Lumbosacral Plexus Injuries PDF

# Lumbosacral Plexus Injuries **M.D MAIA KAPANADZE** ## Lumbar Plexus and Sacral Plexus - **Lumbar Plexus:** - Iliohypogastric n. - Ilioinguinal n. - Genitofemoral n. - Lateral Femoral Cutaneous n. - Femoral n. - Obturator n. - Lumbosacral Trunk - **Sacral Plexus:**...

# Lumbosacral Plexus Injuries **M.D MAIA KAPANADZE** ## Lumbar Plexus and Sacral Plexus - **Lumbar Plexus:** - Iliohypogastric n. - Ilioinguinal n. - Genitofemoral n. - Lateral Femoral Cutaneous n. - Femoral n. - Obturator n. - Lumbosacral Trunk - **Sacral Plexus:** - Superior Gluteal n. - Inferior Gluteal n. - Common Peroneal n. - Sciatic n. - Tibial n. - Posterior Cutaneous n. - Perforating Cutaneous n. - Pudendal n. ## Background - Network of nerve fibers that branch out to innervate the lower limbs - Derived from roots of lumbar and sacral spinal nerves ## Clinical Significance - Spinal disc herniation is the most common cause of damage - Compression of local spinal nerves - Shooting pain down leg - Numbness and muscle weakness in areas of affected nerves ## Lower Limb Nerve Pathology ### Nerves - Obturator: - Pelvic surgery - Thigh adduction - Femoral: - Pelvic fracture or mass of iliopsoas iliacus - Flexion of thigh - Extension of leg - Fibular neck fracture - Common Peroneal: - Foot eversion - Dorsiflexion of toes - Tibial: - Trauma to the knee - Tarsal tunnel syndrome - Foot inversion - Plantar flexion - Toe flexion - Superior Gluteal: - Butt injection - Thigh Abduction - Trendelenburg - Inferior Gluteal: - Posterior hip dislocation - Thigh extension ## Cauda Equina Syndrome - It is considered a neurosurgical emergency and a rare condition - Cauda equina syndrome is due to compression of the collection of nerves distal to the terminal part of the spinal cord known as the cauda equina - **Common causes are -** - Lumbar stenosis: narrowing of the spinal canal in the lumbar region - Spinal trauma - Herniation of the disc - Malignancy - Spinal infections: abscess, tuberculosis - Neural tube defects (e.g. spinal bifida) ## Signs and Symptoms - Saddle anesthesia numbness around saddle region, buttons, anus and genitals - Pain in lower back and down on or both legs - Incontinence - bowel or bladder and sexual dysfunction - Lack of sensation and weakness in legs - Hypotonia - Leg weakness - Hyporeflexia - Diagnosis: MRI of spine - Complication: Permanent paralysis - Treatment: decompression surgery ## Femoral Neuropathy - The femoral nerve mainly controls the thigh muscles and is responsible for hip bending and knee extension and sensation in dermatomes of the legs - Any damage to the femoral nerve leads to femoral neuropathy or mononeuropathy - **Causes:** - Direct trauma - Trauma during spinal surgery - Pressure of femoral nerve due to hematoma or tumor - Fracture - Lithotomy position during childbirth ## Symptoms - Numbness or tingling of the leg - Muscle weakness - Difficulty walking or using the leg - A loss of sensation - A loss of coordination - Diagnosis: Electromyography ## Peroneal Nerve Palsy - The common peroneal nerve is a branch of the sciatic nerve. It supplies movement and sensation to the lower leg, foot and toes. - **Causes:** - Trauma or injury to the knee - Fracture of the fibula - Use of a tight plaster cast (or other long-term constriction) of the lower leg. - Regularly wearing high boots. - Pressure to the knee from positions during deep sleep or coma - Injury during knee surgery ## Symptoms - Decreased sensation, numbness, or tingling in the top of the foot or the outer part of the upper or lower leg - Foot that drops (Unable to hold the foot up) - “Slapping” gait - Toes drag while walking - Walking problems - Weakness of the ankles or feet - Loss of muscle mass because the nerves aren’t stimulating the muscles ## Obturator Nerve Palsy - The obturator nerve arises from the lumbar plexus and provides sensory and motor innervation to the thigh. - Provides motor innervation to the medial compartment of the thigh for balancing, rotating, extending legs and flexing hips and sensation to inner thigh - **Causes:** - Direct Trauma to the groin - Entrapment of the obturator nerve causes exercise-induced medial thigh pain, typically in athletes - Compression during surgery ## Signs and Symptoms - Pain & paresthesias - Leg weakness, trouble walking. - Weak hip adductors on affected side. - Wasting of medial thigh. - Abnormal abduction of hip during ambulation resulting in a circumduction, wide-based gait. - Area of sensory loss of the medial thigh which sometimes may extend below the knee. ## Meralgia Paresthetica - It refers to localised sensory symptoms of the outer thigh caused by compression of the lateral femoral cutaneous nerve. This is a mononeuropathy. - It is also known as a nerve entrapment syndrome. - **Cause:** - **Mechanical:** - Pregnancy (or any condition that increases abdominal pressure), - Obesity, - Different leg lengths, - Pubic symphysis (pelvic girdle) dysfunction. - **Metabolic:** - Neuropathy (from diabetes), - Hypothyroidism. - **Iatrogenic:** - Prolonged traction during spine surgery - Injury to the nerve during retroperitoneal dissection ## Signs and Symptoms - Pain on the outer side of the thigh, occasionally extending to the outer side of the knee usually constant. - Burning sensation, tingling, or numbness in the same area. - Occasionally, aching in the groin area or pain spreading across the buttocks - Usually more sensitive to light touch than to firm pressure - Hypersensitivity to heat (warm water from shower feels like it is burning the area) - Occasionally, patients may complain of itching sensation rather than pain in the affected area. ## Sciatic Neuropathy - Sciatica is pain in the lower extremity resulting from irritation of the sciatic nerve. - The pain of sciatica is typically felt from the low back lumbar area to behind the thigh and radiating down below the knee and may reach the foot. - **Cause:** - Disc herniation - Spinal stenosis - Spondylolithesis - Direct trauma - Irritation during pregnancy ## Sciatica Pain - It is nerve pain which occurs due to irritation of the sciatic nerve. ### Symptoms - Lower Back pain - Hip Pain - Burning or tinging in the leg - Difficulty to move the leg or foot - Difficult to stand up - Pain in the rear or leg while sitting ### Risk Factors - Age - Diabetes - Obesity - Prolonged sitting - Inactive lifestyle ### Diagnosis - X-ray - MRI - CT scan ### Treatment - Physical Therapy - Steroid injections - Surgery - Medication ### Prevention - Follow proper lifting techniques - Regular walk and yoga - Maintain one’s weight - Regular stretching exercises - Maintain proper posture when you sit ## Morton’s Neuroma - Mortons Neuroma is a compressive neuropathy of the interdigital nerve, usually between the third and fourth metatarsals. - Females are affected more - **Causes:** - Compression of the interdigital nerve due to - Narrow toe-box footwear - Hyperextension of the toes in high-heeled shoes - Deviation of the toes - Inflammation of the intermetatarsal bursa - Thickening of the transverse metatarsal ligament - Forefoot trauma - Some high impact sporting activities such as running, football, basketball, metatarsophalangeal joint pathology, and lipoma ## Symptoms - **Burning Pain** - **Tingling Toes** - **Pain Worsens with Shoes** ## What to Expect During an Electromyography Test - Needle electrode inserted into muscle - Neurologist tells you when to contract and rest muscle - Needle records muscle activity during rest and movement ## EMG vs. Nerve Conduction ### Electromyography (EMG) - **What is EMG?** - Your muscles move in response to nerve signals from the brain. Electromyography (EMG) measures how well your muscles respond to those signals. - **How is an EMG conducted?** - To conduct and EMG test, your doctor will insert a small needle electrode into your muscle. Your doctor may ask you to slowly contract your muscle to measures the response, and may move the needle to test different areas - **How long does an EMG test take?** - 30-60 minutes, not counting time to treat any residual soresness. ### Nerve Conduction Study (NCS) - **What is NCS?** - Your nerves carry the signals from your brain to your muscles. A Nerve Conduction Study (NCS) measures how will the nerves in your body carry these electrical signals - **How is an NCS conducted?** - Your doctor will place several flat metal disc electrodes on your skin, fastened with a gentle tape or paste. Several quick electrical pulses will be applied through your nerves, and your doctor will record the time it takes for your nerves to transmit the signal. - **How long does an NCS test take?** - 15 minutes - 1 hour, depending on the extent of the testing. # Thank you