Lymphatic Pathways of Lower Limbs PDF

Lymphatic Pathways VASCULAR PATHOLOGY AND PHYSIOTHERAPY: UNIT 3 Unit Objectives To gain knowledge of the pathways in which lymph travels through the vessels and lymph nodes to the terminus in the following regions: ◦ Head and neck ◦ Upper limbs ◦ Lower limbs ◦ Pelvis and abdomen ◦ Thorax Lower L...

Lymphatic Pathways VASCULAR PATHOLOGY AND PHYSIOTHERAPY: UNIT 3 Unit Objectives To gain knowledge of the pathways in which lymph travels through the vessels and lymph nodes to the terminus in the following regions: ◦ Head and neck ◦ Upper limbs ◦ Lower limbs ◦ Pelvis and abdomen ◦ Thorax Lower Limbs Lower Limb Lymphatic Pathways and Nodes Lymphatic Pathways Superficial Deep Medial Anterior tib Anterolateral Posterior tib Posterolateral Peroneal/fibular Gluteal Femoral Lymphatic Nodes Inguinal Deep (med and lat) Popliteal (deep and superficial) Superficial Superior (med and lat) Superficial Inferior (med and lat) Superficial Pathways Superficial Vessel Pathways They are more numerous than the deep collectors. oMedial collectors- arise from the dorsum of the foot oFollow the route of the great saphenous vein proximally (passing posterior to the femoral medial condyle) oEnter into the superficial inguinal nodes (inferomedial) oAnterolateral collectors- arise from the lateral aspect of the foot oContinues anterolaterally oIt may join the medial route, but with variation on whether it crosses the midline inferior or superior to the knee oSuperficial inguinal nodes (inferolateral) Superficial Vessel Pathways oPosterolateral collectors- arise from the lateral aspect of the foot oRuns proximally following the route of the lesser saphenous vein oSuperficial popliteal nodes → deep pathways oGluteal collectors- arise from the lymphatic capillaries within the gluteal tissue spaces oThey run into the superficial inguinal nodes (superior medial and lateral) Gluteal collectors Medial collectors Posterolateral collectors Anterolateral collectors Deep Vessel Pathways The deep lymphatic collectors of the lower limb are fewer in number than those superficially They follow the routes of the vascular bundles Share name of the accompanying artery Deep Vessel Pathways Lower leg: •Anterior tibial •Posterior tibial •Peroneal/fibular oConverge to form popliteal collectors oFlow into the deep popliteal nodes Thigh: •Femoral oFlow into the deep inguinal nodes Derivative/Alternative Vessel Pathways Similar to the upper limb, some common derivative/alternative pathways exist: oDeep collector vessels following the route of the sciatic nerve oSuperficial collector vessels following the “Giacomini” vein (between the lesser and greater saphenous), to the superficial inguinal nodes Lower Limb Lymphatic Pathways and Nodes Lymphatic Pathways Superficial Deep Medial Anterior tib Anterolateral Posterior tib Posterolateral Peroneal/fibular Gluteal Femoral Lymphatic Nodes Inguinal Deep (med and lat) Popliteal (deep and superficial) Superficial Superior (med and lat) Superficial Inferior (med and lat) Lymph Nodes of the Lower Limbs There are two main groups of nodes within the lower limbs: o Inguinal – the regional nodes of the lower limbs o Popliteal There are also secondary groups (of a few interval nodes) including tibialis anterior group, tibialis posterior group, peroneal group and femoral group. Popliteal Nodes Deep inguinal nodes Femoral collectors Located within the fatty tissue reserve of the popliteal fossa. Some superficial nodes, approx. 4-8 deep. Drains lymph from superficial posterolateral collector pathway, deep pathway collectors, and directly from the knee and fossa itself. Intercommunicating vessels may exist between popliteal nodes. Sup. Popliteal nodes Deep Popliteal nodes Post nodal collectors → deep inguinal nodes. If there is a blockage in this pathway then a secondary route to the superficial inferior inguinal nodes is possible. Posterolateral collectors Deep collectors Superficial Inguinal Nodes The inguinal nodes can be divided into two groups: deep and superficial. Superficial nodes located in femoral (Scarpa´s triangle) Approx. 18-20 nodes The superficial inguinal nodes lie in subcutaneous tissue and can be further divided into: oSuperior (horizontal) medial and lateral oInferior (vertical) medial and lateral Superficial Inguinal Nodes The superior (/horizontal) medial and lateral nodes generally drain lymph from: oGluteal region (including the superficial gluteal collector pathway) oInfraumbilical area oSkin of external genitals and the anal region Superficial Inguinal Nodes The inferior (/vertical) medial and lateral nodes generally drain lymph from: oThe superficial surface of the lower limbs o Medial → medial group o Anterolateral → lateral group oThe efferent vessels from both groups pierce the fascia and pass to the deep inguinal nodes, or directly to lacunar nodes, and then iliac nodes Deep Inguinal Nodes The deep inguinal nodes lie in the upper, inner part of the thigh, commonly along the route of the femoral vascular bundle. The most apical node (Cloquet’s) usually sits just inferior to the inguinal ligament. Deep inguinal nodes Deep Inguinal Nodes The deep inguinal nodes receive lymph from: oDeep collector vessel pathways o(popliteal nodes) oEfferent vessels of the superficial inguinal nodes. Deep inguinal nodes The efferent vessels pass lymph to the lacunar and external iliac lymph nodes (pelvis), and later form the lumbar trunks. Shinaoka A, Koshimune S, Suami H, Yamada K, Kumagishi K, Boyages J, Kimata Y, Ohtsuka A. Lower-Limb Lymphatic Drainage Pathways and Lymph Nodes: A CT Lymphangiography Cadaver Study. Radiology. 2020 Jan;294(1):223-229. doi: 10.1148/radiol.2019191169. Epub 2019 Nov 19. PMID: 31746690. Investigating the Superficial Pathways •Shinaoka et al. (2019) •Fluorescent dye injection into the feet of 130 cadavers •They identified 4 pathways: • • • • Anteromedial Posteromedial Anterolateral Posterolateral Medial collectors Nodes: Inguinal nodes Popliteal nodes 3 nodes (2 superficial inferior inguinal and 1 popliteal) received 73% of the total lymph of the superficial lower limb Genital pathways confirmed as separate (superficial superior) Lower Limb Lymphatic Pathways and Nodes Lymphatic Pathways Superficial Deep Medial Anterior tib Anterolateral Posterior tib Posterolateral Peroneal/fibular Gluteal Femoral Lymphatic Nodes Inguinal Deep (med and lat) Popliteal (deep and superficial) Superficial Superior (med and lat) Superficial Inferior (med and lat) Infection and Cancer in the Inguinal Lymph Nodes •Sexually transmitted diseases may cause inflammation of the superficial superior inguinal nodes (chlamydia and syphilis) •Cancer cells may appear in the inguinal lymphatic nodes, after travelling through the collector vessels from their primary site •Vulvar, penile and anal cancer cells often travel to the superficial superior inguinal nodes •Testicular cancer cells may travel to the nodes of the pelvis (retroperitoneal nodes) From the Inguinal Nodes to the Cardio Vascular System Which trunks does the lymph from the lower limbs run into after the inguinal nodes (and pelvic nodes)? Which lymphatic duct does the lymph from these trunks then enter? Where does the lymph enter the cardiovascular system i.e. where is the terminal location? Terminal Location Where the internal jugular vein anastomoses with the subclavian vein Node Group Pathway/ Tissue Area Drained Deep Inguinal _______ pathways, popliteal nodes Superficial Inguinal- superior group (horizontal) medial and lateral _______, sub-umbilical area, skin of external genitals, anal region Superficial Inguinal- _____ group (________) medial and lateral _______________ collectors, superficial anterolateral collectors (i.e. superficial surface of lower limbs) Superficial and deep ______ Posterolateral collector pathway, deep lower leg vessels, knee, popliteal fossa