andlateral segments (FM & FL) with an interconnectingsegment (FIS). Tere are bers o the psoas major(PM) traversing between this nerve plexus.
fIGure 4.
Variation o the emoral nerve.
Cadaver #10 Right.
Te emoral nerve (F) biurcates into amedial (FM) and lateral (FL) segment. Te lateralsegment travels posterior to the PM proper (PM),exits along the lateral border, and then rejoins themedial segment.with regard to diagnosis o anatomical variations o the lumbar plexus.
Materials and Methods
Cadavers
We initially included 19 human cadav-ers (38 unilateral lumbar plexes) romthe Andrews University Master o Phys-ical Terapy program in this study.Tere were 10 male and 9 emale cadav-ers; average age at time o death was 75.1years. Specimens were excluded i therewas evidence o surgical interventioninvolving the abdomen, lumbar spine,or lumbar plexus to rule out iatrogenicanatomical deviations. O the proposedcadavers, two were excluded due to evi-dence o an abdominal surgical inter- vention leaving 17 (with 34 plexes) thatwere appropriate or this study.
Dissection
Te primary author dissected all cadav-ers. As a proessor o graduate-levelgross anatomy, at the time o this study this author had 10 years o experience incadaveric dissection. Te descriptivestudy presented here was part o thegraduation requirements or an ad- vanced-level doctorate in physical ther-apy centered on a ocused study o the

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