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Principles of Rehabilitation Medicine

Chapter 72: Rehabilitation of Root and Plexus Lesions

ANATOMY
Each nerve fiber is surrounded by an outer endoneurial sheath. Bundles of nerve fibers are collected into fasciculi, with each fasciculus surrounded by
a perineural sheath that provides tensile strength and elasticity to the nerve. Fasciculi are set in areolar connective tissue packing called the
epineurium, which protects the nerve from compression (see Fig. 72–1).1

Figure 72–1

Peripheral nerve connective tissue: Epineurium, perineurium, and endoneurium.(A) The diagram shows the relationships among these
three connective tissue layers in large peripheral nerves. The epineurium (E) consists of a dense superficial region and a looser deep region that
contains the larger blood vessels.

(B) The micrograph shows a small vein (V) and artery (A) in the deep epineurium (E). Nerve fibers (N) are bundled in fascicles. Each fascicle is
surrounded by the perineurium (P), consisting of a few layers of unusual squamous fibroblastic cells that are all joined at the peripheries by tight
junctions. The resulting blood­nerve barrier helps regulate the microenvironment inside the fascicle. Axons and Schwann cells are in turn surrounded
by a thin layer of endoneurium. (X140; H&E)

(C) As shown here and in the diagram, septa (S) of connective tissue often extend from the perineurium into larger fascicles. The endoneurium (E n)
and lamellar nature of the perineurium (P) are also shown at this magnification, along with some adjacent epineurium (E). (X200; PT)

(D) Standard error of measurement (S E M) of transverse sections of a large peripheral nerve showing several fascicles, each surrounded by
perineurium and packed with endoneurium around the individual myelin sheaths. Each fascicle contains at least one capillary. Endothelial cells of
these capillaries are tightly joined as part of the blood­nerve barrier and regulate the kinds of plasma substance released to the endoneurium. Larger
blood vessels course through the deep epineurium that fills the space around the perineurium and fascicles. (X450). (Reproduced with permission
from Nerve Tissue & the Nervous System. In: Mescher AL, eds. Junqueira's Basic Histology, 14e New York, NY: McGraw­Hill; 2016.)

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Roots

The dorsal roots carry afferent sensory neurons whose cell bodies reside in the dorsal root ganglion (DRG). The DRG is located in the intervertebral
perineurium and packed with endoneurium around the individual myelin sheaths. Each fascicle contains at least one capillary. Endothelial cells of
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these capillaries are tightly joined as part of the blood­nerve barrier and regulate the kinds of plasma substance released to the endoneurium. Larger
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blood vessels course through the deep epineurium that fills the space around the perineurium and fascicles. (X450). (Reproduced with permission
from Nerve Tissue & the Nervous System. In: Mescher AL, eds. Junqueira's Basic Histology, 14e New York, NY: McGraw­Hill; 2016.)

Roots

The dorsal roots carry afferent sensory neurons whose cell bodies reside in the dorsal root ganglion (DRG). The DRG is located in the intervertebral
foramen. The ventral roots contain primarily alpha­, beta­, and gamma­type neurons carrying motor outflow from the spinal cord. As they exit the
intervertebral foramen, the dorsal and ventral roots join to form the mixed spinal nerve. (Fig. 72–2)

Figure 72–2

(A) A diagram of the spinal cord indicates the relationship of the three meningeal layers of connective tissue: the innermost pia mater, the
arachnoid, and the dura mater. Also depicted are the blood vessels coursing through the subarachnoid space and the nerve rootlets that fuse to
form the posterior and anterior roots of the spinal nerves. The posterior root ganglia contain the cell bodies of sensory nerve fibers and are located in
the intervertebral foramina.

(B) Section of an area near the anterior median fissure showing the tough dura mater (D). Surrounding the dura, the epidural space (not shown)
contains cushioning adipose tissue and vascular plexuses. The subdural space (S D) is an artifact created by separation of the dura from underlying
tissue. The middle meningeal layer is the thicker weblike arachnoid mater (A) containing the large subarachnoid space (S A) and connective tissue
trabeculae (T). The subarachnoid space is filled with CSF and the arachnoid acts as a shock­absorbing pad between the CNS and bone. Fairly large
blood vessels (BV) course through the arachnoid. The innermost pia mater (P) is thin and is not clearly separate from the arachnoid; together, they are
sometimes referred to as the pia­arachnoid or the leptomeninges. The space between the pia and the white matter (W M) of the spinal cord here is an
artifact created during dissection; normally the pia is very closely applied to a layer of astrocytic processes at the surface of the CNS tissue. (X100; H&E).
(Reproduced with permission from Chapter 1. Back. In: Morton DA, Foreman K, Albertine KH, eds. The Big Picture: Gross Anatomy, New York, NY:
McGraw­Hill; 2011.)

The spinal nerves

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ANATOMY, Leslie Rydberg; Matthew C. Oswald; Ny­Ying
and trunk. The ventral rami coalesce in the cervical, lumbar,Lam; Nassim
and sacral Rad to form their respective brachial, lumbar, and lumbosacral plexuses
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Brachial Plexus
sometimes referred to as the pia­arachnoid or the leptomeninges. The space between the pia and the white matter (W M) of the spinal cord here is an
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artifact created during dissection; normally the pia is very closely applied to a layer of astrocytic processes at the surface of the CNS tissue. (X100; H&E).
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(Reproduced with permission from Chapter 1. Back. In: Morton DA, Foreman K, Albertine KH, eds. The Big Picture: Gross Anatomy, New York, NY:
McGraw­Hill; 2011.)

The spinal nerves then divide into mixed dorsal and ventral rami. The dorsal rami innervate the paraspinal muscles and skin over the back of the neck
and trunk. The ventral rami coalesce in the cervical, lumbar, and sacral regions to form their respective brachial, lumbar, and lumbosacral plexuses

Brachial Plexus

The brachial plexus is a complex network of intertwined nerves arising from the cervical spinal nerves, which innervates the shoulder and upper
extremity. Just distal to their origin, the ventral spinal rami are joined by the gray ramus communicantes from corresponding cervical ganglia of the
sympathetic chain to become the “roots” of the brachial plexus. The C5–C6 roots join to form the upper trunk, the C7 root becomes the middle trunk,
and the C8–T1 roots combine as the lower trunk. The supraclavicular brachial plexus emerges between the anterior and middle scalenes and courses
superficially along the posterior cervical triangle. As the plexus dives behind the clavicle and above the first rib, each of the three trunks splits into
anterior and posterior divisions. The posterior divisions unite to form the posterior cord, which innervates the posterior aspect (sensory and motor) of
the upper limb. The anterior divisions combine to form the medial and lateral cords, which innervate the anterior aspect (sensory and motor) in the
upper limb. The cords are named according to their location relative to the axillary artery, but they also can be generally associated with the aspect of
the limb that they innervate. The infraclavicular plexus runs through the axilla, where the cords ultimately split into their terminal branches as seen in
Figure 72–3 and described in Table 72–1.2,3

Figure 72–3

Schematic of the brachial plexus showing the branches, cords, divisions, trunks, and roots. (Reproduced with permission from Chapter 29. Overview of
the Upper Limb. In: Morton DA, Foreman K, Albertine KH, eds. The Big Picture: Gross Anatomy, New York, NY: McGraw­Hill; 2011.)

Table 72–1
Muscle and Sensory Innervation of Terminal Branches of the Brachial Plexus

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Dorsal scapular (C5) Rhomboids

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Table 72–1
Muscle and Sensory Innervation of Terminal Branches of the Brachial Plexus

Cord Terminal Nerve Muscle Innervation Sensory Distribution

Dorsal scapular (C5) Rhomboids

Suprascapular (C5, C6) Supraspinatus, infraspinatus

Long thoracic (C5, C6, C7) Serratus anterior

Lateral Lateral pectoral (C5, C6, Pectoralis major (clavicular)

C7)

Musculocutaneous (C5, Biceps, brachialis, coracobrachialis Lateral antebrachial cutaneous

C6, C7) (lateral forearm)

Posterior Axillary (C5, C6) Deltoid, teres minor Lateral shoulder

Radial (C5, 6, 7, 8, T1) Brachioradialis, triceps, anconeus, extensor carpi radialis longus and brevis, Dorsal forearm and arm,
PIN: supinator, EDC, EIP, EPL, APL dorsolateral hand

Upper subscapular (C5, Subscapularis

C6)

Lower subscapular (C5, Teres major

C6)

Thoracodorsal (C6, 7, 8) Latissimus dorsi

Medial Medial antebrachial Medial forearm

cutaneous (C8, T1)

Medial pectoral (C8, T1) Pectoralis major (sternocostal), pectoralis minor

Ulnar (C8, T1) FPB, FCU, FDP 4/5, FDI, ADM, Add poll, lumbricals 3 and 4, palmar interossei Fourth and fifth digits

Abbreviations: EDC = extensor digitorum communis; EIP = extensor indicis proprius; EPL = extensor pollicis longus; APL = abductor pollicis longus; FPB = flexor
pollicis brevis; FCU = flexor carpi ulnaris; FDP = flexor digitorum profundus; FDI = first dorsal interosseous; ADM = abductor digiti minimi; Add Poll = adductor pollicis.

Cadaveric studies note that up to 53% of plexuses demonstrate some variant in brachial plexus innervation. A prefixed plexus, where C4 fibers
provided a more prominent contribution, was present in 25.5% to 48% of cases, while 2% to 5% of cases exhibited a postfixed plexus with increased
contribution of T2 fibers.4–6

Lumbar Plexus

The ventral rami of the L1–L4 roots form the lumbar plexus, which lies in the retroperitoneum behind the psoas muscle. The most proximal nerves of
the lumbar plexus are the iliohypogastric (L1), ilioinguinal (L1), and genitofemoral (L1–L2) nerves, which supply sensation to the inferior abdominal
wall and medial groin. The lateral femoral cutaneous nerve (L2–L3) runs under the inguinal ligament near the superior iliac spine and supplies
sensation to the anterolateral thigh. The two most prominent branches of the lumbar plexus are the obturator (L2–L4) and femoral (L2–L4) nerves. The
obturator nerve passes medial to the psoas muscle and exits through the obturator foramen to supply innervation to the thigh adductors, as well as
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nerves of
the lumbar plexus are the iliohypogastric (L1), ilioinguinal (L1), and genitofemoral (L1–L2) nerves, which supply sensation to the inferior abdominal
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wall and medial groin. The lateral femoral cutaneous nerve (L2–L3) runs under the inguinal ligament near the superior iliac spine and supplies
sensation to the anterolateral thigh. The two most prominent branches of the lumbar plexus are the obturator (L2–L4) and femoral (L2–L4) nerves. The
obturator nerve passes medial to the psoas muscle and exits through the obturator foramen to supply innervation to the thigh adductors, as well as
sensation to a small area on the medial thigh. The femoral nerve passes lateral to the psoas muscles and exits under the inguinal ligament to supply
innervation to the hip flexors and knee extensors, as well as sensation to the medial calf (through the saphenous nerve) and anterior medial thigh
(through the medial and intermediate cutaneous nerves of the thigh).

Lumbosacral Plexus

The ventral rami of L5–S4 roots form the lumbosacral plexus, which lies adjacent to the piriformis muscle. Branches of the L4 and L5 roots form the
lumbosacral trunk, which joins the sacral plexus (S1–S3) to form the sciatic nerve. The sciatic nerve exits the pelvis through the greater sciatic foramen,
passes under the piriformis muscle, and then innervates the knee flexors. It subsequently separates into the common peroneal and tibial nerves,
which innervate the muscles of the leg, ankle, and foot and provide sensation to the entire lower leg and foot, with the exception of the medial calf
(saphenous nerve). Distal to the takeoff of the lumbosacral plexus arises the superior gluteal nerve (L4–S1), which innervates the hip abductors and
internal rotators, and the inferior gluteal nerve (L5–S2), which innervates the gluteus maximus muscle. Sensation to the lower buttock and posterior
thigh is provided by the posterior cutaneous nerve of the thigh (S1–S3). The sacral plexus also contributes to the pudendal nerve (S2–S4), which
innervates the external anal sphincter (Fig. 72–4).7,8

Figure 72–4

Diagram of the lumbar plexus (left) and the sacral plexus (right). The lumbosacral trunk is the liaison between the lumbar and the sacral plexuses.
(Reprinted with permission from Haymaker W, Woodhall B. Peripheral Nerve Injuries. 2nd ed. Philadelphia, PA: Saunders, 1953.)

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