Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
The A to Z of
Peripheral
Nerves
Dr A. L. Neill
BSc MSc MBBS PhD FACBS
medicalamanda@gmail.com
A to Z Peripheral Nerves™6B:A to Z Nerves 14/07/09 8:58 AM Page C
The A to Zs...
Soon to be released!
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The A to Z of the Brain (Coming next!)
The A to Z of Surface Anatomy
The A to Z of Hair, Nails & Skin
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The A to Z of the Heart & Circulation
The A to Z of the GIT
The A to Z of the Organs
The A to Z of Histology & Histopathology
nd
The A to Z of Emergency Medicine
The A to Z of Anatomical Exercising
The A to Z of Imaging & Radiology
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http://www.aspenpharma.com.au/atlas/student.htm
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A to Z Peripheral Nerves™6B:A to Z Nerves 14/07/09 8:58 AM Page 1
Introduction
The A to Z of Skeletal Muscles was the first of the A to Zs - a series
of medical pocket reference books listing structures alphabetically so
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the book is its own index. They have proved to be invaluable tools for
the medical practitioner and student alike, and I received some very
helpful feedback and requests for more in the series. The size,
binding, practicality of knowledge retrieval as well as the colours have
all had very positive feedback and so have been maintained. This
book, and ties in with the other publications and each are extensively
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cross referenced. In particular, although a complete volume, this book
ties in with the soon to be released the A to Z of the Brain, which will
incorporate the Brain, Cranial Nerves, Neural pathways and Spinal Cord.
This book is particularly useful for those working in rehabilitation
medicine, neurology ergonomics, trauma and accident victims. It use
extends to those assessing and treating nerve damage from whatever
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causes, where a good understanding of both the nerve root and the
peripheral nerve damage and the resulting loss of function and/or
sensory deficit is essential. The alphabetical listing of each nerve with
its muscle and sensory functions as well as the signs and causes of
loss of the nerve facilitates quick summary and knowledge retrieval.
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Acknowledgement
Thank you ASPENpharmacare Australia: Mr Greg Lan CEO, and all
those who helped in the contribution of this edition and in the feedback
of the other books in this series. Special thanks to Ante Mihaljevic of
TM grapic design, who has assisted greatly with this new edition.
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Dedication
To the fates, may they forgive me.
Other A to Zs
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(ANS). It contains diagrams of their pathways sensory and motor
supply and can be cross-referenced with the A to Z of Skeletal
Muscles, the A to Z of Bones, Joints and Ligaments and the A to Z
of the Head and Neck as it lists all muscular and articular branches.
It will be cross referenced with the A to Z of the Brain and the A to Z
of Topographical/Surface Anatomy (the cutaneous branches) and the
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A to Z of Radiology and Imaging (boney components involved).
The beginning of the book demonstrates the main micro-anatomical
(histological) components of the nervous system alphabetically in the
same format. Components of the basic spinal nerve (SN) structure are
outlined and summarized. The Spinal Roots, Rami, and other
components including, where applicable the nerve plexi (NP) are all
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listed for each nerve, along with lesions of loss or damage and the
commonest event or trauma causing damage to the nerve described,
generally on the opposite page of each diagram as well as listing of
the key/legend to that diagram.
PNs may be known by several names and these, as far as possible,
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Amanda Neill
BSc MSc MBBS PhD FACBS
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Table of contents
Introduction 1
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Acknowledgement 1
Dedication 1
How to use this book 2
Table of contents 3
Abbreviations 4
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Common Terms used in Neurology 6
The Nervous System - and its components 11
Nerve cells - and their components 13
Structure and Substructure of Skeletal Muscle 15
Neuromuscular junctions = Motor end plate 17
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Neuromuscular spindle = muscle stretch receptor 19
Neurotendinous spindle = tendinous stretch receptor 19
The Spinal Nerves 21
Nerve trunk and Peripheral Nerves 25
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Examination of Reflexes 49
Key to Muscles and their SN roots 51
Map of Sensory innervation 53
The Peripheral Nerves – index and regional key 59
Root of the Neck 63
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Abbreviations
A = actions /movements of a joint
A = anterior
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adj. = adjective
aka = also known as
alt. = alternative
AM = arachnoid mater
ANS = autonomic nervous system
ant = anterior
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art = articulation (joint w/o the additional support structures)
AS = Alternative Spelling, generally referring to the diff. b/n British &
American spelling
BBB = blood brain barrier
bc = because
BP = brachial plexus
BS =blood supply
nd
b/n = between
C = cervical / carpal
c.f. = compared to
CN = cranial nerve
CNS = central nervous system
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Co = coccygeal
CoP = coccygeal plexus
collat. = collateral
CP = cervical plexus
Cr = cranial
CSF = Cerebrospinal fluid
CT = connective tissue
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L = left / lumbar
LL = lower limb
Lt. = Latin
lig = ligament
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M = mater
MC = metacarpal
med = medial
MN =myelinated nerve
nMN = non-myelinated nerve
N = nerve
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NS = nervous system/nerve supply
NT = nervous tissue
NTr = nerve tract / trunk
P = plexus
P = posterior
PaNS = parasympathetic nervous system
pl. = plural
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PM = pia mater
PN = peripheral nerve
post. = posterior
proc. = process
prox. = proximal
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R = Right
RC = radiocarpal
S = sacral
sing. = singular
Sc = spinal canal
SC = spinal cord
SN = spinal nerve
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SP = spinous process
SyNS = sympathetic nervous system
T = thoracic
TP = transverse process
UL = upper limb, arm
V = vertebra
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VB = vertebral body
VC = vertebral column
VH = ventral horn (of the spinal cord)
WM = white matter
w/n =within
w/o = without
& = and
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Aetiology the cause of ...the study of causes of illnesses of deficits
Afferent incoming - as with sensory fibres see Sensory
Anasthesia loss of sensation
Ansa - a loop like structure
Ante before , in front - anterior = ventral as in anterior horn = ventral horn
Aperture an opening or space between bones or within a bone.
Articulation joint, which is a point of contact b/n 2 opposing bones / relating to a
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joint. - hence articular branches of a nerve supply the joint described.
Association fibres those N fibres (artic- = arthro-) which connect cortical areas of the
brain ipsilaterally (as opposed to commissural fibres)
Astrocytes hold neurons together, and repair their membranes (see Glia)
Axial refers to the head & trunk (vertebrae, ribs & sternum) of the body.
Axon N process carrying material away from the cell body to the target
organ, each neuron has only one axon
Axon collaterals branches of the axon
nd
Basilar relating to the base or bottom of structures
Basiocranium bones of the base of the skull
Bipolar neurons with 1 dendrite + 1 axon (see unipolar, multipolar)
Blood brain barrier = BBB the barrier protecting the brain from certain
substances found in the BS
Cochlea a snail hence snail-like shape relating to the Organ of Corti in the
middle ear (adj. cochlear)
Commissural fibres those N fibres crossing the Median plane (e.g. anterior commisure)
Commisure a decussation or crossing of large groups of fibres
Condyle a rounded enlargement or process possessing an articulating surface.
Cranial Nerve (CN) N coming directly from the brain not the SC
Cranium the cranium of the skull comprises all of the bones of the skull
except for the mandible., adj. cranial pertianing to the skull cranial
nerves comnig out from the skul directly from the brain as
opposed to the SC for spinal nerves.
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Decussation a crossing of nerve fibres inside the CNS
Dendrite nerve process bringing communication to the cell body (from
dendro = tree, bc of the tree-like shape of the dendrites).
Depolarization the loss of the potential across the cell membrane of a N due to
stimulation and formation of a N impulse (see repolarization)
Dermatome the cutaneous innervation of a SN
Dislocation a displacement of any part particularly of bone = luxation /partial
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dislocation = subluxation
Dermatome the cutaneous distribution of the Spinal nerve root
Distal further away from the axial skeleton (opposite of Proximal)
Dorsal to the back from dorsum -back (= posterior, as in dorsal horn =
posterior horn)
the CSF
Extradural space space external to the Dura mater but w/n the skull or boney canal
of the SC
Fornix an arch
Fracture = #, broken bone
Funiculus cord-like structure (generally on the surface of the brain)
microglia
Grey Matter (AS Gray) N tissue in the brain and SC which contains mainly N cells,
dendrites unmyleinated axons and glial cells (opposite to White
matter which contains mainly myelinated axons)
Groove long pit or furrow
Gyrus a circle, hence a coil of brain cortex.
Horn projection of grey matter in the SC (anterior and posterior horns are
for motor and sensory Ns respectively) - also called dorsal and
ventral horns respectively
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the signal from the sensory to the motor w/o higher imput
Intra within
Introitus an orifice or point of entry to a cavity or space.
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lambdoid) and used to name the point of connection between the
3 skull bones Occipital and Temporals.
Lamina a plate as in the lamina of the vertebra a plate of bone connecting
the vertical and transverse spines (pl. laminae)
Leminiscus ribbonlike, flat band of N fibres (e.g. medial leminiscus)
Lesion deficit or injury - lack of function arising from this pathology
Linea a line as in the Nuchal lines of the Occitipum
Locus a place (c.f. location, locate, dislocate).
nd
Lumbar pertaining to the back particularly the lower back as in lumbago -
pain of the lower back.
the middle to support the BS and Pia (soft) mater, the inner coating
to coat the NT and act as a barrier to foreign substances. CSF flows
b/n the inner 2 coverings.
Microglia phagocytic cells of the NS (see Glia)
Mixed N a nerve containing both sensory and motor components most
peripheral Ns are mixed
Motor / motor N causes muscle contraction. these Ns are efferent or moving away
from the SC
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Neurotransmitter substances in vacuoles at the foot of the nerve process which are
released to induce a nerve impulses or in response to a nerve
impulse.
Nucha The nape or back of the neck adj.- nuchal.
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Occiput The prominent convexity of the back of the head Occipitum =
Occipital bone adj. occipital.
Oligodendrocytes in the CNS only, become Schwann cells in the PNS and SC, act as
a barrier and insulator of axons and neurons.
aN
Perineum body cavity inferior to the the pelvis adj perineal -pertaining to the
perineum.
Perineurium middle of the 3 CT coverings of a PN fibre (see neurium,
perineurium and epineurium)
Peripheral N (PN) coming from the SC, - often the combination of 1 or moreSNs or
part thereof and not the brain directly (cranial N) see Spinal N
Peroneal pertaining to the lower leg - particularly the Fibula.
Plexus knot - a knot or web of nerves.
pl plexi - from tangle or network as in brachial plexus or tangle of
nd
nerves involved in the innervation of the arm.
Polarization the maintenance of an unequal charge across the membrane of the
N, allowing the cell to be stimulated - all excitable cells have a
polarized membrane.
Posterior behind, at the back often used interchangebly with dorsal.
Process A general term describing any marked projection or prominence as
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directions.
Repolarization restoration of the resting potential after transmission of a N
impulse (see depolarization, polarization).
Resting potential the charge difference across the cell membrane of the N created
by ionic imbalance.
Ridge Elevated bony growth often roughened.
Root the segment(s) of origin of the PN from the SN. N roots are pure
either motor or sensory and made up of several rootlets arising
directly from the dorsal or ventral horns of grey matter in the SC.
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&/or reflex
Schwann cells cells supplying phospholipid coat - insulation to the axons to
preserve the N impulse in the PNS - role of the oligodendrocytes in
the CNS.
Spinal Cord (SC) Extension of the brain protected by the VC, PN come from here
Spinal Nerve (SN) N coming directly from the SC not the brain
Spine a thorn adj. - spinous descriptive of a sharp, slender
process/protrusion.
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Splanchocranium the splanchocranium refers to the facial bones of the skull.
Stimulation events which lead to the formation of a N impulse.
Subdural space space beneath the Dura mater external to the Arachmoid mater
Subluxation partial dislocation, particularly in the VC, term used to explain any
mechanical impediment to nerve function.
Sulcus long wide groove often due to a BV indentation –space b/n the gyri
of the grey matter in the brain
Sulcus long wide groove often due to a BV indentation.
nd
Sural pertaining to the lower leg.
Suture The saw-like edge of a cranial bone that serves as joint between
bones of the skull.
Synapse the gap at the joining of N and nerve process, N and N, process to
process or N and muscle for transmission or inhibition of an
impulse via neurotransmitters - presynaptic before the synapse
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PAIRS), the protective coverings of the tissue are made up of - connective tissue -
the MENINGES of which there are 3 layers, the outer or DURA MATER and the inner
often fused 2 layers THE ARACHNOID & PIA MATERS for the diffusions of CSF and
blood around the Brain and SC, and boney coverings, the Skull around the brain
and the vertebral column (VC) around the SC.
In the PNS the Ns form 2 separate divisions the voluntary and the autonomic
aN
(ANS). The ANS is made up of the Sympathetic exiting from the thoracic region
and Parasympathetic Ns, depending upon the region of the SC, and these nerves
may travel with the PNs.
CONNECTIVE
TISSUE
= MENINGES CRANIAL
NERVES (1-12)
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BONEY = VC
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SPINAL
CORD = SC SPINAL
CONNECTIVE
NERVES = SNs
TISSUE
= MENINGES
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aN
nd
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rA
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impulses into the nerve cell body (7). All neurons only have one axon (6), taking an
impulse away from the cell body. They may be insulated on their axons so that the
nerve impulse can travel faster and longer by a myelin sheath (3) a white
phospholipid material, produced by the Schwann cell - a connective tissue cell
which supports the N and protects it from outside influences. The impulse
terminates on to the target organ - generally skeletal muscle in the PNS via a
neuromuscular junction located in the muscle-end-plate (18), or on another N via
aN
a synapse.
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2
2
1 7
aN
6
3
5
nd
4
18
3
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4 4
13
rA
14
15 17
16
13, 14 4
8
9
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10
11
7
12
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1 muscle eg. Biceps
2 epimysium surrounding a whole muscle
3 perimysium surrounding a muscle fascicle
4 endomysium surrounding each muscle fibre
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5 muscle fibre
6 nucleus (note the muscle cell is multinucleated)
7 sarcolemma around each myofibril
8 myofibril
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9 sarcomere basic contractile unit of the muscle
10 myosin filament
11 actin filament
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1
2
3
aN
4
5
6
7
nd
8
2 I
A
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9
rA
H
Z
H
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A
11
10
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Neuromuscular Junction –
Nerve end attaching to Skeletal muscle
longitudinal
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1 axon - sheathed
2 mylein sheath – multiple lipid layers
3 Schwann cell
aN
4 axonlemma – axon membrane
5 pre-synaptic vesicles
6 axon – unsheathed / naked
7 presynaptic membrane
8 junctional folds (in sarcolemma)
nd
9 synaptic cleft (~20nm)
10 mitochondria
11 sarcolemma
12 myofilaments in muscle fibre
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I 2
aN
3 4
5 6
11
nd
10
7
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9
8
rA
12
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Neuro-Muscular Spindle –
feedback loop to stop overextension in Skeletal
muscle
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Neuro-Tendinous Spindle –
feedback loop to tendon
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1 capsule of spindle
2 myelinated motor fibres
3 myelinated sensory fibres
4 unmyelinated motor fibres
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5 annualospiral fibre endings
6 bag of nuclei in intrafusal muscle
7 motor end plates
8 muscle fibres i = intrafusal e = extrafusal
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8e
3
2
aN
4
6 5
8i
nd
7
9 7
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9
rA
10
12
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I
2
7
11
10e
10i
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There are 31 pairs of Spinal nerves that branch off the SC.
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Coccygeal 1
1 cervical enlargement of SC
2 Cervical plexus (CP)
3 Brachial plexus (BP) containing : Auxillary, Radial, Musculocutaneous,
Median, and Ulnar Ns
4 Intercostal Ns - thoracic Ns
5 Lumbar enlargement of the SC
6 Cauda equina
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7 Lumbar plexus (LP)
8 Sacral plexus (SP)
9 Cervical Ns C1-8
10 Thoracic Ns T1-12
11 Lumbar Ns L1-5
12 Sacral Ns S1-5
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13 Coccygeal Ns C1
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1
2 9
aN
3
4
nd
10
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6
rA
11 5
7
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12
8
13
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After leaving the SC the “pure” nerves JOIN together to form a PERIPHERAL NERVE
(generally a mixed nerve), which then re-splits to form VENTRAL and DORSAL RAMI
(branches).
The roots of the PNs are named from exit points of each SN which joins together to
make up the PN. These Ns interact with the ANS, via peripheral ganglion.
The basic structure of all SN is similar and they are classified as cervical, thoracic,
lumbar, sacral and coccygeal depending upon from which region of the SC they exit.
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Reflex arcs only involve the loop of sensory imput from the dorsal root to the outflow
of the ventral roots, bypassing the higher centres, so may remain intact with
complete severance of the SC or brain damage.
Diagrams represent the SC in the VC to show proportion and surrounding structures,
as well as regions within the SC; a typical SN of the thoracic region with its
segmental branches; and a general SN arrangement and pathways, including
convergence with visceral afferents and efferents. The effects of this are seen in the
sites of referred pain (p57).
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1 white matter
2 sympathetic afferent and efferent communicating rami
3 sympathetic ganglion
4 vertebral body of the VC
5 PN mixed N
6 ventral root - pure motor
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21 reflex arc
22 mediastinal structures and BVs
23 dorsal ramus
24 cutaneous branches
25 lateral cutaneous branch of the PN with their anterior and posterior
terminal branches to supply skin in the region
26 muscular branches to supply the regional muscle
27 anterior cutaneous branch to supply skin in medial area
28 viscera or organs and BS
29 cutaneous afferent meet with visceral afferent travelling together as in
referred pain sites.
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8 8
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10
aN
20
9
11
4
nd
23 7
5
1
19 16
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6
2
3
25
22
rA
27
26
18
17 9 21
10 12
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24
29
26 3
13 14
28 28
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which forms and reforms as a plexus eg the BP
These Ns may be mixed containing sensory and motor Ns. They are surrounded by a
protective CT covering, the epineurium, which carries the BVs and lymphatics. The
perineurium surrounds individual PN fascicles and endoneurium surrounds the N
processes. The vessels perforate the coverings to supply the N tissue and supporting
tissues. Axons are further protected by Schwann cell insulating layers. Loose CT
cushions and insulates the PNs w/in the trunk. As observed in referred pain patterns
there may be overlap b/n PNs particularly in the same N tract.
aN
Cross section
Longitudinal section
1 epineurium - surrounding the trunk or large PN
2 perineurium - surrounding the PN and individual fascicles
3 endoneurium covering each process/in the fascicle
nd
4 connective tissue
5 BVs
6 PN
7 feeding BV
8 extrinsic BV
9 oblique perforating BV
10 feeding BV
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rA
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A
6
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aN 1
nd
2
5 3
4
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4 1
5 9
2
rA
3
10
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7 5
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A = Anterior Aspect from the front Posterior Aspect from the back
used interchangeably with ventral and dorsal respectively
B= Lateral Aspect from either side
C = Transverse / Horizontal plane
D= Midsagittal plane = Median plane; trunk moving away from this
plane = lateral flexion or lateral movement moving into this plane
aN
medial movement; limbs moving away from this direction =
abduction; limbs moving closer to this plane = adduction
E = Coronal plane
F = Median
nd
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rA
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aN
nd
ma
rA
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Anatomical Movements
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aN
Hip flexion Hip extension
nd
Hip abduction Hip adduction
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rA
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Foot dorsiflexion Foot plantar flexion
aN
Foot inversion Foot eversion
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Neurological examination
General Considerations
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When examining the neurological patient - look for:
ASYMMETRY muscle wasting, hypertrophy, fasciculation
DEFORMITY limbs held in a strained position / uneven
posture
TONE CHANGES IN THE LIMBS
aN
hyer-reflexia / spasticity / resistance to
passive movement hypo- tonia / flaccidity
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TEST FOR PYRAMIDAL WEAKNESS -
damage to the motor cortex in the brain or the descending tracts
when the patient closes their eyes they cannot maintain the position
of the outstretched arm - it will - ABDUCT, PRONATE & DROP (DOWN,
OUT AND ROUND ABOUT !!)
aN
nd
ma
rA
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patient demonstrates dysmetria (intention tremor) and
dysdiadochokinesia (inability to repeat simple movements rapidly) as
in:
finger nose touching rapid supination and pronation
in the upper limb
aN
nd
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or tapping feet on the floor / running the heel of one leg down the
shin to the big toe of the other
patients cannot stand still without help even with their eyes open (if
rA
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this is not possible only with the eyes closed then the problem is only
SENSORY ATAXIA not motor and sensory ataxia) and have a wide
based gait
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aN
nd
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abnormal - foot will extend, knee will flex and leg will lift
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RADIAL NERVE
TRICEPS (C6-8)
cannot extend arm against resistance
BRACHIORADIALIS (C5-6)
aN
nd
from mid position - arm cannot flex against resistance
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aN
nd
ma
rA
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FLEXOR DIDGITORUM PROFUNDUS (C7-8)
fingers cannot resist extension when flexed (both Ns)
aN
nd
OPPONENS POLLICIS (C8-T1)
thumb cannot touch hypothenar eminence - cannot oppose
ma
(Median N)
rA
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aN
nd
ma
rA
©D
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LONG THORACIC NERVE
SERRATUS ANTERIOR (C5-7)
scapula wings when patient pushes arms into their body
aN
nd
AXILLARY NERVE
DELTOID (C5-6)
arm cannot abduct against resistance >15 degrees
ma
rA
MUSCULOCUTANEOUS NERVE
©D
BICEPS (C5-6)
arm cannot flex against resistance
39 © A. L. Neill
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aN
nd
ma
rA
©D
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INFERIOR GLUTEAL NERVE
GLUTEUS MAXIMUS (L5, S1-2)
(supine) cannot extend hip - ie keep foot on table against
resistance
aN
nd
SUPERIOR GLUTEAL NERVE
GLUTEUS MEDIUS, MINIMUS, TENSOR FACSIA LATA (L4-5)
(supine) cannot abduct hip against resistance
ma
rA
OBTURATOR NERVE
ADDUCTORS (L2-4)
©D
41 © A. L. Neill
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aN
nd
ma
rA
©D
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SCIATIC NERVE
HAMSTRINGS (L5, S1-2)
knee cannot flex against resistance
aN
nd
FEMORAL NERVE
ILIOPSOAS (L1-3)
cannot flex hip against resistance
ma
rA
©D
UADRICEPS (L2-4)
knee cannot extend against resistance
43 © A. L. Neill
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aN
nd
ma
rA
©D
© A. L. Neill 44
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TIBIALIS ANTERIOR (L4-5)
foot cannot dorsiflex against resistance (cannot walk on high
heels) (Deep Peroneal)
aN
GASTROCNEMIUS, SOLEUS (S1-2)
foot cannot plantar flex against resistance (cannot walk on
toes) (Tibial)
nd
EXTENSOR HALLICIS LONGUS
EXTENSOR HALLICIS BREVIS (L5-S1)
ma
PERONEUS LONGUS
PERONEUS BREVIS (L5-S1)
foot cannot evert against resistance (supf Peroneal)
45 © A. L. Neill
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aN
nd
ma
rA
©D
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POSITION SENSE
eill
determination of deficit by lack of detection of change of
position
move the joints of the fingers or toes up and down closing the
patients eyes
aN
VIBRATION
determination of deficit by lack of perception of vibration
tuning fork vibrated over the joints of the fingers and toes
2 POINT DISCIMINATION
nd
determination of deficit by lack of detection of 2 pinpricks at
once over increasing distances (normal - detection at 5mm)
SENSORY INATTENTION
ma
demyelinating disease.
47 © A. L. Neill
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aN
nd
ma
rA
©D
© A. L. Neill 48
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EXAMINATION OF REFLEXES
This is to determine if the neural pathway at the spinal level is intact
even with higher level loss as in Upper motor neurone loss, brain
eill
damage or spinal transection, or if there is progressive loss at a
spinal level without detection of higher level loss, as in peripheral
neuropathy ± deymeliniating diseases .
may be enhanced by asking the patient to clench their teeth.
aN
MUSCULOCUTANEOUS NERVE
BICEPS JERK - (C5,6)
strike Biceps tendon - positive Biceps contraction
RADIAL NERVE
SUPINATOR JERK (C6,7)
nd
strike lower end of radis - positive Elbow and finger flexion
TRICEPS JERK (C7,8)
strike above the Olecranon - positive Elbow extension
HOFFMAN REFLEX -determination of general hyper-reflexia
ma
49 © A. L. Neill
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aN
nd
ma
rA
©D
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and origins
Muscles of the Axis of the Muscles of the Girdles of the Muscles of the Limbs
body body (Pectoral and Pelvic) UL & LL
aN
3 Infrahyoid muscles 7 Levator Scapulae 18 Brachioradialis
4 Diaphragm 8 Rhomboids 19 Supinator
9 Pectoral muscles 20 Triceps
29 Intercostal muscles, 10 Subscapularis 21 Ext Carpi Ulnaris
Subcostales, Levator 11 Serratus muscles 22 Pronator muscles
Costales (Ant = a /Post = b) 23 Flexor Carpi Radialis
30 Tranversus Thoracis 12 Deltoid 24 Ext Digitorum
31 Oblique muscles 13 Teres muscles 25 Flexor Digitorum
nd
32 Rectus Abdominus 14 Latissimus Dorsi 26 Flexor Carpi Ulnaris
33 Transversus Abdominus 15 Supra & Infraspinatus 27 Interossei & Lumbricals
34 Quadratus Lumborum muscles 28 Short muscles of the
thumb & little finger
(urtherae & ani) 36 Pelvic and Gluteal 39 Gracilis & the Adductors
47 Muscles of the ant. muscles 40 Hamstrings
perineum 37 Obturator muscles (Semimembranous
48 Levator ani & Semitendinous & Biceps
Ischiococcygeus femoris) + Quadriceps
41 Pectineus
42 Peroneal muscles
43 Ant. muscles of the leg
rA
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C1 C2 C3 C4 C5 C6 C7 C8
1 1 1
±2 2 2 2
3 3 ±3
4 4 4
eill
±5 5 5 5 ±5
6 6 ±6
7 7
8 8
9 9 9 9 9
10 10 10
11a 11a 11a
12 12 ±12
13 13 13 13
aN
14 14
15 15
16 16
17 17
18 18 ±18
19 22 22 22
20 20 20 20
21 21
23 23 24
25 25
nd
26
28 28
±29
T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12
9
22
24
27
ma
28
11a 11a 11a 11b 11b 11b
29 29 29 29 29 29 29 29 29 29 29 29
30 30 30 30 30
31 31 31 31 31 31 31
32 32 32 32 32 32
33 33 33 33
35
L1 L2 L3 L4 L5
31 31
rA
32 32
33
34 34
35 35 35 35 35
36 36
37 37 37
38 38 38
39 39 39
40 40 40 40
©D
41 41
±42 42 42
±43 43 43
45
S1 S2 S3 S4 S5 Co1
36 36 ±36
37 37
42
44 44
45 45
±46 46 46 46 46
47 47
±48 48 48 48 48
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ANTERIOR
DERMATOMES
(SEGMENTAL) - cutaneous distribution of the N roots
Quick Guide for dermatome level -
aN
T5 = NIPPLE
T10 = Umbilicus
T12 = Inguinal Ligament
PERIPHERAL NERVES
1 Greater Auricular N
nd
2 Supraclavicular Ns + Anterior cutaneous N of the neck
3 Intercostal Ns anterior + lateral branches
4 Axillary N
5 Medial cutaneous N of the arm + forearm (brachial +
antebrachial)
ma
17 Deep Peroneal N
18 Tibial N
19 Greater Occipital N
20 Cutaneous branches of the Dorsal rami
21 Trigeminal N / ganglion
21i Ophthalmic N
21ii Maxillary N
21iii Mandibular N
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21i
eill
V1
21ii
21iii
1 V2
V3
2
C2
aN
C3
4 C4
T2
T3
T4 C5
3 T5
T6 T2
5 T7
nd
6 T8
T9
T10 T1 C6
7
T11
T12
6 10 L1 C
ma
6
C C
S3 8 7
8 11 L2
9
12
15
rA
L3
14
L4
15
©D
16
S1
18 L5
12
14
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POSTERIOR
DERMATOMES
(SEGMENTAL - cutaneous distribution of the N roots)
aN
PERIPHERAL NERVES
1 Greater Auricular N
2 Supraclavicular Ns + Anterior cutaneous N of the
neck
3 Intercostal Ns anterior + lateral branches
4 Axillary N
nd
5 Medial Cutaneous N of the arm +forearm (brachial
+ antebrachial)
6 Inferior lateral cutaneous branches of the Radial N
7 Musculocutaneous N
ma
8 Median N
9 Ulnar N
10 Iliohypogastric + Genitofemoral N
11 Ilioinguinal + Genitofemoral N
12 Lateral Femoral cutaneous N
13 Obturator N
rA
19 Greater Occipital N
20 Cutaneous branches of the Dorsal rami
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19
eill
C2 1
C3
4
C4 T2
aN
C5 T3
T4
T5
T6
T7 20
T8
T2
T9 3
T10
T11 5
nd
T1 T12
C6 L1
7
L2
L3 10
5
ma
C8 S5 S3
C
7
S4
12 9
rA
S2
©D
L4
L5
S1
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VISCERAL
eill
mapping of the viscera -organs with sensory innervation,
basis of referred pain sites.
REFERRED PAIN
Visceral afferents converge on the same neurones in the
aN
posterior horn.
Patient perceives pain in the cutaneous distribution
(see p16 for Nerve pathways).
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C1
C2
C3
C4
aN
C5
C6
C7
C8
T1
T2
2
T3
nd
T4
1
T5
T6
3
ma
T7
T8
T9 7
T10 4
rA
T11 6
T12
5
L1
L2
L3
8
©D
L4
L5
S1
S2
S3
S4
S5
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aN
nd
ma
Key
part of the Dorsal rami
rA
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Anococcygeal nerves (see Dorsal rami sacral and coccygeal region)
Ansa Cervicalis (= Ansa Hypoglossi, loop of the Hypoglossal N, nerve loop of the neck)
Anterior Cutaneous nerve of the neck (= transverse cutaneous nerve of the neck)
Anterior Tibial nerve (see Deep Peroneal nerve)
Axillary nerve
Common Peroneal nerve (= Fibular nerve) (see Posterior Interosseous nerve)
Clunial nerves (see Femoral nerve)
Cubital nerve (see Ulnar nerve)
aN
Deep Peroneal nerve (= Anterior Tibial nerve)
Dorsal rami of the Spinal nerves - overview
Dorsal nerve of the penis (see Pudendal nerve)
Dorsal rami - Cervical region
see also Greater occipital and Suboccipital nerves
Dorsal rami - Lumbar region
Dorsal rami - Thoracic region
Dorsal rami - Sacral (and Coccygeal) region
nd
Dorsal Scapular nerve (see also Nerves to Levator Scapulae)
Femoral nerve
Fibular nerve (see Common Peroneal nerve)
First Dorsal ramus (see Suboccipital nerve)
First Thoracic IC nerve (= one of the intercostobrachial nerves)
Genitofemoral nerve
ma
Intercostobrachial nerves
(see First thoracic IC nerve & Second thoracic intercostobrachial nerve)
Intercostal nerves - lower
Intercostal nerves - upper
Labial nerve (see Pudendal nerve)
Lateral cutaneous femoral nerve
Lateral pectoral nerve
Lateral plantar nerve
©D
eill
Medial plantar nerve
Median nerve
Median nerve -palmar digital branches
Middle Subscapular nerve (see Thoracodorsal nerve)
Musculocutaneous nerve (see also Radial nerve)
Obturator nerve (see also Accessory Obturator)
Obturator internus nerve (= nerve to Obturator internus)
Perforating cutaneous nerve
aN
Perineal nerve (see Pudendal nerve)
Phrenic nerve (see also Accessory phrenic nerve)
Piriformis nerve (= nerve to Piriformis)
Posterior femoral cutaneous nerve
Posterior Interosseous nerve (= Deep radial nerve) (see also Radial Nerve)
Pudendal nerve
Quaratus femoris nerve (=nerve to Quadratus femoris)
Radial nerve (see also Musculocutaneous nerve)
nd
Radial nerve - terminal branches
Rectus capitus anterior nerve (= nerve to Rectus captious anterior)
Rectus capitus lateralis nerve (= nerve to Rectus capitus Lateralis)
Sacral nerves - muscular
Sacral plexus - overview
Saphenous nerve (see Femoral Nerve)
ma
Scaleni and Longus colli nerve (=nerve to Scaleni and Longus colli)
Scalenus medius nerve (=nerve to Scalenus medius)
Sciatic nerve
Scrotal nerve (see Pudendal nerve)
Second Thoracic Intercostal nerve (= one of the intercostobrachial nerves)
Spinal Nerves - cervical
lumbar
sacral & coccygeal
thoracic
rA
Suprascapular nerve
Sural nerve (see Sciatic nerve)
Third dorsal ramus
Thoracic nerves - summary
Thoracodorsal nerve (= Middle Subscapular nerve)
Tibial nerve
Trapezius nerve (= nerve to Trapezius)
Twelfth thoracic nerve (see Subcostal nerve)
Ulnar nerve
Ulnar nerve - Deep terminal branch
Upper subscapular nerve (see also Lower subscapular nerve)
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aN
nd
ma
rA
©D
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1 vertebral artery (L)
2 TP of CI (Atlas) (L)
3 superior cervical ganglion (L)
4 Levator Scapulae
aN
5 Scalenus Medius
6 phrenic N (N roots C3,4,5)
7 Scalenus Anterior
8 upper trunk of the BP (L)
nd
9 thyrocervical trunk and deep cervical branch
10 inferior cervical ganglion (L)
11 Thoracic duct
12 subclavian vessels (L)
ma
13 Sternothyroid (L)
14 Trachea
15 hyoid muscles (R) = Sterno- hyoid thyroid
16 common carotid artery
rA
R 17 CN X = Vagus N
18 Omohyoid
19 BP = brachial plexus
20 Oesophagus
©D
21 TP of C6 (anterior tubercle)
22 middle cervical ganglion (R)
23 sympathetic trunk
24 Longus Colli
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aN
24 1
2
3
23
nd
4
5
22
6
ma
21 7
8
9
1
20 10
rA
11
12
19
17
©D
18 16 13
15 14
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It is divided into
ROOTS 5 C5-T1 (all the resulting SNs come from these
roots)
TRUNKS 3 the 4 major Ns emerging from the neck
aN
above the CLAVICLE
UPPER, MIDDLE & LOWER
DIVISIONS 6 the ANTERIOR & POSTERIOR branches of
each TRUNK
CORDS 3 described for their relation around the
AXILLARY artery
LATERAL, POSTERIOR & MEDIAL
nd
Branches above the clavicle
1 Nerves to Scalani & Longus colli
2 branch to the Phrenic N
3 Dorsal scapular N
ma
4 Long thoracic N
rA
©D
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Trunks Roots
Divisions
Cords
aN
nd
ma
1
2
3
4
5
rA
6
©D
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eill
LATERAL cord branches
1 Lateral pectoral N
2 Musculocutaneous N
3 Lateral root to the Median N
Lesions Erb Duchenne paralysis loss of shoulder abduction,
external rotation + weak elbow flexion and supination.
aN
MEDIAL cord branches
4 Medial Pectoral N
5 Medial Cutaneous N of the`arm
6 Medial Cutaneous N of the forearm
7 Medial root to the Median N
nd
8 Ulnar N
Lesions Klumpke’s paralysis: paralysis of the wrist and finger
flexors ± Horner’s syndrome because of sympathetic
outflow effects = eye constriction and pupil
contraction loss of sweating on the face and neck.
ma
13 Radial N
Lesions (Saturday night Palsy- crutches pushing into the
Post. cord and causing damage) wrist drop due to
damage to the Radial nerve. Erb Duchenne
paralysis loss of shoulder abduction, external
rotation + weak elbow flexion and supination.
©D
14 Subclavian artery
15 Axillary artery
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aN
nd
14
ma
1
3
12
9
4
2 10
rA
5
13 6
7 11
8
15
©D
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It is divided into
SUPERFICAL & DEEP BRANCHES
SUPERFICAL branches
Ascending and descending superficial branches
aN
1 Lesser Occipital N
2 Greater auricular N
3 Anterior Cutaneous N of the Neck
4 Supraclavicular N
Lesions mainly loss of innervation of the front & side of the neck
DEEP branches - MEDIAL
nd
5 Rectus Capitus Lateralis N
6 Rectus Capitus Anterior N
7 Longus Capitus N
8 Longus Colli N
9 Ansa Cervicalis
ma
13 Scalenus N
Lesions mainly loss of lateral flexion and rotation of the neck
other Nerves in this region include
14 Hypoglossal N (CNXII)
15 branch to the Vagus N (CNX)
©D
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2 1
2
3
aN
4 3
nd
4
ma
14
20
19 5
7 9
15
rA
18 6
7 8
2
13 16
12
©D
13
12 8
9
17
4
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Spinal Roots L3-4
Nerve type motor
Muscular branches to Pectineus
to Abductor Longus
Articular Branches NONE
aN
Cutaneous branches NONE
LESIONS weakens the hip
associated lesions/losses iatrogenic - cut in pelvic surgery
causes associated with ovarian cancer /
cancerous groin nodes
nd
1 to Pectineus
2 to Adductor longus
3 sympathetic chain
4 12th rib
ma
rA
©D
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4 3
aN
nd
ma
2
rA
2
©D
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from Ansa cervicalis
from Nerve to Subclavius
aN
crura (1-3)
Articular Branches NONE
Sensory branches supplies branches to the pleura
over the diaphragm and the
diaphragm, including the central
tendon for proprioception
nd
LESIONS minimal loss of function with an
intact Phrenic N
typical aetiologies damage to neck-Hyoid and thyroid
muscles and Clavicle
associated lesions/losses associated with deep neck injuries
ma
5 costal cartilages
6 12th rib
7 central tendon with aorta and IVC passing through
8 Clavicle
9 Scapula
10 oesophagus
©D
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3
aN
1
5
nd 2
10 7
6
ma
4 8
rA
©D
© A. L. Neill 74
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A Ansa Cervicalis
(= Ansa Hypoglossi = loop of Hypoglossal nerve = nerve loop
of the neck)
eill
see also Hypoglossal Nerve*
CP overviews
aN
muscles
Articular Branches NONE
Cutaneous branches NONE
LESIONS loss/weakness of infrahyoid
muscles and depression of the
Hyoid bone and Thyroid cartilages
nd
hence speech and/or swallowing
difficulties
typical aetiologies congenital malformation (at C2
bony points) deep wounds /
trauma, #s, dislocations iatrogenic
ma
surgical injuries
associated lesions/losses part of a C2 root radiculopathy
severe trauma to the neck as in
strangulation / hanging
8 N to N to Thyrohyoid
9 Mandible
10 tongue
11 Hyoid bone
12 Clavicle
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10
aN
1
11
8
2
nd
6
5
9
4
ma
3
rA
12
7
©D
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Spinal Roots C2, C3
Nerve type sensory
Muscular branches NONE
Articular Branches NONE
Cutaneous branches skin over the anterior and lateral
neck to the Manubrium -
aN
ascending (1) & descending (2)
branches
LESIONS loss of sensation/parasthesia on
the area described
nd
ma
rA
©D
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aN
nd
ma
2
rA
©D
© A. L. Neill 78
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A Axillary Nerve
BP (Infraclavicular branches)
eill
Spinal Roots C5, C6
Nerve type mixed = motor + sensory
Muscular branches to Teres Minor & Deltoid (1-2)
Articular Branches to the Glenohumeral joint (3)
Cutaneous branches to the skin over the Deltoid and
aN
Triceps (also from the
Suprascapular nerve)
LESIONS weak external rotation of the
Humerus weak abduction of the
Humerus parasthesia over the
Shoulder and back of the Arm
typical aetiologies inferior dislocation of the shoulder
nd
associated lesions/losses sports injuries
1 N to Teres Minor
2 N to Deltoid
ma
3 N to Genohumeral joint
4 Axillary artery
5 Scapula
6 Clavicle
7 2nd rib
rA
©D
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aN
2
1
nd
5
2
ma
6
rA
3
4
©D
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Spinal Roots L4, L5, S1, S2
Nerve type sensory
MAJOR BRANCHES deep peroneal (anterior tibial)
superficial tibial
(musculocutaneous)
Muscular branches NONE
aN
Articular Branches 3 to the knee (3,4,5,)
Cutaneous branches branches to the proximal leg an
lateral foot
LESIONS pain in leg and on the lateral side
of the foot
typical aetiologies common with injuries with crossed
nd
legs impact in car accidents
associated lesions/losses sciatic N damage also commonly
involves this nerve sacral / plexus
injuries also commonly -trauma to
leg, particularly if crossed or
ma
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9
aN
3
7
nd
4
ma
5
1 8
2
rA
6
©D
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D Spinal Roots L4, L5, S1, S2
Nerve type mixed = motor +sensory
MAJOR BRANCHES Superficial peroneal
Lateral terminal branch (S1,2)
Medial terminal branch (S1,2)
aN
Muscular branches to the dorsum of the foot and toes
Articular Branches to the ankle, medial of the foot and
medial 3 toes
Cutaneous branches branches to the 2 medial toes -
hallcus and the 2nd toe
LESIONS partial foot drop - weak
nd
dorsiflexion spared if superficial
peroneal nerve intact
typical aetiologies common ankle sprains,
dislocations and injuries
particularly from hyper-
ma
1 Superficial peroneal N
2 Lateral terminal branch
3 Medial terminal branch
4 N to Tibialis anterior
5 N to Extensor hallicus longus
6 N to Extensor Digitorum longus
©D
7 N to Peroneus tertius
8 1st interosseous muscle
9 Extensor digitorum brevis
10 Extensor hallicus brevis
11 2nd dorsal interosseous muscle
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D
1
4
aN
6
5
nd
7
ma
3
2
2
rA
9 3 10
11
8
©D
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Nerve type mixed = motor +sensory
D
supply the muscle & the skin of the back muscles & their
joints - mixed Ns, most of the supply is segmental, regions
discussed in Spinal Nerves.
aN
Cutaneous innervation often overlaps with the lateral
branches of the ventral rami.
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3 D
1
2
aN
4 5
nd
6
ma
7
rA
9
©D
10
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D Spinal Roots C1-8 cervical dorsal rami
Nerve type mixed = motor + sensory
MAJOR BRANCHES each dorsal ramus has at least
Medial and Lateral branches
Muscular branches Lateral - to the lateral neck muscles
aN
Medial - to posterior medial neck muscles
some overlap and dual innervation
Articular Branches Lateral - NONE
Medial - cervical zygapophysial joints
Cutaneous branches Lateral - NONE
Medial - to the dorsum neck - over Trapezius
nd
LESIONS generally little parasthesia because of
multiple innervation in this region and
synergistic muscle actions prevent muscle
weakness from being shown but intrinsic
muscles of the neck are vulnerable if there
ma
2 Semispinalis Cervicus
3 Multifidus
4 Interspinalis
Lateral branches send branches to …
5 Iliocostalis cervicus
6 Longissimus capitus
7 Longissimus cervicus
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D
3 2
aN 4
nd
ma
rA
7
©D
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Nerve type mixed = motor + sensory
D MAJOR BRANCHES each dorsal ramus has at least Medial
and Lateral branches
Muscular branches Lateral - to the lateral deep lumbar
back muscles
Medial - to posterior medial deep
aN
lumbar back muscles
some overlap and dual innervation
Articular Branches Lateral - NONE
Medial - lumbar zygapophysial joints
Cutaneous branches Lateral - supply gluteal skin and
region of greater trochanter
nd
Medial - NONE
LESIONS generally little parasthesia because of
multiple innervation in this region and
synergistic muscle actions prevent
muscle weakness from being shown
ma
4 Iliocostalis lumborum
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D
3 4
aN 2
nd
1
ma
rA
©D
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Spinal Roots S1-5 (Co1) sacral dorsal rami
D Nerve type mixed = motor + sensory
MAJOR BRANCHES each dorsal ramus has at least
Medial and Lateral branches
Muscular branches Lateral - NONE
aN
Medial - to Multifidus
Articular Branches Lateral - sacroliliac joint
Medial - NONE
Cutaneous branches Lateral - medial buttock region
and skin over coccyx
Medial - NONE
LESIONS parasthesia in this region damage
nd
typical aetiologies to the lower back and coccyx /
sports injuries, particlarly falling
associated lesions/losses sitting on the floor after a chair is
pulled away
ma
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D
aN
1
3
nd
ma
rA
3
©D
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Nerve type mixed = motor + sensory
D MAJOR BRANCHES each dorsal ramus has at least Medial
and Lateral branches
Muscular branches Lateral - to the lateral deep thoracic
muscles
Medial - to posterior medial deep
aN
thoracic back muscles
some overlap and dual innervation
Articular Branches Lateral - NONE
Medial - thoracic zygapophysial joints
Cutaneous branches Lateral - supply skin lateral to costal
angles, iliac crest and buttocks
nd
Medial - to the mid-back as far as the
mid scapula line
LESIONS generally little parasthesia because of
multiple innervation in this region and
synergistic muscle actions prevent muscle
ma
2 Multifidus
3 Longissimus thoracis
4 Spinalis thoracis
Lateral branches send branches to …
5 Iliocostalis cervicus
6 Longissimus thoracis (cut to show deeper structures)
7 Levator costrum breves
8 Levator costrum breves + longus
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D
1 2 5
aN
7
2
nd
1
ma
4
rA
©D
3
3 6
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Spinal Roots ±C3, ±C4, C5
Nerve type motor
D Muscular branches to Levator Scapulae (1), Rhomboids
Major and Minor (1-2)
Articular Branches NONE
Cutaneous branches NONE
aN
LESIONS ± Rhomboids and Levator
Scapulae weakened - paralyzed
resulting in winged scapula
typical aetiologies neck and BP injuries
associated lesions/losses unable to fully assess injuries to
BP with injury to this N
nd
ma
rA
©D
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D
aN
1 1
2
nd
ma
2
rA
©D
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Femoral nerve
LP (emerges from the lateral border of Psoas major)
eill
Spinal Roots L2, L3, L4 (same as Obturator N)
Nerve type mixed = motor + sensory
MAJOR BRANCHES ANTERIOR division, POSTERIOR division
Muscular branches ABDOMINAL to Iliacus
F to Pectineus
to Sartorius
aN
ANTERIOR
POSTERIOR to Rectus Femoris
to the Vasti muscles
to Articular genus
Articular Branches ABDOMINAL, ANTERIOR NONE
POSTERIOR to the hip and knee
Cutaneous branches ABDOMINAL NONE
nd
ANTERIOR anterior thigh, knee & leg
POSTERIOR medial of the ankle & the foot
LESIONS weak hip and knee flexion of the anterior
only - weakens the hip, knee flexion and
instability of the posterior only - weak knee
ma
flexion
associated lesions/ iatrogenic - cut in pelvic surgery cut in
losses causes varicose vein surgery & knee surgery
(posterior-Saphenous N) trauma to the
femoral triangle (abdominal)
rA
1 ANTERIOR division
2 POSTERIOR division
3 to Iliacus
4 to Pectineus
5 Intermediate Femoral Cutaneous
6 Medial Femoral Cutaneous anterior branch
7 Medial Femoral Cutaneous posterior branch
©D
8 to Rectus Femoris
9 to Vastus lateralis
10 to Vastus medialis
11 to Vastus intermedius
12 to Articular genus
13 to the hip
14 to the knee
15 Saphenous nerve
16 Infrapatellar branch
17 adductor canal for deep BVs and Ns
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F
aN
1
4
nd
ma
2 13
5 8
1
rA
6
11
5
6 17
©D
7
10
5 12
9 15
14 16
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Spinal Roots T1
Nerve type mixed = motor + sensory
Muscular branches to intercostal muscles (1-2)
Articular Branches costovertebral joints and
F sternocostal joints
Cutaneous branches to skin overlying the 1st IC space
aN
anteriorly and axilla (3-4)
LESIONS radicular pain over 1st IC space
typical aetiologies neck and BP injuries of the
Median and Ulna nerves
associated lesions/losses unable to fully assess injuries to
BP with injury to this N - unless
nd
associated with other IC nerve
injuries
1 N to internal intercostal
2 N to external intercostal
ma
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5
F
aN
2
1
nd
3
ma
4
rA
©D
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Genitofemoral nerve
LP (emerges from the anterolateral border of Psoas major)
eill
Spinal Roots L1, L2
Nerve type mixed = motor + sensory
Muscular branches to Genital area (cremaster
muscle in males)
Articular Branches NONE
Cutaneous branches to femoral triangle
aN
G to genital area
LESIONS loss of cremaster reflex /
parasthesia over area described
associated lesions/losses iatrogenic - cut in appendectomy
causes
nd
1 Genital branch
2 Femoral branch
3 Genital branch (cutaneous)
ma
rA
©D
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aN
G
nd
ma
1
rA
3
2
©D
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Spinal Roots C2, C3
Nerve type sensory
Muscular branches NONE
Articular Branches NONE
Cutaneous branches skin over the Parotid Gland (1)
skin over the mastoid process
aN
G and the back of the ear (2)
LESIONS loss of sensation on the area
nd described
ma
rA
©D
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aN
2 G
1
nd
ma
rA
©D
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Nerve type mixed = motor + sensory
MAJOR BRANCHES Medial and Lateral branches
Muscular branches to the capitus muscles in the neck
/ head (3-6)
Articular Branches to the atlanto-occipital and
atlanto-axial joints
aN
G Cutaneous branches to the dorsum neck and head to
the level of the ear
LESIONS parasthesia to the back of the
head in occipital region
typical aetiologies whiplash injuries to the neck in
car accidents
nd
associated lesions/losses injury to sternocleidomastoid /
occiptal nerves often
overcompensate and cause muscle
spasm and headaches (seen
several weeks after the accident)
ma
1 Medial branch
2 Lateral branch
3 to Obliquus capitus inferior
4 to Semispinalis capitus
5 Longissimus capitus
rA
6 to Splenius capitus
©D
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aN
G
1
4
3
nd
6
2
ma
5
rA
©D
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Iliohypogastric nerve
LP (emerges from the lateral border of Psoas major)
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Spinal Roots T12, L1
Nerve type mixed = motor + sensory
Muscular branches to Transversus Abdominus
to Internal abdominal oblique
(also see intercostals - lower T7-12, and ilioinguinal n)
Articular Branches NONE
aN
Cutaneous branches lateral cutaneous branch
anterior cutaneous branch
LESIONS weakening of abdominal wall
I associated lesions/ iatrogenic - cut in appendectomy
losses may develop a direct inguinal or
abdominal hernia
nd
Ilio-inguinal nerve
LP (emerges from the lateral border of Psoas major)
Spinal Roots L1
ma
labia majora
LESIONS weakening of abdominal wall
associated lesions/ iatrogenic - cut in appendectomy,
losses causes nephrectomies / pfannenstiels
excision may develop in large
pregnancies a direct inguinal or
©D
1 to Transversus Abdominus
2 to Internal abdominal oblique
3 lateral cutaneous branch
4 anterior cutaneous branch
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2 1
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aN I
nd
ma
2
1
rA
©D
3 4
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Spinal Roots L5, S1, S2
Nerve type motor
Muscular branches to GM (2)
Articular Branches NONE
Cutaneous branches NONE
LESIONS difficulty running jumping and
aN
climbing stairs, rising from a
seated position, skating
typical aetiologies commoner than superior gluteal
I N injuries, but rare to be
injured alone
associated lesions/losses pelvic and back injuries
nd
1 Pyriformis
2 to Gluteus Maximus
ma
rA
©D
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aN I
nd
1
ma
rA
2
©D
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Spinal Roots S2, S3, S4
Nerve type mixed = motor + sensory
MAJOR BRANCHES from the PUDENAL nerve
Perineal
aN
Posterior scrotal or Labial nerves
Dorsal nerve to the Penis (Clitoris)
Muscular branches to the levator ani, external anal
sphincter & coccygeas
I Articular Branches NONE
Cutaneous branches skin between the anus and the
coccyx and lining the anal canal
nd
below the circumanal line
LESIONS sagging of the pelvic floor /
compromised rectal and bladder
control (particularly in the female)
cystocoele or rectocoele / prolapse
ma
1 Perineal branch
rA
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aN I
nd
4
ma
1
rA
7
3
5
2 6
©D
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Nerve type mixed = motor + sensory
Muscular branches to muscles of thorax and abdomen
Articular Branches costovertebral joints and sternocostal
joints (ac)
Cutaneous branches supplies skin over the abdomen
and latissimus dorsi and the costal
aN
surface of the diaphragm
T10 supplies skin over the umbilicus
LESIONS loss of sensation and movements of the
rectus muscles with entrapment in the
I muscle of nerve and fat - abdominal
muscles cannot move so contraction
occurs unilaterally
nd
Clicking rib syndrome - subluxation of
interchondral joints refers pain to the
abdomen in areas described - “clicks”
when moving thorax/abdomen in sitting up
typical aetiologies osteoporosis / leukaemia thoracic
vertebral fractures
ma
eill
5
13
1
2
14
aN
4
I
nd
6
9
ma
8
11
3
7
rA
3
10
8
12
5
©D
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Nerve type mixed = motor + sensory
NAMED BRANCHES Collateral branches (cb) 1
-terminal Lateral Cutaneous branches (lc) 2
Anterior Cutaneous branches (ac) 3
Muscular branches to muscles of the chest and back (4-10)
Articular Branches costovertebral joints and sternocostal
aN
joints (ac)
Cutaneous branches supplies skin over the intercostal space
anteriorly laterally and posteriorly (lc, ac)
I LESIONS loss of sensation in areas described -
needs 2 or more intercostals nerves
involved to be detected because of
nd
innervation overlap T4 corresponds to
the nipple line T5,T6 pain in the same
area as heart mistaken for angina
pectoris / oesophageal spasm
typical aetiologies osteoporosis / leukaemia thoracic
ma
vertebral fractures
associated lesions/ thoracic vertebral damage / from trauma
losses or disease
1 Collateral branches
2 Lateral Cutaneous branch with their anterior and
rA
8 to Tranverse thoracis
9 to Serratus posterior inferior
10 to External oblique
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9
2
1
aN 7
I
nd
6
ma
2
rA
4
8
10
5
©D
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additional educational resources: GPO 637 Sydney 2001
aN
nd
Origins, insertions, actions, blood supply and All anatomical terms are listed along with a
nerve supply listed for all muscles, separate pronunciation guide and etymology (word
ma
listing of all major muscle groups; separate origin), Tables of abbrev. medical prefixes,
index of all muscles; regional index of the suffixes & word roots; degrees & professional
muscle along the side and cross referencing associations are included, along with guides
with common muscle names. to basic anatomical principles.
rA
©D
All bones are separately listed, as well as an All bones, their joints, movements, ligaments,
examination of all cavities, joints and relations, Blood and Nerve supply are listed.
anthropological markers. Radiology of the Each major joint is discussed in detail -
skull and its cavities are shown and shown with and without their additional
explained from several aspects. supportive structures.
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medicalamanda@gmail.com
aN
nd
All peripheral nerves, their pathways, All the bones and muscles of the Head &
branches, alternative names and nerve root Neck region are described indiv.
ma
The
A to Z
rA
of the
Brain
COMING
©D
SOON!
As well as all the Bones Joints and ligaments The Brain, CNs, SC, & neural pathways are
of the body drawn individually - a separate described, in colour coded sections and listed
section on postures, vertebral development alphabetically as well as clinical examination
and regional differences along with of the CNs, neural damage assessment, the
movements is included. cerebral BS and is significance - cross ref.
with all the other A to Zs.
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Spinal Roots L2-3
Nerve type sensory
Muscular branches NONE
Articular Branches NONE
Cutaneous branches supplies skin of thigh and gluteal
region (1-2)
aN
LESIONS parasthesia to area described
associated lesions/losses iatrogenic - cut in surgery
causes nd
L
ma
rA
©D
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aN
nd
L
ma
2
rA
1
1
2
©D
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Spinal Roots C5-7 (lateral cord - ant divisions)
Nerve type motor
Muscular branches to muscles of the chest (1-2)
Articular Branches to Glenohumeral joint
Cutaneous branches NONE
LESIONS weakness in scapula, adduction
aN
and medical rotation of arm i.e.
difficulty in reaching to touch
opposite shoulder
1 Pectoralis Major
2 Pectoralis Minor
nd
L
ma
rA
©D
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aN
nd
2
L
1 1
ma
2
rA
©D
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Spinal Roots L4, L5, S1, S2, S3
Nerve type mixed = motor + sensory
Muscular branches to the lateral toes 4th and 5th / and
adductors of the big toe
Articular Branches to the joints of the 4th and 5th toes
aN
Cutaneous branches to the skin on 4th and 5th toes and
the lateral side of the foot
LESIONS parasthesia on the 5th toe and
inability to abduct toes
particularly the lateral digits
typical aetiologies foot wear damage / trauma to the
side of the foot and little toe
nd
trauma and associated ankle dislocations
losses and trauma
L
1 superficial branch
2 deep branch
ma
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5
6
1
aN
nd
7
13
L
1
8 10 12
ma
3 13
14
10
9
11
14
rA
14 14
4
©D
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Spinal Roots C2, ±C3
Nerve type sensory
Muscular branches NONE
Articular Branches NONE
Cutaneous branches skin on the neck along the
posterior border of
aN
Sternocleidomastoid to the
Mastoid process, behind and
around the Pinna of the ear
LESIONS loss of sensation on the area
described
nd
L
ma
rA
©D
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aN
nd
L
ma
rA
©D
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BP (supraclavicular branches)
aN
Muscular branches to Levator Scapulae
Articular Branches NONE
Cutaneous branches NONE
LESIONS dropped shoulders, poor “shrugging”;
winged* scapula(e) ; poor abduction of
both ULs, particularly > 20º;
unstable scapula - compromising the
nd
Deltoids, Rhomboids, Serratus and
Spinati muscles - innervation is
L ispilateral hence unilateral injuries
affect the same side
typical aetiologies rare - direct injury in this area
ma
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aN
nd
L
ma
rA
©D
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Spinal Roots C5, C6, C7
Nerve type motor
Muscular branches to Serratus Anterior (2)
Articular Branches NONE
Cutaneous branches NONE
LESIONS “winged scapula” because of
aN
unopposed action of Levator
Scapulae and Rhomboids
cannot lift arm above the
horizontal
typical aetiologies heavy weights crushing the
shoulder injuries to the posterior
nd
triangle* of the neck
associated lesions/losses unable to fully assess injuries to
L the UL cannot assess shoulder
function little UL abduction
ma
1 Axillary artery
2 Serratus Anterior
3 Glenoid fossa
rA
©D
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3
aN
nd
1
L
ma
rA
©D
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Spinal Roots C1, C2, C3
Nerve Type motor
Muscular branches to Longus Capitus
Articular Branches NONE
Cutaneous branches NONE
LESIONS loss/weakness of flexion of the
aN
neck loss/weakness/asymmetry
of neck rotation
typical aetiologies whiplash injuries from automobile
or athletic injuries
associated lesions/losses part of a C2 radiculopathy seen
with loss of sensation on the neck
nd
L Longus Colli (Nerve to)
CP (deep branches)
BP (supraclavicular branches)
ma
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aN
nd
L
ma
rA
©D
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Spinal Roots C5, C6, C7
Nerve type motor
Muscular branches to Subscapularis (inferior) (1) & to
Teres major (2)
Articular Branches NONE
aN
Cutaneous branches NONE
LESIONS weak adduction & medial rotation
of the Humerus
typical aetiologies BP injuries
associated lesions/losses BP injuries
nd
L
ma
rA
©D
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aN
nd
L
ma
rA
2
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Nerve type motor
Muscular branches to Quadratus Lumborum
to Psoas minor (L1)
to Psoas major (L1-3)
Articular Branches NONE
Cutaneous branches NONE
aN
LESIONS weakening of hip flexion (L2>L3)
parasthesia over anterior thigh (L2>L1)
1 to Quadratus Lumborum
nd
2 Psoas minor
3 Psoas major
L 4 Iliohypogastric N
5 Ilioinguinal N
6 Lateral femoral cutaneous N
ma
7 Femoral N
8 Genitofemoral N
9 Obturator N
10 Accessory Obturator N
11 upper root of the Lumbosacral trunk
12 inguinal ligament
rA
13 pubic symphysis
14 anterior superior iliac spine
©D
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1
4
2
aN
5
8
nd
L
7
ma
14 11
9
rA
10
13
©D
12
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Lumbar Plexus
summary
eill
Spinal Roots T12, L1, L2, L3, L4
Nerve type mixed = motor + sensory
MAJOR BRANCHES Muscular branches (1)
Iliohypogastric N (2)
Ilio-inguinal N (3)
aN
Genitofemoral N (4)
5 Obturator N
6 Accessory obturator N
nd
from Dorsal Divisions
L 7 Lateral femoral cutaneous N
8 Femoral N
9 Lumbosacral trunk to Sacral plexus
ma
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2 1
aN
6 1
4
8
nd
6
5
9 L
ma
2
3
4
rA
6 6
7
©D
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Spinal Roots C8, T1 (medial cord - ant divisions)
Nerve type mixed = motor + sensory
Muscular branches NONE
Articular Branches NONE
aN
Cutaneous branches skin on medial aspect of the arm
and over the elbow (see also
intercostobrachial n + second intercostal n)
LESIONS loss of sensation on the area described
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aN
nd
M
ma
rA
©D
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Spinal Roots C6-8, T1 (medial and lateral cords -
ant division)
Nerve type motor
Muscular branches to anterior chest muscles (1-2)
Articular Branches NONE
Cutaneous branches NONE
aN
LESIONS weakness when touching opposite
shoulder with arm
nd
M
ma
rA
©D
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1
aN
nd
2
M
ma
rA
1
2
©D
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Spinal Roots L4, L5, S1, S2, S3
Nerve type mixed = motor + sensory
Muscular branches to the big toe Hallicus, and associated
flexor foot muscles (4-6)
Articular Branches to the ankle tarsus and metatarsus
Cutaneous branches to the skin on the medial side of the
aN
sole of the foot and ball of the toes
LESIONS Tarsal tunnel syndrome - “jogger’s foot”
typical aetiologies damage to the tibial nerve in tarsal
tunnel from external pressure from foot
wear ± thickened retinaculum
sensory loss at the heel indicates lesion
nd
above the ankle and tarsal tunnel
associated lesions/ ankle dislocations and trauma
losses
M
1 hallucial medial digital N
ma
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aN
5
4
nd
1 2
M
7
ma
5
rA
6
©D
3 3
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Median Nerve
BP (Infraclavicular branches)
eill
Spinal Roots C5-8 T1 (medial + lat cords - ant
division)
Nerve type mixed = motor + sensory
NAMED BRANCHES Anterior interosseous (AI)
(1) (terminal) Palmar digital (Pd) (2)
Muscular branches to Pronator teres
aN
to Flexor carpi radialis
to Palmaris Longus
to Flexor digitorum superficialis
to Flexor pollicus longus (Ai)
to Pronator quadratus (Ai)
to Flexor digitorum profundus (Ai)
nd
Articular Branches to the elbow joint
to the radio-ulnar proximal
to the interosseous membrane
M Cutaneous branches supplies the palmar skin on the
lateral side
ma
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4
5
6
aN
3
3 1
6
5
nd
4
9
7 8 M
ma
7
5
rA
2
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Spinal Roots C5-8 T1 (medial + lat cords - ant
division)
Nerve type mixed = motor + sensory
NAMED BRANCHES Lateral branch, Common palmar digital
(terminal) branches, Proper palmar digital
branches (ppd), Palmar cutaneous
aN
branch (pc) (1-4)
Muscular branches to intrinsic hand muscles on the lateral
side of the hand (5-9)
Articular Branches to the finger and wrist joints
Cutaneous branches supplies the skin on the sides and
palm of resective digits (ppd)
nd
LESIONS supf wrist lacerations may result in
parasthesia of the thumb and 1st 2
fingers carpal tunnel syndrome
M weak wrist and finger flexion
Ape hand = cannot oppose the thumb
ma
1 Lateral branch
2 Common palmar digital branches
3 Proper palmar digital branches
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4 7
10
aN
5
6 1
2
8
nd
7
9 M
ma
rA
3
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Musculocutaneous Nerve
BP (Infraclavicular branches)
eill
Spinal Roots C5-7 (lateral cord - ant divisions)
Nerve type mixed = motor + sensory
Muscular branches flexors of the UL see also Radial N
Articular Branches NONE
Cutaneous branches lateral antebrachial cutaneous
branch to skin on anterolateral surface
aN
of arm forearm from elbow to thumb
LESIONS loss of sensation on the area described
inability to flex the elbow while
supinated loss of biceps tendon reflex
1 to Coracobrachialis
nd
2 to Biceps Brachii
3 to Brachialis
4 lateral antebrachial cutaneous branch
M 5 Brachial artery
ma
rA
©D
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2
aN
nd
M
ma
5
1
3
rA
4
4
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Obturator nerve
LP (emerges from the anteromedial border of Psoas major)
eill
Spinal Roots L2-4
Nerve type mixed = motor + sensory
Muscular branches ANTERIOR
to Adductor longus
to Gracilis
to Adductor Brevis
aN
to Pectineus (see also accessory obturator)
POSTERIOR
to Obturator externus
to Abductor magnus
±to Adductor brevis
Articular Branches to the hip and knee joints
nd
Cutaneous branches to groin / medial thigh
LESIONS inability to stabilze the hip / to
cross legs
associated lesions/ iatrogenic - cut in pelvic surgery
losses causes associated with ovarian cancer /
ma
1 to Adductor longus
2 to Gracilis
3 to Adductor Brevis
4 to Pectineus
5 to Obturator externus
6 to Abductor magnus
©D
7 cutaneous branches
8 hip joint (anterior)
9 to the knee joint (posterior)
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aN
nd
8 4
5 1
ma
4 6
3
2 O
rA
1
7
©D
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Spinal Roots L5, S1, S2
Nerve type motor
Muscular branches to Obturator internus (1)
to Gemellus superior (2)
aN
Articular Branches NONE
Cutaneous branches NONE
LESIONS weak external rotation of the thigh
typical aetiologies abdominal injuries - anything damaging
L4/5 discs rare to see isolated
associated lesions/ pelvic, back injuries degeneration
losses
nd
ma
O
rA
©D
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aN
nd
2
ma
O
rA
1
©D
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Spinal Roots S2, S3
Nerve type sensory
MAJOR BRANCHES Superficial peroneal
Lateral terminal branch (S1,2)
Medial terminal branch (S1,2)
aN
Muscular branches NONE
Articular Branches NONE
Cutaneous branches branches to skin over Gluteus
Maximus (1)
LESIONS parasthesia over area described above
typical aetiologies CP injuiries
associated lesions/
nd
losses
ma
P
rA
©D
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aN
nd
ma
P
rA
1
©D
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Phrenic Nerve
CP (deep branches) see also Accessory Phrenic Nerve
eill
Spinal Roots C3, C4, C5*
Nerve type mixed = motor + sensory
Muscular branches to the Diaphragm including the crura (1-3)
Articular Branches NONE
Sensory branches supplies branches to the pleura over
aN
the Diaphragm and the Diaphragm
including the central tendon for
proprioception (1-3)
LESIONS unilateral - paralysis of ½ the
Diaphragm on the same side -
minimal loss of function
bilateral - complete paralysis of the
nd
Diaphragm - severe dyspnea;
coughing; sneezing; respiratory
muscles, atrophy of the diaphragm
typical aetiologies damage to cervical spinal roots and/or
cords trauma to the Chest
ma
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3
aN
2
nd
ma
P
rA
©D
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Spinal Roots S1, S2
Nerve type motor
Muscular branches to Piriformis
Articular Branches NONE
Cutaneous branches NONE
LESIONS weak external rotation of the thigh
aN
typical aetiologies abdominal injuries - anything damaging
L4/5 discs rare to see isolated
associated lesions/ pelvic, back injuries degeneration
losses
1 to Piriformis
nd
2 Sciatic N
3 Greater Trochanter
ma
P
rA
©D
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aN
nd
3
1
ma
P
rA
2
©D
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Spinal Roots S1, S2
Nerve type sensory
Muscular branches NONE
Articular Branches NONE
Cutaneous branches Gluteal branches (cluneal)
Perineal branches
aN
branches to the back of the thigh and leg
LESIONS parathesia over the area described
typical aetiologies prolonged bicycle riding
associated lesions/ pelvic and back injuries
losses
nd
1 Gluteal branches
2 Perineal branches
3 branches to the back of the thigh and leg
4 gluteal line inferior border of Gluteus maximus
ma
P
rA
©D
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aN
nd
1
4 2
ma
P
rA
3
©D
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Spinal Roots C5, C6, C7, C8, T1
Nerve type motor
Muscular branches to muscles on the back of the forearm
(1-9)
Articular Branches to the radioulnar joint
aN
to the interosseous membrane
to the RC IC and IMC joints
Cutaneous branches NONE
LESIONS weak extension/flexion of the Elbow
weak extension of the wrist
“wrist drop”
nd
weak supination parasthesia on the
back of the arm and forearm and lateral
surface of the arm
typical aetiologies BP injuries, broken arm, elbow injuries
associated lesions/ UL injuries
ma
losses
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3
5
aN 8
nd
1
7 9
4
6
ma
3
P
rA
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Pudendal nerve
SP (anterior division directly from SP)
eill
Spinal Roots S2, S3, S4*
Nerve type mixed = motor + sensory
MAJOR BRANCHES Inferior Rectal / Inferior Haemorrhoidal
Perineal
Posterior scrotal or Labial nerves
Dorsal nerve to the Penis (Clitoris)
Muscular branches to the levator ani, external anal sphincter
aN
& coccygeas, muscles of the
anterior perineum
Articular Branches to ligaments and joints of the pelvis -
pubic symphysis and ligaments
Cutaneous branches skin between the anus and the coccyx
and lining the anal canal below the
circumanal line - all areas of the labia
and scrotal areas / clitoris / penis
nd
including sensation of the urethra
LESIONS sagging of the pelvic floor / compromised
rectal and bladder control (particularly in
the female) cystocoele or rectocoele /
prolapse of uterus in older females /
anesthesia of the scrotal and labial area
ma
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9 10
6
aN
4
7
8
1
nd
7 3
9 11
2
10
ma
P
rA
4
4
©D
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Spinal Roots L4, L5, S1
Nerve type motor
Muscular branches to Quadratus Femoris (1)
to Gemellus inferior (2)
aN
Articular Branches to the hip joint
Cutaneous branches NONE
LESIONS weak external rotation of the thigh
typical aetiologies abdominal injuries - anything damaging
L4/5 discs rare to see isolated
associated lesions/ pelvic, back injuries degeneration
losses
nd
ma
Q
rA
©D
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aN
nd
2
ma
Q
rA
1
©D
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Radial Nerve
BP (Infraclavicular branches) see also Posterior interosseous
and Radial nerve - terminal branches
eill
Spinal Roots C5, C6, C7, C8, T1 post cord
Nerve type mixed = motor + sensory
NAMED BRANCHES Superficial Terminal (ST)
terminal Deep radial = Posterior interosseous
nerve (PIN)
aN
Muscular branches to muscles on the back of the arm and
forearm (3-9) see also Musculocutaneous nerve
Articular Branches to the elbow joint carpo/metacarpo/and
phalangeal joints of thumb to middle finger (ST)
Cutaneous branches supplies the skin on the back of the
arm and the lateral part of the forearm
and back of the wrist (1, 10-12) - and
nd
thumb to middle finger (ST)
LESIONS weak extension/flexion of the Elbow
weak extension of the wrist
“wrist drop”
weak supination parasthesia on the
back of the arm and forearm and
ma
R
1 Superficial terminal branch
2 Posterior interosseous N = Deep Radial N
3 Triceps long head
4 Triceps medial head
5 Triceps lateral head
©D
6 Anconeus
7 Brachioradialis
8 Extensor carpi radialis longus
9 Brachialis
10 Posterior Brachial cutaneous
11 Inferior lateral brachial cutaneous branch
12 Posterior antebrachial cutaneous branch
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5
5
3
aN 9
nd
4
7
ma
6
rA
2 R
8
10 11
©D
12 1
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nerve
BP (Infraclavicular branches) see also Radial nerve
aN
Muscular branches 1-10 listed below
(all from posterior
interosseous nerve- PIN)
Articular Branches to all the distal forearm, wrist and hand
joints (PIN) to proximal and distal
phalangeal jts. (ST)
Cutaneous branches supplies the skin on the back of the
nd
(all from ST) arm and the lateral part of the forearm
and back of the wrist and thumb to
middle finger (10)
LESIONS weak extension of the wrist
“wrist drop”
ma
R losses
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3
aN
8
5
1
7 9
4
nd
6
3
10
ma
rA
10
©D
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Spinal Roots ±C1, C2, C3
Nerve Type motor
Muscular branches to Rectus Capitus Anterior (1)
Articular Branches NONE
Cutaneous branches NONE
aN
LESIONS loss/weakness of flexion of the head at
the atlanto-occipital jt part of a C2
radiculopathy
typical aetiologies whiplash injuries from automobile or
athletic injuries
nd
Rectus Capitus Lateralis (Nerve to)
CP (deep branches)
R
©D
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aN 1
nd
ma
rA
2 R
©D
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Spinal Roots S4
Nerve type motor
MAJOR BRANCHES Peroneal (then to the anal sphincter)
Muscular branches to the levator ani and coccygeus
Articular Branches NONE
aN
Cutaneous branches skin between the anus and the coccyx
LESIONS sagging of the pelvic floor /
compromised rectal and bladder
control (particularly in the female)
cystocoele or rectocoele / prolapse of
uterus in older females
typical aetiologies pressure on the Sacrum
nd
associated lesions/ uterine prolapse / obesity / large
losses abdominal mass
1 Peroneal branch of S4
2 to Levator ani
ma
3 to Coccygeus
4 to the external anal sphincter
rA
S
©D
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aN
4
1
3
nd
ma
2
rA
4
S
3
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Nerve type mixed = motor +sensory
aN
Sacral muscular Ns
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4
5
aN
1
3 6
nd
2
9
8
ma
7
rA
6
11 10 S
13
12 14
©D
16
10
15
12
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Spinal Roots ±C4, C5, C6, C7 C8
Nerve type motor
Muscular branches to the Scaleni muscles and Longus Colli
Articular Branches NONE
aN
Cutaneous branches NONE
LESIONS ± TOS with resultant muscle spasm in
injury innervation is ispilateral hence
unilateral injuries affect the same side -
weakness of neck flexion and weak
contralateral rotation of the neck
(loss limited by synergism with
nd
Sternocleidomastoid)
typical aetiologies rare - direct injury in this area
associated lesions/ unable to fully assess injuries to
losses BP with injury to this N
ma
1 to Scalaneus anterior
2 to Scalenus Medius
3 to Scalenus Posterior
4 to Longus Colli
rA
S
©D
eill
aN
2
4
nd
3
ma
1
rA
S
©D
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Spinal Roots C3, C4, C5-C8
Nerve type motor
Muscular branches to Scalenus Medius
Articular Branches NONE
Cutaneous branches NONE
aN
LESIONS ± TOS innervation is ispilateral hence
unilateral injuries affect the same side
(weak neck flexion and turning, function
may be taken over by SCM.
typical aetiologies rare - direct injury in this area
synergism with Trapezius and SCM
nd
limits functional loss
associated lesions/ unable to fully assess injuries to
losses BP with injury to this N
ma
rA
S
©D
eill
aN
nd
ma
rA
S
©D
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Sciatic nerve
LP SP (dorsal + ventral divisions)
eill
Spinal Roots L4, L5, S1, S2, S3
Nerve type mixed = motor + sensory
Muscular branches hamstrings, all the muscles of the leg
and foot and adductor magnus
Articular Branches to the hip joint
Cutaneous branches to the back and sides the thigh and all
aN
of the leg and foot
LESIONS complete - paralysis of leg and foot
with parasthesia in the leg and foot /
weak hip adduction DD injuries of
common peroneal only
typical aetiologies car accidents, hip trauma, spinal
nd
injuries, L4/5 disc damage
associated lesions/ pelvic and back injuries
losses
S
©D
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7
aN
nd
4 5
ma
5 3 6
6
7
6
rA
3 5 S
7
2
©D
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Nerve type mixed = motor + sensory
NAMED BRANCHES Anterior Cutaneous branch (ac) (1)
-terminal Lateral Cutaneous branch /
intercostobrachial nerve (ic) (2)
Muscular branches to the intercostal muscles (3,4,7) and
accessory muscles of respiration
aN
Articular Branches costovertebral joints and sternocostal
joints (ac)
Cutaneous branches supplies skin over the 2nd intercostals
space (ac) supplies skin to axilla floor
/upper half of arm on medial and
posterior side (ic)
nd
LESIONS loss of sensation in areas described - in
particular underarm numbness
typical aetiologies iatrogrenic - in breast cancer surgery
associated lesions/ surgery in thoracic region as in
losses mastectomies
ma
6 to Tranverse thoracis
7 to intercostals intimi
S
©D
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4 5
3 aN
nd
7
2 1 2
2
ma
6
rA
3
4 S
©D
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Nerve type mixed = motor + sensory
LESIONS see sensory / motor map of the SNs
typical aetiologies VC damage accidents
aN
3 dorsal root ganglion
4 ventral ramus
5 grey rami communicans
6 sympathetic chain imput from thoracic Ns
7 vertebral artery
8 white matter - myelinated axons
nd
9 grey matter - nerve cell bodies - unmyelinated nerve
processes
10 dura mater
11 arachnoid mater
12 spinous process of the VB
ma
*note 8 cervical Ns and 7 cervical vertebrae C8 exits b/n C7 and T1 C2-7 b/n C1-C7.
rA
S
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aN
6
5
7
4
nd
9
8
3
ma
10 2
1
11
rA
12
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Nerve type mixed = motor + sensory
LESIONS see sensory / motor map of the SNs
typical aetiologies VC damage accidents
aN
3 dorsal root ganglion
4 ventral ramus
4A ventral root
5 grey rami communicans
6 sympathetic chain
7 vertebral artery
nd
8 white matter - myelinated axons t
9 grey matter - nerve cell bodies - unmyelinated nerve
processes
10 dura mater
11 arachnoid mater
ma
note the SC finishes in the adult at L1/2, hence the SN may exit at a level lower
than their Spinal roots the roots running down in the VC until their exit - L1 - arises
at the level of T10, but exits b/n T12/L1 / L2-3 arise at T11 / L4-5 arise at T12
S
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aN
9
1
8
6
nd
4A 4
3
ma
2
rA
10 S
11
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eill
Nerve type mixed = motor + sensory
LESIONS see sensory / motor map of the SNs
typical aetiologies VC damage accidents
aN
3 dorsal root ganglion
4 ventral ramus
5 grey rami communicans
6 sympathetic chain
7 vertebral artery
8 white matter - myelinated axons t
nd
9 grey matter - nerve cell bodies - unmyelinated nerve
processes
10 dura mater
11 arachnoid mater
12 spinous process of the VB
ma
13 cauda equina
14 sacrum with S1-5 N foraminae
rA
S
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7
aN
nd
13
14
ma
14
14
14 1
rA
S
14
14 4
©D
15
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eill
Nerve type mixed = motor + sensory
LESIONS see sensory / motor map of the SNs
typical aetiologies VC damage accidents
aN
3 dorsal root ganglion
4 ventral ramus
4A ventral root
5 grey and white rami communicans
6 sympathetic chain
7 vertebral artery
nd
8 white matter - myelinated axons t
9 grey matter - nerve cell bodies - unmyelinated nerve
processes
10 dura mater
11 arachnoid mater
ma
S
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6
aN
5
13 4A
4
nd
ma
4
3
rA
1
3 S
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Spinal Roots + Cranial Ns Cranial XI (Accesssory) C1-C5
Nerve type mixed = motor + sensory
Muscular branches to the Sternocleidomastoid (1)
to Trapezius (2)
Articular Branches NONE
Cutaneous branches NONE
aN
LESIONS unilateral - cannot rotate head to
the affected side, cannot shrug
ipsilateral shoulder bilateral -
cannot rotate head or shrug
shoulders, cannot lift chin - head
drops forwards
nd
typical aetiologies intracranial damage to Accessory
nerve as in stroke
head trauma affecting jugular
foramen
associated lesions/ any injury to the jugular foramen
ma
S
Discussed in gretaer detail in the A to Z of the brain
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aN
2
nd
1
ma
rA
S
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Spinal Roots C5, C6
Nerve type motor
Muscular branches to Subclavius
Articular Branches NONE
Cutaneous branches NONE
aN
LESIONS none unless the Accessory
Phrenic nerve is injured -
diaphragm weakness
typical aetiologies broken clavicle (collar bone)
associated lesions/losses
nd
ma
rA
S
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aN
nd
ma
rA
S
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Subcostal Nerve
part of the LP (twelfth thoracic nerve)
eill
Spinal Roots T12 (ventral ramus)
Nerve type mixed = motor + sensory
MAJOR BRANCHES Medial and Lateral branches
Muscular branches to the muscles of the abdominal
wall (1-6)
aN
Articular Branches to the 12th costovertebral joint (10)
Cutaneous branches to the skin overlying pubis, greater
trochanter and gluteal area (8-9)
LESIONS weakness and bulging of the lower
abdominal wall (Beever’s sign)
typical aetiologies spinal injuries
associated lesions/losses any injuries involving the SC and
nd
VC , iatrogenic laminectomy and
other operations in this area.
1 to Quadratus lumborum
2 to Transverse abdominus
ma
3 to Internal oblique
4 to External oblique
5 to Rectus Abdominus
6 to Pyramidalis
7 Inguinal ligament
8 lateral Cutaneous N
rA
9 anterior Cutaneous N
S 10 to costovertebral joint
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10
eill
4 3
1
2
aN
nd
6 5
8
ma
7 8
9 9
rA
S
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Nerve type mixed = motor + sensory
MAJOR BRANCHES Medial and Lateral branches
Muscular branches to the capitus muscles in the
head and neck
Articular Branches to the craniovertebral joints
aN
Cutaneous branches to the dorsum neck and head
crosses and supplies similar area
to the lesser occipital nerve
LESIONS parasthesia to the back of the
head in occipital region
typical aetiologies whiplash injuries to the neck in
car accidents
nd
associated lesions/losses injury to sternocleidomastoid /
occiptal nerves often
overcompensate and cause muscle
spasm and headaches (seen
several weeks after the accident)
ma
6 Medial branch
7 Lateral branch
S
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1
aN 3
nd
2
ma
6
4
7
5
rA
S
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Spinal Roots L4, L5, S1, S2
Nerve type mixed = motor + sensory
Named branches medial (1)
lateral (2)
dorsal digital (3)
Muscular branches to Peroneus longus (4) and brevis (5)
aN
Articular Branches NONE
Cutaneous branches NONE
LESIONS weak eversion of the foot /
unopposed inversion of the foot
parasthesia on the lateral side of
the lower leg
nd
typical aetiologies abdominal injuries - anything
damaging L4/5 discs
iatrogenic pudendal block etc
incorrect rare to see isolated
associated lesions/losses pelvic and back injuries
ma
1 medial
2 lateral
3 dorsal digital
4 to Peroneus longus
5 to Peroneus brevis
rA
S
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4
5
aN 4
nd
4
ma
1
2
rA
S
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Spinal Roots L4, L5, S1
Nerve type motor
Muscular branches superior and inferior branches to
muscles in the buttock and the
hip abductors (1-5)
Articular Branches to the sacroiliac joint
aN
Cutaneous branches NONE
LESIONS Trendelenburg’s sign = dropping
1
S
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aN
1
3
2
5
nd
4
1
ma
9
rA
6 S
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Supraclavicular Nerve
CP (superficial branches)
eill
Spinal Roots C3, C4
Nerve type sensory
Muscular branches NONE
Articular Branches NONE
Cutaneous branches skin above the clavicle anterior (1)
aN
lateral (2) and posterior (3)
LESIONS loss of sensation on the area described
nd
ma
rA
S
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aN
nd
1
ma
1
rA
3 S
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Suprascapular Nerve
BP (supraclavicular branches)
eill
Spinal Roots C5, C6
Nerve type motor ±sensory
Muscular branches to the dorsal muscles around the
Scapula (1, 2)
Articular Branches to the shoulder joints (3, 4)
Cutaneous branches to the skin over the Deltoid
aN
LESIONS weak abduction and lateral
rotation of the Humerus atrophy
of muscles around the Scapula
typical aetiologies Injuries to the BP
injuries to Clavicle
associated lesions/losses BP injuries, neck injuries
nd
1 to Supraspinatus
2 to Infraspinatus
3 to Glenohumeral joint
4 to Acromioclavicular joint
ma
5 Clavicle
6 Acromian
7 spine of Scapula
rA
S
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4 1
aN
3 7
2
nd
6
4
2
ma
1
5
rA
S
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Nerve type mixed = motor + sensory
MAJOR BRANCHES Medial and Lateral branches
Muscular branches to the capitus muscles in the neck
and head (3-5)
Articular Branches to the atlanto-occipital and atlanto-
axial joints (6)
aN
Cutaneous branches to the dorsum neck and head to
the level of the ear
LESIONS parasthesia to the back of the
head in occipital region
typical aetiologies whiplash injuries to the neck in car
accidents
nd
associated lesions/losses injury to sternocleidomastoid /
occiptal nerves often
overcompensate and cause muscle
spasm and headaches (seen
several weeks after the accident)
ma
1 Medial branch
2 Lateral branch
3 to Splenius capitus
4 to Semispinalis capitus
5 to Longissimus capitus
rA
T
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aN
1
6
nd
3
2
ma
5
rA
T
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Thoracic Nerves
Summary
eill
do not form plexi - remain segmental, ventral rami do not
fuse and do not communicate form the intercostal Ns (IC Ns)
aN
T6-12 = thoraco-abdominal Ns
= lower thoracic IC Ns
1 IC Ns to Rectus Abdominus
2 abdominal wall muscles segmentally supplied by the
IC Ns.
3 inguinal ligament
rA
4 Pubic Symphysis
5 ASIS = anterior superior iliac spine
6 costal cartilages
T 7 IC spaces
8 IC muscles
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aN
8
7
nd
ma
1 6
2
rA
T
5
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3
4
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Thoracodorsal Nerve
= Middle Subscapular nerve
BP (Infraclavicular branches)
eill
Spinal Roots C6, C7, C8
Nerve type motor
Muscular branches to Latissimus Dorsi
Articular Branches NONE
aN
Cutaneous branches NONE
LESIONS weak adduction, extension and
medial rotation of the Humerus
typical aetiologies BP injuries, clavicular injuries
associated lesions/losses BP injuries
nd
ma
rA
T
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aN
nd
ma
rA
T
©D
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Tibial nerve
SP (ventral divisions) from sciatic N
eill
Spinal Roots L4, L5, S1, S2, S3
Nerve type mixed = motor + sensory
Muscular branches to the back of the leg and soul of the
foot
Articular Branches to the knee and ankle joints
Cutaneous branches to the skin on the sole and medial heel
aN
LESIONS uncommon due to deep placement of
the N cannot flex or abduct or adduct
toes toes / cannot stand on tip toes /
weak knee flexion / weak plantar
flexion
some parasthesia of the foot and toes
nd
typical aetiologies car accidents, leg - knee trauma, L4/5
disc damage
associated lesions/ leg and knee injuries
losses
ma
7 to Tibialis posterior
8 to knee joint
9 to tibiofibular joints
T 10 Medial calcaneal cutaneous nerve
11 Medial plantar nerve
12 Lateral plantar nerve
©D
13 Sural nerve
14 to flexor digitorum longus
15 to flexor hallicus longus
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1 4
3
2 13
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5
5
6
7
aN
7 14 15
10
nd
7 12
11 14
15
ma
6
15
3 4 14
1 2
rA
8 10
9 7
12 T
14
5
©D
6 11
9
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Spinal Roots + Cranial Ns Cranial XI (Accesssory) C3, C4
Nerve type mixed = motor + sensory
(proprioceptive)
Muscular branches to Trapezius
Articular Branches NONE
aN
Cutaneous branches NONE
LESIONS unilateral - dropped ipsilateral
shoulder ; winged* scapula
bilateral - cannot properly move
arms at all particularly not over 20º
compromising the function of
nd
Deltoids, Rhomboids, Serratus
and Spinati muscles
typical aetiologies damage to Accessory nerve in the
posterior triangle
iatrogenic eg when sampling
ma
T
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aN
nd
ma
rA
T
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Ulnar Nerve
BP (Infraclavicular branches)
eill
Spinal Roots C8, T1 (medial card - ant division)
Nerve type mixed = motor + sensory
NAMED BRANCHES Dorsal (Do) (1)
(terminal) Superficial (ST) (2)
Deep (De) (3)
Muscular branches to Flexor Carpi Ulnaris (4)
aN
to Flexor Digitorum Profundus (5)
to Palmaris Brevis (ST)
to all the intrinsic hand muscles (De)
Articular Branches to the elbow joint
to the joints in the little and ring fingers (Do)
to some of the wrist joints (De)
nd
Cutaneous branches supplies the palmar skin on the ulnar
side and the little and ring fingers (ST) F
LESIONS weak flexion and ulna deviation of the
wrist “clawed hand”
wasting of Palmaris brevis in the
ma
losses
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1 9
aN
7
4
nd
5
1
ma
1
6
2 7
rA
8
3
U
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Ulnar Nerve -
Deep Terminal branch (De)
BP (Infraclavicular branches)
eill
Spinal Roots C8, T1 (medial card - ant division)
Nerve type mixed = motor + sensory
Muscular branches to Abductor digiti minimi (1)
to Flexor Digiti Minimi (2)
aN
to Opponens digiti minimi (3)
to Dorsal interossei (4)
to Palmar interossei (5)
to 3rd and 4th Lumbricals (6)
to Adductor Pollicus (7)
Articular Branches to some of the wrist joints
Cutaneous branches NONE
nd
LESIONS inability to spread fingers and
extend little finger wasting and
paralysis of the hypothenar
muscles no thumb adduction
typical aetiologies elbow injuries
ma
U
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8 aN 3
2
1
nd
5
ma
6
7
4
4
5
4
4
rA
U
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Spinal Roots C5, C6, C7
Nerve type motor
Muscular branches to Subscapularis (superior)
Articular Branches NONE
Cutaneous branches NONE
aN
LESIONS weak medial rotation of the
Humerus
typical aetiologies BP injuries
associated lesions/losses BP injuries
nd
ma
rA
U
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aN
nd
ma
rA
U
©D
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aN
nd
ma
rA
©D
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Dr. A. L. NEILL
BSc MSc MBBS PhD FACBS
medicalamanda@gmail.com
www.amandasatoz.com
0410 018 681
fax: 61 2 9365 1000