MS PT 2S Lecture# 4 (A)
Lumbosacral Plexus
By: Dr. Chaman Lal PT
B.S.PT, PPDPT (M.Phil Physiotherapy), MPH (M.Phil Public Health),
Master in Physical Education & Sports Injuries (UOS),
Dip. in sports Injuries, PG in Clinical Electroneurophysiology (AKUH),
Registered.EEGT (USA), Member of ABRET, AANEM & ASET (USA),
MPPS(PAK), MPPTA(PAK),
PhD Physiotherapy Scholar (Malaysia).
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Outline
❖ Lumbosacral plexus anatomy
❖ Sample MRI protocol + search pattern
❖ Important pathology to recognize:
❖
❖
❖
❖
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Compression Neuropathy
(Trauma)
Infectious and Inflammatory Pathology
Tumor and Tumor-Like Conditions
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The Lumbosacral Plexus
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Spinal Cord
Lumbar & sacral enlargements – sites
where nerves serving the limbs
emerge.
Conus medullaris :
It is the terminal portion of the spinal
cord.
Cauda equina : It is the collection of
nerve roots at the inferior end of the
vertebral canal.
Spinal Cord ends at the level of L2
vertebrae.
Spinal nerves – 31 pairs
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Lumbosacral Plexus
Lumbosacral Plexus is combination of two plexus at a time:
Lumbar plexus
&
Sacral Plexus
Lumbar Plexus:
Lumbar plexus is formed by the ventral rami of
L1,L2,L3, & part of L4 in substance of psoas major muscle , &
branches emerge from both lateral and medial sides of psoas
major muscle. (in 50% of cases also having contribution from
ventral primary of T12)
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Psoas Major
O: Anterior and lateral surfaces of T12 thru L5
I: Lesser trochanter
A: Hip Flexion
Inv: L2 and L3
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Iliacus
O: Iliac Fossa
I: Lesser trochanter
A: Hip flexion
Inv: Femoral Nerve
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Lumbar Plexus
Anatomy
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Components of Lumbosacral Plexus
Components of Lumbosacral plexus is as
below:
Components:
Lumbar plexus:
L1, L2,L3,L4
Lumbosacral trunk:
L4 &L5
Sacral plexus:
S1,S2,S3,S4
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Lumbosacral plexus Cont’d
• Smaller branches of the Lumbar plexus innervate the
posterior abdominal wall and psoas muscles
• Main branches innervate the anterior thigh and their
relative muscles.
• Key to remember :
Root → Branches →Divisions →Terminal Branches
*R.B.D.T
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Lumbosacral plexus Cont’d
• Roots: These are constituted by the anterior primary rami of
L1, L2,L3&L4 (T12 may be)
•
•
•
•
Branches: L1 root gives an upper and & a lower branch.
L2root gives an upper and a lower branch
L3 do not give any branch.
L4 gives an upper and a lower branch.
• Divisions: So lower branch of L2 , upper branch of L4 &
ventral rami of L3 nerve root divides into small anterior and
large posterior divisions.
• From L2 & L3 each gives two posterior divisions.
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Lumbosacral plexus Cont’d
• Terminal Branches:
•
From contribution of T12 & upper
branch of L1 there arises two nerves :
•
•
1.
2.
Iliohypogastric Nerve (T12 , L1,) &
Ilioinguinal Nerve (L1).
• The lower branch of L1 joins the upper branch
of L2 to form the;
✓ “Genitofemoral nerve (L1 & L2)“.
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Lumbosacral plexus Cont’d
From posterior division of L2 & L3 there arises
a sensory nerve branch termed as:
✓“
Lateral Femoral Cutaneous Nerve of Thigh (L2,L3).”
From another posterior division of L2,L3, & L4
there arises
✓ “Femoral Nerve (L2,L3,L4 )”.
From all three anterior divisions of L2,L3, & L4
there arises ;
✓“Obturator nerve (L2,L3,L4 )”.
Lower branch of L4 & L5 unite to form
“Lumbosacral Trunk”.
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Lumbar Plexus
Derived from the ventral rami of T12-L4
Courses within or posterior to the psoas
major muscle
Anterior:
 Genitofemoral nerve (L1, L2)
Medial:
 Obturator nerve (L2-L4)
** *
*
Lateral:




Iliohypogastric (L1)
Ilio-inguinal (L1)
Femoral (L2-L4)
Lateral cutaneous nerve of the thigh (L2, L3)
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*
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FEMORAL NERVE
• It is formed by the dorsal or posterior division of the
anterior rami of L2,L3, & L4 roots.
• The femoral nerve is the largest branch of the lumbar
plexus.
• It gives a sensory branch “ Saphenous nerve” which
emerges to become superficial just above the medial
aspect of the thigh (medial epicondyle of the femur).
• Saphenous is the largest sensory branch of the femoral
nerve.
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Femoral Nerve
Roots
L2-L4 posterior divisions; lumbar plexus
Motor
❖ Anterior compartment of the thigh (quadriceps, sartorius)
❖ Pectineus
❖ Iliacus
Sensory
Anterior thigh and knee, anterior and medial knee and leg (saphenous
nerve)
Ax T1
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Obturator Nerve
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Roots
L2-L4 anterior divisions, lumbar plexus
Motor
❖ Medial compartment of the thigh (adductors, gracilis)*
❖ Obturator externus
Sensory
Medial upper thigh, hip joint, knee joint
Lumbosacral
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*Hamstring portion of adductor magnus is supplied by the sciatic and femoral nerves
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Sensory Distribution of the Lower Limb
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Lumbosacral Trunk & Sacral Plexus
• The sacral plexus is formed by the
lumbosacral trunk (L4 ,L5 ), & ventral rami of
S1,S2,S3,S4 . Contribution of the fourth sacral
ventral rami is partially & the remainder of the
last (S5 ) joins the coccygeal plexus.
• Key to remember sacral plexus:
• Root → Divisions →Terminal Branches
• *R.D.T
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Lumbosacral plexus Cont’d
Roots:
These are constituted by the anterior primary rami of L4
,L5,S1,S2,S3,&S4
Divisions:
The lower branch of L4 ventral rami & ventral rami of L5
,S1 & S2 give anterior and posterior divisions. While S3
forms & shares only anterior division .
Terminal Branches:
These anterior and posterior divisions unite to form the
terminal nerve branches.
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Lumbosacral plexus Cont’d
• The posterior division of L4 ,L5 & S1 joins to form Superior Gluteal
Nerve .
• The posterior divisions of L5,S1 & S2 unites to form the Inferior
Gluteal Nerve.
• The posterior divisions of L4 ,L5 ,S1 &S2 joins to form Common
fibular or Peroneal Nerve. It’s the about one-half the size of the
tibial nerve.
• The anterior divisions of L4 ,L5 ,S1,S2 & S3 unites to form Tibial
Nerve.
• The anterior divisions of S2,S3& S4 unites to form Pudendal
Nerve.
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Lumbosacral plexus Cont’d
• So both these nerves i.e. Tibial and peroneal run in a
single covering of sheath and called as Sciatic Nerve
(L4 ,L5,S1,S2 &S3) . Which is the largest nerve of the
body.
• Sciatic Nerve descends along the back of the thigh
and through the middle of the popliteal fossa, to the
lower part of the Popliteus muscle. It divides just 5cm
above the politial fossa into Common Peroneal &
Tibial nerves to supply their relative muscles.
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Sciatic Nerve
Roots
L4-S3 from lumbosacral trunk and sacral plexus
Motor
❖ Posterior compartment of the thigh
❖ Branch to adductor magnus
❖ Anterior, posterior, and lateral compartments of the leg (tibial,
deep fibular, superficial fibular)
Sensory
Lateral calf (common fibular), posterolateral calf (sural), calcaneus
and plantar foot (plantar nerves, medial calcaneal branches)
Deep/Superficial
Fibular
Tibial
Sciatic
THIGH
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Ax T1
LEG
Ax T1
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Pudendal Nerve
Roots
S2-S4 anterior divisions, sacral plexus
Motor
❖
❖
❖
❖
Sensory
Perineum
Sensory and sympathetic innervation of the sex organs
Pelvic Floor (bulbospongiosus, ischiocavernosus)
Levator ani (iliococcygeus, pubococcygeus, puborectalis)
External anal sphincter
External urethral sphincter
Ax T1
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Lumbosacral
Plexus
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Lumbosacral
Plexus
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Sacral Plexus
 Derived from the lumbosacral trunk (L4, L5)
and the ventral rami of S1-S4
 Courses along the ventral piriformis muscle
 Each ventral ramus has anterior and
posterior divisions which combine with other
levels
Terminal Nerves
Superior/inferior gluteal nerves
Sciatic nerve
Pudendal nerve
Nerve to piriformis
Posterior cutaneous nerve of the thigh
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*
* **
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Sensory Distribution to the Legs:
• Superficial Peroneal: it’s the cutaneous branch from the
common peroneal nerve which supplies to the anterio-lateral
aspect of leg upto dorsum of the foot.
• Sural nerve
formed by the junction of the medial sural
cutaneous (it is the sensory branch of tibial nerve) with the
peroneal anastomotic branch (its branch of lateral sural
cutaneous nerve), passes downward near the lateral margin of
the tendo-calcaneous, lying close to the small saphenous vein,
to the interval between the lateral malleolus and the
calcaneous.
• It supplies to the psterio-lateral aspect of the leg upto lateral
malleolus.
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Nerve Name
Iliohypogastric
Origin
T12,L1
Ilioinguinal
L1
Genitofemoral
L1, L2
Femoral
L2, L3, L4
Obturator
L2, L3, L4
Lumbosacral trunk
L4, L5
Posterior femoral
cutaneous
Pudendal
S2, S3
S2, S3, S4
Supplies
Motor supply to internal oblique, transverses
muscles, sensation over lower anterior abdominal
wall
Sensation over anterior pubis (mons) and anterior
scrotum or labia
Genital branch: motor supply to cremastor muscle,
sensation to anterior scrotum; femoral branch:
sensation to anterior thigh
Motor supply to extensors of the knee, sensation to
anterior thigh
Motor supply to adductors of the thigh, sensation to
medial thigh
Joins the sacral nerves to form the lumbosacral
plexus that supplies motor and sensory innervations
to the lower extremities
Sensation to perineum, posterior scrotum, and
posterior thigh
Motor to levator ani, muscles of the urogenital
diaphragm, anal and striated urethral sphincter,
sensation to the perineum, scrotum, and penis
Lumbosacral Plexus By: Dr. Chaman Lal PT
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Nerve Name
Nerve to quadratus
femoris
Origin
Superior gluteal
L4,L5,S1
gluteus medius & minimus, tensor fasciae
latae
Inferior gluatel
L5,S1,S2
Gluteus maximus
Nerve to obturator
L5,S1,S2
obturator internus, superior gemellus
sacral plexus
(ventral primary
rami of L4-L5, S1S3)
(via its tibial & common peroneal branches)
semitendinosus, semimembranosus, biceps
femoris, part of adductor magnus, muscles of
leg & foot
skin of leg & foot (excluding medial side of leg
& foot)
L4,L5,S1
Supplies
quadratus femoris, inferior gemellus
internus
sciatic
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Essential Information
Patient history
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Physical exam findings
Lumbosacral Plexus By: Dr. Chaman Lal PT
EMG results
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Case Based Review




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Compressive Neuropathy
(Trauma)
Infectious and Inflammatory Pathology
Tumor and Tumor-Like Conditions
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Chronic Compressive Neuropathy
Compression
Progressive medial thigh numbness, weakness in adduction following complex
rectocele/cystocele resection and reconstruction
Ax T1
Ax T2 FS
Ax T2 FS
 Adductor edema and atrophy
 Enlarged, hyperintense obturator nerve
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Piriformis Syndrome
Compression
Right sided deep gluteal pain
*
*
Cor Oblique T1
Axial T1
Accessory piriformis muscle, compressing the right S2
nerve root at the level of the sacral foramina
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Compression
Piriformis Syndrome
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Compression
Pudendal Neuropathy
Left sided perineal pain and numbness
Ax T2 FS
Ax T1
Enlarged, hyperintense left pudendal nerve in
Alcock’s canal distal to the ischial spine.
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Compression
Pudendal Neuropathy
Ax T2 FS
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Infectious Neuritis
Infection
Inflammation
Pain, swelling and fevers; two weeks after hamstring tendon repair
Ax T1 FS +C
Ax T2 FS
Cor STIR
 Abscess adjacent to the ischial tuberosity
 Enlarged, hyperintense sciatic and pudendal nerves
 Extensive perineural and muscular edema
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Infection
Inflammation
Chronic Inflammatory Neuropathy
Myasthenia gravis; presenting with worsening right buttock
pain and weakness
*
Ax T2 FS
Ax T2 FS
 Enlarged, hyperintense right sciatic and superior gluteal nerves
 Loss of normal nerve fascicular pattern (sciatic)
 Gluteus medius/minimus edema and atrophy (not shown)
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Infection
Inflammation
Radiation Plexopathy
Prostate cancer and right pelvic nodal metastases treated with radiation presenting
with right leg pain and weakness
Cor STIR
Ax T1 FS +C
 Diffuse enlargement of the nerves of the lumbosacral plexus
 Edema and enhancement of the right piriformis muscle
 No focal nodularity or perineural masses
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Neuropathy Related to
Pelvic Carcinomatosis
Tumor and
Tumor-Like
History of prostate cancer and radiation presenting with sx of pudendal neuropathy
*
*
Ax T1 FS +C
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*
* *
*
Cor
STIR T2 FS
Oblique
Coronal
Multiple ill-defined enhancing masses in the
pelvis, tethering the rectum, causing right
hydronephrosis
Enlarged,
enhancing
right
pudendal
nerve
Lumbosacral
Plexus By:
Dr. Chaman
Lal PT
Ax T1 FS +C
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Tumor and
Tumor-Like
Peripheral Nerve Sheath Tumor: Benign
History of rectal cancer and a presacral mass on multiple CTs
Ax T1 FS + C
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Cor T2 FS
Well-circumscribed mass
Homogeneous T2 hyperintensity and enhancement
Tail going into the S2 neural foramen
Low level FDG
update
Lumbosacral Plexus By: Dr. Chaman Lal PT
Ax PET/CT
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Tumor and
Tumor-Like
Peripheral Nerve Sheath Tumor: Malignant
History of NF1 and a growing posterior thigh mass
Mass arising from the sciatic
nerve
Peripheral, irregular
enhancement
Central necrosis
Perilesional edema
Growth
*
*
Ax T1 FS + C
Cor STIR
5/6/2022
❖Imaging does not consistently differentiate
between benign and malignant nerve sheath
tumors.
Lumbosacral Plexus By: Dr. Chaman
Lal PT
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Tumor and
Tumor-Like
Plexiform Neurofibroma
History of NF1, presenting with worsening bilateral leg weakness
Cor STIR
Cor STIR
Sag T2 FS
 Extensive nodular/beaded nerve enlargement
 Pathognomonic for NF1
 5-10% incidence of malignant transformation
 Look for long bone bowing, vertebral body scalloping/dural ectasia,
cutaneous neurofibromas
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Tumor and
Tumor-Like
Chronic Inflammatory Demyelinating
Polyneuropathy (CIDP)
Two months of progressive back pain and weakness
Rare autoimmune demyelinating
disorder of peripheral nerves
Presents with progressive pain,
weakness, sensory deficits, and areflexia
lasting > 2 months
Considered a chronic form of GuillainBarre syndrome
Symmetric enlargement of the nerves,
“onion bulb” pattern
DDx: Charcot-Marie-Tooth
Cor STIR MIP
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Tumor and
Tumor-Like
Chronic Inflammatory Demyelinating
Polyneuropathy (CIDP)
Two months of progressive back pain and weakness
Cor STIR MIP
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Conclusion
❖The diagnostic work-up of patients with
symptoms of plexopathy symptoms is
complex and multi-modal
❖Knowledge of plexus anatomy is key to
accurately identifying and characterizing
abnormalities of the plexus on MRI
❖
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EMG findings and a solid clinical history are
invaluable and can help focus your search
pattern
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Lumbosacral Plexus By: Dr. Chaman Lal PT
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