PPT Ilmiah Spine

Surgical Exposure of Peripheral Nerves

of the Lower Extremity : Sciatic Nerve
and Its Branches (Peroneal and Posterior
Tibial Nerves)
Present By : Vito Masagus, dr.

Spine Division Neurosurgery Departement

Faculty of Medicine – Universitas Padjajaran
Bandung - 2022
CONTENTS on this presentation :

SCIATIC PERONEAL TIBIAL

NERVE NERVE NERVE

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 01. SCIATIC NERVE
Clinical Anatomy of the Sciatic Nerve
• The sciatic nerve is the largest nerve of the body, originating from the L4–S3 nerve roots.
• The nerve is formed from the lumbosacral and sacral plexuses in the pelvis and quickly
exits this region through the greater sciatic notch  this nerves descends into the posterior
thigh to the popliteal fossa
the nerve
divides into its
branches:

the peroneal tibial nerves

supplying the calf muscles, and enters the medial foot, supplying sensation
to the weight-bearing portion of the foot as well as innervating the toe flexors

Deep • The deep branch innervates muscles in the anterior compartment of the leg (e.g.,
branches
anterior tibialis, extensor hallucis, and toe extensors).

Superficial • The superficial branch supplies the peroneus muscles and sensation to the anterior
branches surface of the foot

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 01. SCIATIC NERVE
Pathological conditions of the sciatic nerve that may require neurosurgical intervention include

Iatrogenic
Entrapment Tumor Trauma
Injury

Differential diagnoses :
• Lumbar radiculopathies and abdominal or pelvic masses.
• Fractures and dislocations of the hip or knee must be excluded

Imaging and Supporting Examination

• MRI
• Electromyographic
• Nerve conduction studies

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 01. SCIATIC NERVE
Surgical Exposure of the Sciatic Nerve in the Gluteal Region

The incision begins near the

All pressure points are
Patient in the prone position
padded, and the legs and
with the knees slightly bent.
ankles are slightly elevated.
The entire buttock and leg posterior–inferior iliac spine,
are prepared for potential curves laterally toward the
sural nerve harvest. greater trochanter, and again
medially into the gluteal fold

The sciatic nerve may be

palpated in the upper thigh
This muscle inserts on the After incision of the skin and
between the ham string
femur and iliotibial tract subcutaneous tissue, the
muscles and a finger placed
laterally and the iliac crest gluteus maximus muscle is
superficial to the nerve under
rostrally. encountered.
the inferior border of the
gluteus maximus.

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 01. SCIATIC NERVE
Surgical Exposure of the Sciatic Nerve in the Gluteal Region

A portion of the rostral aspect

The gluteus maximus is then Edges of the cut muscle The posterior cutaneous
of the muscle should also be
split superiorly, leaving a cut should be marked with suture nerve of the thigh should be
divided from the iliac crest to
at its lateral attachment to aid to aid with reapproximation protected and medially
aid in a more medial
in closing. during closure. displaced.
exposure

The muscle flap may then be

reflected medially, with care
to avoid injury to the inferior
gluteal nerve (supplies the
gluteus maximus) and artery,
which should be displaced
medially with the muscle.
The sciatic nerve is then
visualized, emerging from the
greater sciatic notch.
The nerve passes over the
piriformis, superior gemellus,
obturator internus, inferior
gemellus, and quadratus
femoris
The nerve may lie dorsal or
ventral or m ay be split by the
piriform is muscle

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 01. SCIATIC NERVE

• Surgical exposure of the sciatic nerve in the extrapelvic gluteal

region.
• A question mark incision is made with the curve surrounding the
gluteus maximus muscle laterally, connecting with a straight line in
the proximal dorsal thigh.

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 01. SCIATIC NERVE
The sciatic nerve is identified in the caudal aspect of the exposure after gentle
retraction of the head of the biceps femoris and the semitendinous muscles.

The gluteus maximus muscle may be mobilized medially by dividing its fascial
attachment laterally, without dissecting or incising muscle fibers.

It also facilitates the closure.

The nerve is followed proximally to where it comes under the piriformis muscle.

This is a commonly described site of entrapment of the sciatic nerve.

The cause of the entrapment may be inflammation of the piriformis muscle or an

abnormal course of the sciatic nerve through this muscle

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 01. SCIATIC NERVE
The sciatic nerve proximal to the popliteal fossa is a
single nerve.

Often pathology affects only one of its divisions.

The sciatic may be split into its tibial and peroneal

divisions if necessary.

A septum may be seen and/or palpated.

A scalpel may then be used to separate the divisions

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 01. SCIATIC NERVE
Entrapment of the Sciatic Nerve (Piriformis Syndrome)

• Piriformis Syndrome (PS) : Entrapment of the sciatic nerve by the piriformis muscle
• PS may be secondary to piriformis muscle inflammation or an abnormal course of the sciatic nerve
through this muscle
• Complaints : sciatic nerve distribution pain or pain in the buttocks secondary to superior gluteal nerve
involvement

Surgical Exposure of the Sciatic Nerve in the Thigh

The incision is
begun laterally
The entire leg in the gluteal The
is prepped for crease and semitendinosus The sciatic
potential sural A midline extends down The incision muscle nerve is readily
The patient is
graft harvest  posterior the midline of then continues medially and identified in this
positioned
the incision is the thigh, in a laterally over biceps femoris upper thigh
prone.
contralateral recommended. medial-to- the fibular head muscle laterally region between
leg is prepared lateral are identified these muscles
as well. orientation into and separated.
the popliteal
fossa

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 01. SCIATIC NERVE

The sciatic nerve may be exposed in the posterior thigh.

An incision is begun laterally in the gluteal crease and extends down

the midline thigh in a medial-to-lateral orientation into the popliteal fossa
and continues laterally over the fibular head.

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 01. SCIATIC NERVE

The dissection is carried down to expose the semitendinosus

medially and biceps femoris muscles laterally.

Careful separation of these muscles will expose the sciatic nerve

immediately superficial to the adductor magnus muscle.

If necessary, the nerve may be followed distally to the popliteal

fossa with care to preserve any branches to the hamstring
muscles.

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 02. PERONEAL NERVE
Clinical Anatomy of the Peroneal Nerve

Sciatic nerve in
popliteal Fossa

Divides to • The common peroneal nerve is the most commonly injured nerve of the lower extremity.
common • The nerve in this region may be injured by fractures of the fibula, knee dislocations, tumors,
peroneal nerve iatrogenic injury, or gunshot wounds

The deep branch continues anteriorly into the anterior compartment of the leg. It supplies the
Deep tibialis anterior, extensor hallucis longus, and toe extensors

The superficial branch innervates the peroneus muscles (foot everters) and then continues
Superficial into the anterior surface of the foot to provide sensory innervation, except for the web space
of the great toe.

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 02. PERONEAL NERVE
Surgical Exposure of the Peroneal Nerve

The incision begins just

medial to the short head of
The patient is positioned
the biceps femoris and
prone with both legs
extends into the popliteal
prepared for potential sural
fossa, then laterally over the For exposure of the common
nerve harvest.
surgical neck of the fibula peroneal nerve, an incision is
into the lateral leg
made just medial to the short
head of the biceps femoris.

It extends into the popliteal

fossa and then laterally over
The nerve is first easily the surgical neck of the fibula
exposed in the lower thigh into the lateral leg
just medial to the short head
of the biceps femoris and the
lateral tendinous insertion of
the gastrocnemius and
soleus muscles

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 02. PERONEAL NERVE
The common peroneal nerve is first found in the distal thigh just medial to the biceps
femoris muscles and the lateral tendinous insertion of the gastrocnemius and soleus
muscles.

This is then followed into the popliteal fossa.

In this dissection the tibial nerve, artery, and vein are readily visualized.

The peroneal and tibial contributions to the sural nerve are also seen.

The nerve is then followed around the head of the fibula, where it splits into its superficial
and deep branches

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 03. TIBIAL NERVE
Clinical Anatomy of the Tibial Nerve

The posterior tibial

nerve has three
terminal branches:

(1) medial (2) medial plantar (3) lateral plantar

calcaneal nerve nerve nerve

arise proximal and innervates the abductor

superficial to the digitiminimi, adductor
hallucis, and
flexor retinaculum
interosseous, and
provides sensation to the
lateral aspect of the
plantar surface

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 03. TIBIAL NERVE
Surgical Exposure of the Tibial Nerve in the Popliteal Fossa

The patient is placed in the prone position.

For exposure of the tibial nerve in
the popliteal fossa, an incision is
Both legs are prepared for potential sural nerve performed vertically to the flexor
harvest. crease of the leg. It travels in the
crease for a short distance, then
vertical again in the upper leg
An incision is performed vertically to the flexor crease
of the leg, travels in the crease for a short distance,
and then travels vertically again in the upper leg

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 03. TIBIAL NERVE
Exploration of the interval between the short head of the biceps femoris and
semimembranosus facilitates visualization of the distal sciatic nerve and the
proximal tibial nerve

Exploration of the
interval between the
The gastrocnemius
short head of the
The tibial nerve may and soleus muscles Branches to the calf
biceps femoris and
then be followed must be split for muscles and to the
semimembranosus
into the leg with the some distance sural nerve must be
facilitates
artery and vein deep because the tibial identified and
visualization of the
to it. nerve travels deep preserved
distal sciatic nerve
to them.
and the proximal
tibial nerve.

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 03. TIBIAL NERVE
Surgical Exposure of the Tibial Nerve in the Midleg

With the patient in the prone

The gastrocnemius muscle
position, the incision already Alternatively, an incision
mass must be split and may Many small muscular
described may be continued along the medial leg, with the
be retracted rostrally to branches are visualized and
in somewhat of a medial patient in the supine position,
continue exposure of the should be preserved.
trajectory to continue may also be used
nerve.
exposure of the nerve.

The tibial nerve in the leg may

also be identified, albeit with
somewhat more difficulty. An
incision is made in the medial leg

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 03. TIBIAL NERVE
Surgical Exposure of the Tibial Nerve in the Midleg
The gastrocnemius
and soleus muscles
must be split, as The exposure is
The leg is simply already described, somewhat deep 
externally rotated to identify the tibial therefore, good
for the exposure. nerve, which runs retraction is
along the medial necessary
border of the flexor
hallucis longus.

• The dissection is carried down to the gastrocnemius

and soleus muscles.
• The tibial nerve may then be visualized.
• Good retraction is necessary for this approach

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 03. TIBIAL NERVE
Surgical Exposure of the Tibial Nerve in the Distal Leg and Ankle

The incision
begins in the distal
medial leg and
continues in a
The patient is
curvilinear fashion
positioned supine
under the medial
with the leg
malleolus onto the
externally rotated.
medial foot, but
For decompression of the tarsal tunnel, the patient is positioned
not onto the
weight-bearing supine with the leg externally rotated. The incision begins in
surface of the foot the distal medial leg and continues in a curvilinear fashion
under the medial malleolus onto the medial foot, but not onto
the weight-bearing surface of the foot

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
 03. TIBIAL NERVE
Surgical Exposure of the Tibial Nerve in the Distal Leg and Ankle

The nerve is initially

The flexor retinaculum
identified in the proximal
(roof of the tarsal tunnel)
incision and followed into
is completely excised.
the tarsal tunnel.

The tendinous
aponeurosis in the
The calcaneal branch
plantar surface of the
must be identified and
foot should be released
preserved.
to complete the
decompression.

Wolfla E Christopher Neurosurgical Operative Atlas – Spine and Peripheral Nerves.3rd ed. 2017. Thieme Publishing
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