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Lumbar and Sacral Plexus with Clinical Cases

by Annie Burke-Doe, PT, MPT, PhD
Practicing physical therapist and associate professor at the University of St. Augustine for Health Sciences in San Diego, California

Slide 1: Lumbar and Sacral Plexus with Clinical Cases

Welcome to Neuroanatomy in Physical Therapy. I am Dr. Annie Burke-Doe, a practicing physical therapist and an associate professor at the
University of St. Augustine for Health Sciences in San Diego, California.

This lecture series has been developed for physical therapists embarking on the study of neurology. In this lecture we will focus on the lumbar and
sacral plexus, which provides nervous innervation to the lower limb.

Slide 2: Lumbar Plexus

The lumbar plexus is a nervous plexus in the lumbar region of the body, which forms part of the lumbosacral plexus. As with the brachial plexus, the
spinal nerves contributing to the lumbar plexus have both anterior and posterior divisions (anterior on this slide is shaded yellow and posterior is
shaded blue). The lumbar portion of the plexus is formed by the ventral divisions of the first four lumbar nerves (L1 through L4) and from
contributions of the last thoracic nerve (T12). Additionally, the ventral rami of the fourth lumbar nerve passes communicating branches to the sacral
plexus. The nerves of the lumbar plexus pass in front of the hip joint and mainly support the anterior portion of the thigh. So, when you think about
this ventral aspect, you should think about it supporting the anterior portion of the thigh.

The plexus is formed lateral to the intervertebral foramina (which are not pictured here) and pass through psoas major. Its smaller motor branches are
distributed directly to the psoas major, while larger branches leave the muscle at various sites to run obliquely downward through the pelvic area and
leave the pelvis under the inguinal ligament, with the exception of the obturator nerve, which exits the pelvis through the obturator foramen.

Slide 3: Femoral and Obturator Nerves

It is most clinically important to be familiar with the functions of the femoral, obturator, sciatic, tibial, and peroneal nerves in the lower extremity.
Let’s start with the motor functions of the femoral and obturator nerves (pictured here).

I would like you to begin by tracing the largest and longest nerve in the plexus, the femoral nerve, with your finger. That way you can follow its
pathway. You can see that it gives motor innervation to iliopsoas (which refers to both the psoas and iliacus at their inferior ends), pectineus, sartorius,
and the quadriceps muscle group. Motor functions of the femoral nerve include hip flexion at L2-3 (lift my knee) and knee extension at L3-4 (kick the
door).

Next, trace the obturator nerve with your finger as it leaves the lumbar plexus and descends behind the psoas major on its medial side, then travels
into the lesser pelvis, and finally leaves the pelvic area through the obturator canal. In the thigh, it sends motor branches to obturator externus before
dividing into an anterior and posterior branch, both of which will continue distally. These branches are separated by adductor brevis and supply all the
thigh adductors with motor innervation, including pectineus, adductor longus, adductor brevis, adductor magnus, adductor minimus, and gracilis.

Slide 4: Femoral and Obturator Nerves

Here on the right we can see the sensory distribution of the femoral nerve, which provides sensory innervation to the anterior thigh, posterior lower
leg, and hindfoot. In the thigh, it divides into numerous sensory and motor branches and the saphenous nerve, which is its long, sensory, terminal
branch that continues down to the foot.

The obturator nerve (pictured in darker blue) has an anterior branch that supplies the skin on the medial, distal part of the thigh.

When testing sensation clinically, it is also important to link the dermatomes (which are pictured on the left) to provide the clinician information
related to the spinal level involved.

Slide 5: The Sacral Plexus

The sacral plexus (pictured here) arises from L4 through S3 and S4 at the lumbosacral enlargement. Some authors do not differentiate between the
lumbar and the sacral plexus and describe them together. The sacral plexus provides motor and sensory nerves for the posterior thigh, most of the
lower leg, the entire foot, as well as part of the pelvis. The most clinically important branches arising from the plexus are the sciatic, tibial, and
peroneal nerves. Branches from the posterior division are in blue, and branches from the anterior division are in yellow.

Trace your finger beginning at L4-5 to see that the posterior division leads to the superior gluteal nerve, which innervates the gluteus medius,
minimus, and tensor fasciae latae, whose actions are abducting and medial rotation of your thigh. As you continue to travel down with your finger,
you will find the inferior gluteal nerve, which innervates the gluteus maximus, and whose actions are to extend and laterally rotate the thigh, as well
as to extend the lower trunk. You will now descend down to the sciatic and common peroneal nerve. Now follow the anterior division of the tibial
nerve that innervates the lower extremity, which will be discussed further as we go forward.

Slide 6: The Sciatic Nerve

Here on slide 6, we are looking at the sciatic nerve. The sciatic nerve is the largest peripheral nerve in the body. It is comprised of the tibial and
common peroneal nerve and exits the pelvis inferior to the piriformis muscle, between the ischial tuberosity and the greater trochanter of the femur.
Motor functions include thigh adduction, medial rotation, and hip extension, as well as knee flexion.

Clinically, in sciatic neuropathy, there is weakness of all foot and ankle muscles, of knee flexion, loss of Achilles tendon reflexes, and sensory loss in
the foot and lateral leg below the knee. The term “sciatica” is a vague term and refers to all disorders causing painful paresthesias in a sciatic
distribution.

Slide 7: The Tibial Nerve

The tibial nerve (pictured here) is the larger, medial and terminal branch of the sciatic nerve. Trace the tibial nerve with your finger as it continues the
line of the sciatic nerve through the popliteal fossa and into the leg. In the popliteal fossa, the nerve gives off branches to gastrocnemius, popliteus,
plantaris, and soleus muscles. The tibial nerve also provides an articular branch to the knee joint and a cutaneous branch that will become the sural
nerve. The sural nerve will supply the lateral side of the foot.

Below the soleus muscle, the nerve lies close to the tibia and supplies tibialis posterior, the flexor digitorum longus, and flexor hallucis longus. The
nerve passes into the foot running posterior to the medial malleolus. Here it is bound down by the flexor retinaculum in company with the posterior
tibial artery.

In the foot, the nerve divides into medial and lateral plantar branches. Motor functions of the tibial nerve include foot plantar flexion and inversion
and toe flexion.

Slide 8: The Tibial Nerve

In the foot, the tibial nerve divides into medial and lateral plantar branches. Cutaneous distribution of the medial plantar nerve is to the medial sole
and the medial three-and-a-half toes, including the nail beds on the dorsum, like the median nerve in the hand.

The lateral plantar nerve cutaneous innervation is to the lateral sole and lateral one-and-a-half toes, like the ulnar nerve.

Slide 9: The Common Peroneal Nerve

Now, let’s trace the common peroneal nerve in its pathway as it descends obliquely along the lateral side of the popliteal fossa to the head of the
fibula. Where the nerve winds around the head of the fibula, it is palpable.

The common peroneal nerve divides into the superficial peroneal nerve and the deep peroneal nerve.

The superficial peroneal nerve supplies the muscles of the lateral compartment of the leg, including peroneus longus and peroneus brevis. These two
muscles help in eversion and plantar flexion of the foot. The deep peroneal nerve innervates the muscles of the anterior compartment of the leg,
which are tibialis anterior, extensor hallucis longus, extensor digitorum longus, and peroneus tertius. Together these muscles are responsible for
dorsiflexion of the foot and extension of the toes.

Clinically, peroneal nerve palsy can cause drop foot with weakness of foot dorsiflexion and eversion and sensory loss over the dorsolateral foot and
shin. An ankle foot orthotic may improve function if the foot drop is significant.

Slide 10: The Common Peroneal Nerve with Superficial and Deep Peroneal Sensory Distribution
Depicted here on slide 10, the common peroneal nerve supplies sensation to the lateral and anterior surfaces of the upper part of the leg. The
superficial peroneal nerve supplies sensation to the distal third of the leg and the dorsum of the foot, while the deep peroneal nerve supplies
contiguous sides of the first and second toes.

Slide 11: Regions of Sensory Innervation Supplied by Cutaneous Nerve Branches

Here on slide 11, we see regions of sensory innervation supplied by the lateral cutaneous nerve of the thigh and the obturator nerve (both depicted in
gray).

Slide 12: Case 1: Lower Extremity Weakness

The following interactive cases are designed for you to read and answer the questions in preparation for your coursework in neurology, as well as for
your licensure preparation. Please proceed through each of the cases and determine the answers to the questions.

Slide 13: Case 1: Jane Has Lower Extremity Weakness

A 68-year-old female was admitted to the hospital due to an acute chest pain. She underwent cardiac catheterization and angioplasty through the right
femoral artery.

She was referred to physical therapy one month later for evaluation of her right lower extremity weakness and numbness in her thigh. She described
her pain as moderate in her groin and anterior thigh.

Slide 14: Case 1: Jane’s History

Her Medical History:

• One month ago, the patient underwent femoral catheterization and angioplasty with resulting lower extremity weakness, sensory changes, and
groin pain.
• On the third day after her admission, a neurologic examination and a CT scan of her pelvis identified a right retroperitoneal hematoma
involving the iliacus muscle extending to the iliac crest with surgical evacuation.

Social History:

• She is employed as an administrative assistant.

• She is divorced; has one daughter and two grandchildren.
• She enjoys entertaining and spending time with her grandchildren.

Medication:

• Her medications include Lovenox, Lipitor, and Metoprolol.

Family History:

• Her family history includes hypertension, cardiac disease, and diabetes.

Please stop and review the following:

1. What are the key findings from the history?

2. What is the anatomy and innervation of the iliacus?
3. Look up the medications involved and what they do in the body.
4. Describe why social history is important to the physical therapist.

Slide 15: Case 1: Jane’s Neurologist Report

Jane’s neurologic examination during her acute stay revealed complete paralysis of the right quadriceps and iliopsoas. Thigh adductors and ankle
dorsiflexion were normal. The right knee jerk was absent. There was loss of touch and pain sensation over the anterior thigh and medial leg.

Please review the following before proceeding:

1. What nerves innervate the quadriceps and iliopsoas?

2. What nerves innervate the thigh adductors and ankle dorsiflexors?
3. What spinal cord level is responsible for the knee jerk?
4. What spinal cord levels provide sensation to the anterior thigh and medial leg?

Slide 16: Case 1: Jane’s PT Examination

Jane presents for her physical therapy examination with the following findings:

Vital Signs:

• Her blood pressure was 140/90.

• Heart rate, 80 beats per minute.
• Her skin was dry and had scales bilaterally on the lower extremities.
• Her endurance, she demonstrated shortness of breath with activity.
• Passive range of motion was within normal limits.
• Her mental status, she was alert and oriented and provided good history.
• Her cranial nerves were intact.
• Her tone was normal.
• Strength in the bilateral upper extremities was within normal limits.
• The right lower extremity, quadriceps, and iliopsoas were 3-/5.
• Right adductors and dorsiflexors were 5/5.
• Her reflexes, she was hyperreflexive at the right knee jerk.
• Coordination of the right lower extremity was impaired.

Slide 17: Case 1: Examination, Continued

Further physical therapy examination found:

1. Balance, sitting statically and dynamically within normal limits.

2. Good standing static balance and fair standing dynamic balance.
3. Jane ambulates with some loss of balance noted with self-recovery at community level distances on even surfaces.
4. Sensation was diminished, touch and pain, over the anterior thigh and medial leg.

Slide 18: Case 1: Jane's Goals

Jane’s goals were to return to independent ambulation on all surfaces and return to recreational activities including taking care of her grandchildren.

Slide 19: Case 1: Questions

Please answer the following question.

Which of the following nerves are responsible for this patient’s weakness in the quadriceps musculature?

A. Sciatic
B. Obturator
C. Femoral
D. Tibial

Slide 20: Case 1: Questions

Which of the following key signs in the right lower extremity indicate femoral neuropathy versus L4 radiculopathy?

A. Sparing of the right foot dorsiflexion

B. Sparing of right thigh adduction
C. Sparing of right foot plantar flexion
D. Sparing of right knee flexion

Slide 21: Case 1: Questions

Which nerve is responsible for the following pattern of weakness and sensory impairment?

1. 0/5 left tibialis anterior and extensor hallucis longus, 3/5 left foot evertors
2. Decreased pinprick sensation on the dorsum of the right foot especially pronounced in the web space between the second toes

When looking at this pattern of weakness and sensory impairment, is it:

A. Common peroneal nerve

B. Obturator nerve
C. Femoral nerve
D. Tibial nerve

Slide 22: Case 1: Questions

Which nerve is responsible for the following pattern of weakness and sensory impairment?

1. Diminished tone and S1 DTR, the right foot

2. 0/5 right tibialis anterior and extensor hallucis longus, right foot evertors, invertors and gastrocnemius, 3/5 power right hamstrings
3. Decreased light touch, pinprick, vibration, and joint proprioception in the right lateral calf and entire foot

Is it:

A. Tibial nerve
B. Obturator nerve
C. Femoral nerve
D. Sciatic nerve

Slide 23: Case 2: Sally Has Numbness and Pain with Pregnancy
Slide 24: Case 2: Sally’s Case Presentation
Sally is a 25-year-old female, who, one day after giving birth, developed a burning pain and numbness in her left lateral thigh, which increased when
ambulating.

She was referred to physical therapy for evaluation of her left lower extremity pain and numbness in her thigh.

Slide 25: Case 2: Sally’s History

Sally’s medical history includes that she is a healthy 25-year-old female, who, one day after giving birth, developed a burning pain and numbness in
her left lateral thigh, which increased when ambulating.

Her social history includes the fact that she’s married, and she plans to stay at home and care for her newborn.

The only medication she is currently taking is ibuprofen, and she has a family history of diabetes.

Please stop and review the following:

1. What are the key findings from the history?

2. Please look up the medications involved and what they do in the body.
3. What types of activities do you think will be required to care for a newborn?

Slide 26: Case 2: Sally’s PT Examination

Sally’s physical therapy examination findings are as follows:

Her vitals:

• Blood pressure 115/75.

• Heart rate, 65 beats per minute.
• Her skin was unremarkable.
• No endurance or fatigue was noted during the evaluation.
• Range of motion was within normal limits.
• She is alert and oriented with intact cranial nerves, normal muscle tone.
• Her strength, reflexes, and coordination were all within normal limits.

Slide 27: Case 2: Examination, Continued

Additional examination findings include normal balance, gait, but diminished sensation to light touch and pinprick, and cold on the right lateral thigh.
Pain was initially described as burning, rated 3/10 at rest and 6/10 with ambulation.

Slide 28: Case 2: Patient Goals

Sally’s physical therapy goal is to have her leg feel normal and have no pain in her right thigh in order to care for her child.

Slide 29: Case 2: Questions

Please answer the following question:

Which of the following nerve roots should be considered in the differential diagnosis as a source of the patient’s key signs and symptoms?

A. L1 myotome
B. L2 myotome
C. L3 myotome
D. L4 myotome
E. Both B and C myotomes

Slide 30: References

 • Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science. 4th ed. New York: McGraw-Hill; 2000.
• Schuenke M, Schulte E, Shumaker U. Thieme Atlas of Anatomy. New York, NY: Thieme; 2006: 470-471.
• Seigal A, Sapru HN. Essential Neuroscience. New York: Lippincott Williams & Wilkins; 2006.
• Blumenfeld, H. Neuroanatomy through Clinical Cases. Sunderland, MA: Sinauer Associates; 2002.
• Goodman C, Fuller K, et al. Pathology Implications for the Physical Therapist. 3rd ed. St. Louis, MO: Saunders; 2008.
• Hoppenfeld S. Physical Examination of the Spine and Extremities. New Jersey: Prentice-Hall; 1976.

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