SARAF SPINAL

Spinal nerves carry somatosensory information into and motor instructions out of the
spinal cord. They arise from the spinal cord as nerve roots and merge to form a web
(plexus) of interconnected nerve roots and once again branch to form nerve fibers. The
formation of nerve plexuses rather than a direct continuation of the nerve roots to
peripheral nerves serves as an essential safety measure so that injury at one site or body
region may not affect the vital functions of our body. The spinal nerves help to control the
function and movement for the rest of the body. The 31 pairs of spinal nerves include 8
cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal. Their names match the adjacent
spinal vertebra from which they exit. In the cervical region, the nerve root exits above the
corresponding vertebrae (the nerve root between the skull and C1 vertebrae is the C1
spinal nerve). In the thoracic to the coccygeal region, the spinal nerve root originates
below the corresponding vertebrae. The reason for this difference is due to the naming and
location of the spinal root between C7 and T1 vertebrae (C8 spinal nerve root). In the
lumbar region, the spinal cord ends at L1 from the region named conus medullaris, but the
spinal nerve roots travel within the dural sac below the L2 level, this region is known as
the cauda equina.

(neuroanatomy, somatic nervous system)

Spinal nerves connect the CNS with sensory receptors, muscles and glands throughout the
body. There are 31 pairs of spinal nerves: eight cervical, 12 thoracic, five lumbar, five sacral
and one coccygeal (Jenkins and Tortora 2013). Spinal nerves are surrounded by a series of
protective connective tissue layers: the endoneurium (innermost layer), the perineurium,
which surrounds each bundle of fibres, and the epineurium (outermost layer). A typical
spinal nerve has two connections with the spinal cord – an anterior and a posterior nerve
root. The anterior nerve root contains motor nerve fibres and the posterior root contains
sensory nerve fibres that combine at the intervertebral foramen to form a spinal nerve,
therefore a spinal nerve can be considered a mixed nerve (Jenkins and Tortora 2013).

On emerging from the intervertebral foramen, spinal nerves divide into branches or rami. A
typical spinal nerve has anterior, posterior and communicating rami. The anterior rami
innervate the anterior and lateral aspects of the neck, trunk and upper and lower limbs,
while the posterior rami innervate the skin and muscles of the posterior of the trunk. The
communicating rami are part of the autonomic nervous system (ANS).

PLEXUS

Plexuses are large masses of nerves. Several segments of the spinal cord are involved in the
innervations of complex peripheral musculature, with nerves arising at different points
along the spinal cord. Anterior roots intermingle to form a plexus. This intermingling means
that damage to one spinal nerve does not cause total loss of function to a given region.
There are five large plexuses of mixed nerves on the left and right sides of the vertebral
column: the cervical plexus, brachial plexus, lumbar plexus, sacral plexus and coccygeal
plexus (Waugh and Grant 2010) (Table 2). The thoracic nerves do not form plexuses (Waugh
and Grant 2010).

TABLE 2
Functions of plexuses
Plexus Function
Cervical Sensory nerves supply the scalp, ears,
chest, neck and shoulders; motor nerves
supply the neck muscles and diaphragm.
Brachial Sensory and motor nerves innervate the
shoulders and upper limbs.
Lumbar Sensory and motor nerves innervate the
lower abdomen, external genitals and part of
the lower limbs.
Sacral Sensory and motor nerves innervate the
buttocks, perineum and lower limbs.
Coccyg Sensory and motor nerves innervate the skin
eal around the coccyx and anal area.
(nervous system part 3)

Each spinal nerve is formed by the fusion of two roots of the spinal cord: the ventral root is
formed by the spinal motor rootlets (motor neuron axons); and the dorsal root contains the
dorsal root ganglion containing cell bodies of all sensory neurons of the PNS. These two
roots unite to form the mixed spinal nerve. There are eight pairs of cer- vical spinal nerves,
twelve pairs of thoracic spinal nerves, five pairs of lumbar spinal nerves, five pairs of sacral
spi- nal nerves, and a few pairs of coccygeal nerves.

CERVICAL PLEXUS

The cervical plexus is located below the sternocleidomas- toid muscle. Its sensory fibers
carry exteroceptive infor- mation from scalp, neck, and chest, and proprioceptive
information from muscles, tendons, and joints. Its motor fibers innervate cervical muscles
and diaphragm. Sym- pathetic sudomotor and vasomotor fibers pass through this plexus to
blood vessels and glands.

BRACHIAL PLEXUS
The brachial plexus is formed by the C5, C6, C7, C8, and T1 ventral and dorsal roots. C4
contributes only very slightly to the formation of this plexus. Sympathetic fibers are also
involved in the formation of this plexus. The roots give rise to three trunks (superior, middle,
and inferior). Each of these trunks divides into a ventral and a dorsal branch and three cords
are formed (lateral, pos- terior, and medial), which finally will give rise to the nerves of the
upper limbs: musculocutaneous, scapulary, axillary, radial, median, and ulnar nerves. For
instance, the median nerve is the combination of nerve fibers from C5, C6, C7, C8, and T1
roots. This plexus is very vulner- able to trauma during birth (superior plexus palsy) with
deltoid, biceps, brachialis, and brachioradialis paralysis and loss of sensation in the deltoid
region. Hands are affected by the rarer lower plexus palsy. Compression of the lower plexus
by a cervical rib (C8, T1) or infiltration by cells originating from a breast or pulmonary cancer
is responsible for paralysis of the small muscles and flexors of the hand, hypoesthesia in the
ulnar territory, and Horner syndrome.

Musculocutaneous, scapulary, axillary, radial, median, and ulnar nerves

Musculocutaneous nerve (C5, C6) innervates the biceps brachii, coracobrachialis and the
brachialis muscles, which are involved in flexion of the upper and lower arm, supination of
the lower arm, and ele- vation of adduction of the arm. Sensory innervation supplies the
lateral forearm.

Dorsal scapulary nerve (C5) innervates the levator scapulae and rhomboid muscles for
elevation and adduction of the scapula toward the vertebral column.

Suprascapular nerve (C5–C6) innervates the supras- pinatus and infraspinatus muscles for
abduction and outward rotation of the arm, resulting in abduction of the first 15◦ and
external rotation of the arm.

Axillary nerve (C5–C6) innervates the deltoid and

teres minor muscles for abduction of the arm to the horizontal and outward rotation of the
arm.

Radial nerve (C6–C8) innervates the triceps, anco- neus, brachioradialis, extensor carpi
radialis, exten- sor digitorum, and supinator muscles for extension and flexion of the elbow
and supination of the fore- arm; extensor carpi radialis, extensor digitorum communis,
extensor digiti V, extensor carpi ulnaris, supinator, abductor pollicis longus, extensor pollicis
brevis, and extensor pollicis longus and extensor indicis proprius muscles for extension and
flexion of the elbow, supination of the forearm, extension of wrist and fingers, abduction of
the thumb; sen- sory innervation is to the posterior upper arm and forearm, and posterior
region of the proximal part of fingers 1, 2, 3 and the lateral half of finger 4.
Median nerve (C5–T1) innervates the flexor carpi radialis, pronator teres, palmaris longus,
flexor digi- torum superficialis and profundus, flexor pollicis longus, abductor pollicis brevis,
flexor pollicis bre- vis, and lumbrical muscles of index and middle fin- gers allowing flexion of
the fingers, abduction and opposition of the thumb, pronation of the forearm; sensory
innervation is to the palm and the adjacent thumb, the index and middle fingers, and the
lateral half of the fourth finger

Ulnar nerve (C8–T1) innervates flexor carpi ulnaris, flexor digitorum profundus, adductor
pollicis, abduc- tor digiti V, dorsal and palmar interosseous, and lumbrical muscles to fourth
and fifth fingers allowing abduction and adduction of fingers and wrist flexion; sensory
innervation supplies dorsal and pal- mar medial faces of the hand.

Medial cutaneous brachial and the medial cutaneous antebrachial (C8–T1) nerves arise from
the medial fascicle and provide sensory innervation to the medial surface of the arm and the
forearm, respectively.

THORACIC NERVES

The 12 pairs of thoracic nerves originate from dorsal and ventral roots of corresponding
spinal segments. These nerves give rise to the cutaneous innervation of the tho- racic
dermatomes, to muscles, vessels, periosteum, pari- etal pleura, peritoneum, and breast.
Motor fibers supply innervation of muscles of the thoracic and abdominal walls; as for all
spinal nerves, pre- and postganglionic sympathetic fibers are also present along these fibers.

LUMBO-SACRAL PLEXUS

The lumbar plexus is located within the psoas muscle. It is composed of primary branches of
the anterior roots L1, L2, L3, and L4. Ilio-gastric, ilioinguinal, and genitofemoral nerves arise
from the L1 root (and part of L2) andinnervate transverse and oblique abdominal muscles.
Femoral, obtu- rator, and lateral femoral cutaneous nerves are formed from the remaining
roots. These nerves are responsible for flexion and adduction of the thigh, leg extension,
and sensory innervation of the anterior thigh and leg.

The sacral and coccygeal plexi are located anterior to the piriformis muscle; they are formed
from roots coming from L4 to S4. Its main terminal branches are the superior (L4–S1) and
inferior gluteal nerves (L5–S2), the posterior femoral cutaneous nerve (S1–S3), the sciatic
nerve (L4–S3) and its divisions into the tibial and common fib- ular nerves, and the pudendal
nerve. They result in exten- sion of the hip, flexion of the knee, and extension/flexion of the
ankle and toes. The pudendal nerve helps to close the bladder and rectum sphincters and
supply sensory innervation of the thigh and perianal region.
Femoral, obturator, sciatic, tibial, and common fibular nerves

Femoral nerve (L2–L4) motor fibers supply iliop- soas, sartorius, and quadriceps femoris
muscles resulting in flexion at the hip and extension of the leg; sensory innervation is to the
anterior thigh and anterior and medial surfaces of the leg.

Lateral femoral cutaneous nerve is purely sensory and innervates the anterior and lateral
surfaces of the thigh.

Obturator nerve (L2–L4) motor fibers supply pecti- neus, adductor (longus, brevis, and
magnus), gracilis, and external obturator muscles resulting in adduction and rotation of the
thigh; cutaneous inner- vation is on the internal thigh.

Superior gluteal nerve (L4–S1) motor fibers supply gluteus medius and minimus, tensor of
the fascia lata and piriformis muscles resulting in abduction and extension of the hip.

Inferior gluteal nerve (L4–S1) motor fibers supply the gluteus maximus, obturator internus,
gemellus, and quadratus muscles resulting in extension of the thigh at the hip and outward
rotation of the thigh.

Sciatic nerve (L4–S3) motor fibers supply the biceps femoris, semitendinosus, and
semimembranosus muscles resulting in flexion of the knee, and also muscles supplied by the
tibial and fibular branches that are terminal branches of the sciatic nerve.

Posterior femoral cutaneous nerve (S1–S3) supplies sensory innervation of the posterior
thigh, lateral perineum, and lower buttock.

Tibial nerve (L4–S2) motor fibers supply gastrocne- mius, soleus, tibialis posterior, flexor
digitorum longus, flexor hallucis longus muscles resulting in plantar flexion, inversion of the
foot, and toe flex- ion. Sensory innervation is devoted to lateral calf, foot, heel, and small
toe.

Common fibular nerve (L4–S1) supplies branches to the deep fibular nerve which gives rise
to motor fibers supplying tibialis anterior, extensor hallucis longus, extensori digitorum
longus, extensor digi- torum brevis muscles, and to the superficial fibular nerve, which gives
rise to motor fibers supplying per- oneus longus and brevis muscles resulting in foot
dorsiflexion, eversion, and toe extension. Sensory innervation is to the lateral part of the leg
and dorsal surface of the foot.

(gross anatomy)

The spinal nerves emanate from the spinal cord as pairs of nerves composed of both sensory
and motor fibers that function as the intermediary between the central nervous system
(CNS) and the periphery. These mixed nerves that collectively transmit sensory, motor, and
autonomic impulses between the spinal cord and the rest of the body. In total, there are 31
pairs of spinal nerves, grouped regionally by spinal region. More specifically, there are
eight cervical nerve pairs (C1-C8), twelve thoracic nerve pairs (T1-T12), five lumbar nerve
pairs (L1-L5), and a single coccygeal nerve pair. While the nerves branch directly from the
spinal cord and the central nervous system, the spinal nerves classify as a part of the
peripheral nervous system.

STRUKTUR DAN FUNGSI

Spinal nerves are mixed nerves that interact directly with the spinal cord to modulate motor
and sensory information from the body’s periphery. Each nerve forms from nerve fibers,
known as fila radiculara, extending from the posterior (dorsal) and anterior (ventral) roots of
the spinal cord. The roots connect via interneurons. Grossly, the root fibers join together
within the intervertebral foramina to form a spinal nerve.

The dorsal root is composed of afferent sensory axons that transmit visceral and somatic
sensory information from peripheral receptors back to the central nervous system. Areas of
cutaneous sensory innervation by specific spinal nerves are mappable in an organized
fashion in regions across the body known as dermatomes. While the dorsal root is synapses
at the dorsal horn of the spinal cord, the sensory cell bodies of these pseudounipolar
neurons are in the dorsal root ganglion, an oval enlargement just outside the cord. To
communicate with the effector division of the spinal nerve, the dorsal root will synapse on
an interneuron in the cord’s gray matter as part of the motor reflex arc. However, fibers of
the dorsal root may instead ascend through multiple pathways in the spinal cord to provide
sensory information to the thalamus.[1][2]

Meanwhile, the ventral (anterior) root bundle is responsible for transmitting somatic motor
output from the brain and spinal cord to the body’s skeletal muscles. Cell bodies of the
efferent motor fibers get housed in the anterior horn of the spinal cord, specifically the
anterior and lateral gray columns.[2] All the muscles innervated by a particular spinal nerve
as known as the nerve’s myotome. There are robust enlargements of the cord at the cranial
and lumbosacral regions as these areas are responsible for a significant degree of skeletal
muscle innervation of the upper and lower extremities, respectively.[2][3][4] The ventral
root is composed of both alpha and gamma motor neuron axons, which supply extrafusal
and intrafusal striated muscle, respectively.

The spinal nerve exits the vertebral canal through the intervertebral foramina as a single
fascicle of mixed nerve fibers. The only exception to this rule is at the C1 spinal level,
where the C1 spinal nerve exits the column between the occiput and the atlas (C1). Because
the spinal cord does not track the entire length of the vertebral column, spinal nerves in the
more cranial regions exit the spinal cord horizontally before directly passing into the
periphery. Meanwhile, spinal nerves caudal to the terminus of the spinal cord (typically at
the L1 or L2 vertebral level) must travel inferiorly in the column before exiting. These
rootlets are seen anatomically without the spinal cord and are called the cauda equina.
Tracking inferiorly from C1, all spinal nerves above C7 exit the vertebral column above
their associated vertebrae. Spinal nerve C8 exits the intervertebral foramina between C7
and T1. All remaining spinal nerves depart the vertebra column caudally to their respective
vertebrae.[2][5]

After exiting the vertebral column, the bundled spinal nerve divides into ventral and
dorsal rami. Both rami contain mixed fibers that provide both sensory and motor
innervation. The dorsal ramus is typically smaller than its ventral counterpart and consists
of a medial and a lateral branch; however, some literature may also refer to a third,
intermediate branch.[2][6] The branches of the dorsal rami are responsible for innervating
paraspinous muscles (the nerve’s myotome) and regions of skin (the nerve’s dermatome)
related to the ramus’ vertebral level.
Responsibility of the lateral and medial branches of dorsal rami in thoracic spinal nerves
varies based on vertebral level. Superior to T6, the medial branch provides muscular and
cutaneous innervation, and the lateral branch solely provides solely muscular innervation.
The opposite is true for these branches caudally to T6. Meanwhile, ventral rami are much
more robust in size and function in comparison to their dorsal counterpart. The ventral rami
provide the spinal contributions to all major neural plexuses. As such, they are responsible
for the majority of the body’s sensorimotor innervation.[2][6]

Also of note, preganglionic cells within the autonomic nervous system (ANS) closely
associated with the sensorimotor outflow tracts of spinal nerves. The goal of the ANS is to
control visceral motor tone involuntarily. Autonomic central neuronal bodies originate in
the regions of the cord’s lateral horn of the cord’s gray matter, specifically in the
intermediolateral nucleus. In the thoracic and upper lumbar regions (T1 to L2), these
neurons give rise to preganglionic sympathetic axons that exit with somatic motor axons
through the spinal cord’s ventral (anterior) root. The preganglionic fibers travel within
white rami communicantes to paravertebral ganglia within the sympathetic trunk. From
the ganglia, the sympathetic tone can undergo modulation in smooth and cardiac muscle,
glands, and immune system cells via a series of gray rami communicantes and
postganglionic fibers.[2][3]

In the parasympathetic portion of the ANS, preganglionic cells originate in the craniosacral
system. Included in this system are cranial nerves III, VII, IX, and X as well as S2 to S4 of
the sacral spinal cord. The preganglionic fibers of the parasympathetic system are much
longer than their sympathetic counterparts. Rather than terminating abruptly at paravertebral
ganglion, parasympathetic preganglionic nerves carry impulses to peripherally located
visceral ganglia that are anatomically associated with the nerve’s target tissue.[3]

Cervical Plexus

Much of the upper half of the cervical nerves comprise the cervical plexus, specifically
from the anterior rami of C1 to C5. Its sensory fibers provide cutaneous innervation to the
scalp, neck, chest, and axilla as well as proprioceptive innervation of the same area via the
lesser occipital nerve (C2 to C3), the great auricular nerve (C2, C3), transverse cervical
nerve (C2, C3), and the supraclavicular nerve (C3, C4). The motor branches of the
cervical plexus promote movement of the neck and innervation of the diaphragm. The
cervical plexus also provides motor innervation to the infrahyoid muscles and the
sternocleidomastoid via the ansa cervicalis (C1 to C3). Additionally, the anterior rami of
C3 and C4 loop and combine with outputs from C5 to innervate the phrenic nerve to
regulate respiration.[2][7]

Brachial Plexus

The brachial plexus is a highly complex network of nerves, formed from the ventral roots
C5-C8, with additional contribution from T1. The five nerve roots coalesce into trunks,
divisions, cords, and branches that innervate about 50 muscles and skin in the upper
extremities and pectoral region.[8] C5-C6 form the superior trunk, C7 extends as the middle
trunk, and C8 and T1 join to create the inferior trunk. Several significant mixed nerves
extend from the brachial plexus, including the axillary (C5, C6), musculocutaneous (C5,
C6) radial (C6-C8), median (C5-T1), and ulnar (C8, T1) nerves. Meanwhile, there are a
handful of other nerves in the plexus that are solely muscular or cutaneous sensory nerves.
[4] The nerve fibers of the brachial plexus are also accompanied by autonomic fibers,
particularly from T1, that regulate vasomotor control of the upper extremity and trunk.[8]

Thoracic Nerves

There are 12 pairs of spinal nerves in the thoracic spine, one for each corresponding spinal
segment. The thoracic nerves are responsible for cutaneous innervation of the skin,
musculoskeletal system, and viscera. Peripheral and visceral motor fibers also innervate the
musculature of the thorax and deep back, abdominal wall, and gut. Because much of the
sympathetic trunk arises from the thoracic spine, pre- and postganglionic sympathetic fibers
are also found coursing with spinal nerves in this region.[3]

Lumbosacral Plexus

The lumbar and sacral plexuses share nerve root overlap and are thus often referred to
simply the lumbosacral plexus. The combined plexus contains roughly 200000 axons and
provides all sensory and motor innervation to the lower extremity, with some additional
innervation of the abdominal wall. The combined plexus gives rise to six sensory nerves
and six more sensorimotor branches.[8]

Despite the connection via the lumbosacral trunk, the two plexuses exist as separate bundles
anatomically. The lumbar plexus arises from primary branches of the anterior roots of spinal
nerves L1-L4. It lies superior to the pelvic rim and passes through the psoas muscle. Arising
from the L1 and L2 roots of the plexus are the iliohypogastric, ilioinguinal, and
genitofemoral nerves. The lateral femoral cutaneous nerve receives a contribution from L2
and L3, while the femoral and obturator nerves both branch from L3 and L4. The nerves
originating from L1 and L2 innervate the transverse abdominal and anterior internal oblique
muscles and provide sensory innervation to that same region, in addition to the sex organs.
Meanwhile, the nerves of L3 and L4 are responsible for generating flexion and adduction of
the thigh, leg extension. These nerves also provide cutaneous sensory innervation to the
thigh and medial leg.[3][8] Preganglionic sympathetic fibers originating in the lateral horn
of the spinal cord’s gray matter are also located at spinal levels L1 and L2.[3]

The main branches of the sacral plexus originate below the pelvic rim and are housed in the
pelvic girdle.[8] It includes the superior gluteal nerve (L4-S1), the inferior gluteal nerve
(L4-S1), the posterior femoral cutaneous nerve (S1-S3), and the sciatic nerve (L4-S3). The
sciatic nerve is unique in that can be discretely mapped into its tibial (L4-S2) and common
peroneal (L4-S1) branches. The pudendal nerve may also branch from the common sciatic
nerve. The gluteal and common sciatic nerves are responsible for motor innervation of the
gluteal region and posterior thigh to generate movement of the hip in all directions as well
as flexion of the knee. The tibial and common peroneal nerves also dictate all motor
innervation of the leg, ankle, foot, and toes. These two nerves also provide sensory
innervation of the posterolateral half of the leg and the foot. The posterior femoral
cutaneous nerve is solely responsible for gluteal and perineal sensory innervation.[3][8] It is
also important to specify that preganglionic parasympathetic fibers originating in the sacral
region are between S2 and S4.[3]

(neuroanatomy, spinal nerves)

Buku saraf tepi dan masalah dan penangananannya

The 31 pairs of spinal nerves leave the spinal cord and pass through intervertebral foramina in the
vertebral column. (For details, see Fig. 1-5.) Each spinal nerve is connected to the spinal cord by two
roots: the anterior root and the posterlor root (Fig. ~13). The anterior root consists of bundles of nerve
fibers carrying nerve impulses away from the CNS, the efferent fibers. The posterlor root consists of
bundles of nerve fibers carrying nerve impulses to the CNS, the afferent ftbers. Because these fibers are
concerned with conveying information to the CNS, they are called sensory fiber and the cell bodies of these
nerve fibers are situated in a swelling on the posterior root called the posterior root ganglion