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Stratificational relationship among the main nerves from the dorsal division of the sacral plexus and the innervation of the piriformis.

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THE ANATOMICAL RECORD 233533-642 (1992)
Stratificational Relationship Among the Main Nerves From
the Dorsal Division of the Sacral Plexus and the
Innervation of the Piriformis
KEIICHI AKITA, HIROKAZU SAKAMOTO, AND TATSUO SAT0
Department of Anatomy, Tokyo Medical and Dental Uniuersity, 1-5-45, Yushima,
Bunkyo-ku, Tokyo, 113 Japan
ABSTRACT
In order to comprehend more completely the morphology of the
nerves to the piriformis, it is necessary to obtain a detailed understanding of the
relationship of the origin and the course of these nerves from the dorsal division of
the sacral plexus, with reference to the superior and inferior gluteal nerves.
Twelve of seven human pelvic halves were carefully dissected in order t o examine
the origins of the nerves from the dorsal division of the sacral plexus. Six of these
pelvic halves were further dissected under a stereomicroscope to examine the
nerves to the piriformis.
1. The origin of the superior gluteal nerve was more proximal and dorsal in the
sacral plexus than that of the inferior gluteal nerve.
2. The superior gluteal nerve consisted of a thick cranial part and a thin caudal
part; the former continued as the inferior branch of the nerve, and the latter, the
superior branch. The cranial and caudal parts crossed before reaching the glutei
medius and minimus.
3. The nerves to the piriformis arose from three main nerves from the dorsal
division of the sacral plexus: 1) the caudalmost root of the superior gluteal nerve,
2) the caudal roots of the inferior gluteal nerve and 3) the common peroneal nerve.
Considering the stratificational relationship among the main nerves from the dorsal division of the sacral plexus, the piriformis appears to be composed of parts
from different muscle layers. o 1992 Wiley-Liss, Inc.
Most textbooks state that the nerves to the piriformis
arise from the dorsal branches of the first and second
sacral ventral rami (e.g., Clemente, 1985; Williams et
al., 1989). In general, most studies regarding the piriformis have focused on the relationship of this muscle
to the sciatic nerve (e.g., Beaton et al., 1938; Lee and
Tsai, 1974) and the homology of the muscle in man
with that in other animals. As the nerves to the piriformis in man have been considered to be the dorsalmost branches of the sacral nerves, in comparative
anatomical studies the piriformis in mammals has
been compared with the sole muscles in lower vertebrates (Romer and Persons, 1977; Starck, 1982).
Only Schwalbe (1881) pointed out that sometimes
the nerves to the piriformis arise from the root of the
superior gluteal nerve which originates from the
second sacral nerve. Interestingly, during our routine
dissection we often observed that some nerves to the
piriformis arose from the roots of the superior and
inferior gluteal nerves. If the nerves to the piriformis
in man consist of numerous branches of various
origins, the piriformis should be considered a complex
muscle.
Therefore, rather than the study of the homology or
the positional relationship of the piriformis to the sciatic nerve, here we focused on the dorsoventral rela0 1992 WILEY-LISS,INC.
tionship among the nerves from the dorsal division of
the sacral plexus and the sites of origin of the nerves to
the piriformis.
MATERIALS AND METHODS
Twelve pelvic halves of seven cadavers (ten halves of
six males and two halves of one female) were dissected;
in all specimens 24 presacral vertebrae ((37, Th12, L5)
were found. In the dissection procedure, in order to
obtain detailed data of the nerves of the dorsal division
of the sacral plexus, the bony elements were completely
removed. For a more detailed examination, in six pelvic halves of three cadavers (four halves of two males
and two halves of one female), the positional relationships of the origins of the nerves from the plexus, as
well as the mutual relationships of the origin, course
and distribution of their branches were examined under a stereomicroscope.
Received November 20, 1991; accepted January 27, 1992.
634
K. AKITA ET AL.
Fig. 1. Specimen 1 (right, female). Composition and ramification of the sacral plexus (dorsal aspect).
Shaded nerves belong to the ventral division of the sacral plexus (Figs. 1-61,
OBSERVATIONS
1. Segmental Composition of the Nerves From the Dorsal
Division of the Sacral Plexus
The segmental composition of the nerves from the
dorsal division of the sacral plexus in twelve pelvic
halves is listed in Table 1.The superior gluteal nerves
were generally formed by nerves of three segments (L4
t o Sl or L5 to S2). The segmental composition of the
inferior gluteal nerve and the common peroneal nerve
was almost the same as that of the superior gluteal
nerve, and all three nerves had common cranialmost
segments.
Bis
gfP
Fem
Gi
Gscd
Gscr
Gsi
Gss
Obt
Per
Pr
Tib
Abbreviations
branch to the short head of the biceps femoris
posterior femoral cutanteous nerve
dorsal rami of the lumbar and sacral nerves
femoral nerve
inferior gluteal nerve
caudal part of the superior gluteal nerve
cranial part of the superior gluteal nerve
inferior branch of the superior gluteal nerve
superior branch of the superior gluteal nerve
obturator nerve
common peroneal nerve
nerves to the piriformis
tibia1 nerve
11. Positional Relationships of the Nerves of the Dorsal
Division of the Sacra/ Plexus
A detailed description of the findings of Specimen 1
is given. Thereafter, only the specific differences in
each specimen are noted.
Specimen 1 (right, female) (Fig. 1)
From the dorsal surface of the trunks of L4, L5 and
S1, and from the union of L4 and L5, roots of the superior gluteal nerve arose as the proximalmost dorsal
branch of each ventral primary ramus. The superior
gluteal nerve consisted of a cranial part originating
from L4 and L5 and a caudal part from L5 and S1. The
roots of the inferior gluteal nerve arose from the dorsal
surfaces of the union of L4 and L5 and from the trunk
of S1. All roots of the inferior gluteal nerve arose more
distal than those of the superior gluteal nerve. The
cranial root of the inferior gluteal nerve which arose
from the union of L4 and L5 received nerve fibers from
the common peroneal nerve. The nerve to the short
head of the biceps femoris was formed by a branch from
the ventral surface of the inferior gluteal nerve and
branches from the dorsal surface of the common peroneal nerve. Three branches of the nerve to the piriformis arose from the caudalmost root of the caudal
part of the superior gluteal nerve, and one branch arose
from the caudalmost root of the inferior gluteal nerve.
The posterior femoral cutaneous nerve was formed by a
branch from the caudalmost root of the inferior gluteal
635
STRATIFICATION OF T H E SACRAL PLEXUS
c
Pe r
Tib
Fig. 2. Specimen 2 (left side of specimen 1).
TABLE 1. Segmental composition of the nerves of the dorsal division of the
sacral dexus
Specimen
1
2
3
4
5
6
7
8
9
10
11
12
Cadaver
1
1
2
2
3
3
4
4
5
5
6
7
Side
R
L
R
L
R
L
R
L
R
L
L
L
Sex
F
F
M
M
M
M
M
M
M
M
M
M
nerve, a branch from the dorsal surface of the caudal
root of the common peroneal nerve, and branches from
the roots of the tibia1 nerve.
Specimen 2 (left side of specimen 1) (Fig. 2)
The caudal part of the superior gluteal nerve originated from only S1. The formation of the inferior gluteal nerve and its relationship to the superior gluteal
nerve was the same as in the right half. The nerve to
the short head of the biceps femoris arose from the
ventral surface of the union of the branches to the in-
N. eluteus
Superior
Inferior
L4,L5,Sl
L4,L5,Sl
L5,Sl,S2
L5.S1,S2
L4;L5;s1
L4,L5,Sl
L53 1 3 2
L4,L5;s1
L5.Sl
L4,L5,Sl
N. peroneus
communis
L4,L5,Sl.S2
L4;L5;s1'
L5,sl,S2
L5.sl .s2
L4,L$Sl
L5.S
ferior gluteal nerve. The three nerves to the piriformis
arose only from the superior gluteal nerve. The posterior femoral cutaneous nerve was formed essentially
the same as in the right half, except for an additional
branch from the pudendal nerve.
ma'e) (Fig.3,
'pecirnen
As there were only a few thin branches connecting
L4 and L5, the superior gluteal nerve was considered to
be formed only by branches from the dorsal surface of
L5 to S2 (cranial part, L5 and S1; the caudal part, S1
K. AKITA ET AL.
636
cfp
A
-\
\
Fig. 3. Specimen 3 (right, male).
Fig. 4. Specimen 4 (left side of specimen 3).
STRATIFICATION OF T H E SACRAL PLEXUS
631
Fig. 5. Specimen 5 (right, male).
and S2). The inferior gluteal nerve was formed by
branches from the dorsal surface of the trunks of L5 to
S2, and arose more distal than the superior gluteal
nerve. The nerve to the short head of the biceps femoris
was formed by branches from the inferior gluteal nerve
and from the common peroneal nerve.
There were six nerves to the piriformis: four from the
caudalmost root of the caudal part of the superior gluteal nerve, and two from the ventral surface of the
caudal root of the common peroneal nerve.
Specimen 4 (left side of specimen 3) (Fig. 4)
The piriformis originated from the ventral surface of
the sacrum between the first and third pelvic sacral
foramina. The caudal portion, originating between the
second and third pelvic sacral foramina, was sandwiched by the cranial and caudal roots of the inferior
gluteal nerve and by the common peroneal and tibia1
nerves.
Although there was no contribution from L4, the formation of the superior gluteal nerve was similar t o that
of the right side. The cranial portion of the inferior
gluteal nerve was formed by the convergence of
branches from the dorsal surface of L5 and S1, and the
cranial half of S2. The caudal portion was formed only
by S2. These two roots joined creating a unique space
through which the caudal portion of the piriformis
passed. The formation of the nerve to the biceps femoris
was similar to that of the right side.
There were three nerves to the piriformis: one each
from the caudalmost root of the superior gluteal nerve,
the cranial root of the inferior gluteal nerve, and the
dorsal surface of the caudal root of the inferior gluteal
nerve.
Specimen 5 (right, male) (Fig. 5)
As the caudal part of L4 united only with the ventral
division of the plexus. The cranial portion of the superior gluteal nerve, formed by L5 and S1 consisted of
numerous branches compared to the caudal portion,
formed by S1 and S2. The nerve to the short head of the
biceps femoris was formed by the union of a branch
from both the inferior gluteal nerve and the common
peroneal nerve.
There were five nerves to the piriformis which arose
from the superior and inferior gluteal nerves, and the
dorsal surface of the trunks of S1 and S2.
Specimen 6 (left side of specimen 5) (Fig. 6)
Interestingly, the superior and inferior gluteal
nerves were formed by nerves from four segments, L4
to S2. The nerve to the short head of the biceps femoris
arose from the ventral surface of the inferior gluteal
nerve and connected with the dorsal surface of the common peroneal nerve.
There were four nerves t o the piriformis: two from
the caudal part of the superior gluteal nerve, and two
638
K. AKITA ET AL.
Fig. 6. Specimen 6 (left side of specimen 5).
teal nerve arises one segment cranial to the inferior
gluteal nerve. However, from the present observations,
the superior gluteal nerve, the inferior gluteal nerve,
111. The Branches to the Glutei Medius and Minimus
and the common peroneal nerve originated from the
As previously described, the superior gluteal nerve same group of segments. With L4 as the cranialmost
consisted of cranial and the caudal parts, except in nerve of the dorsal division of the sacral plexus (Figs. 1,
specimen 12 in which this nerve was formed by only 2,6), the inferior gluteal nerve included a root from L4.
two segments (L5 and S1) (see Table 2). In all cases, the Therefore, it can be concluded that the superior gluteal
cranial part continued as the inferior branch of the nerve does not arise one segment cranial to the inferior
nerve which ran with the lower ramus of the deep di- gluteal nerve.
No recent reports have described the dorsoventral
vision of the superior gluteal artery; the caudal part
continued as the superior branch, accompanied by the relationship between the superior and inferior gluteal
upper branch of the deep division of the superior glu- nerves. Eisler (1892) stated that the caudalmost roots
teal artery (Williams et al., 1989). Therefore, the cau- of the superior gluteal nerve cross behind the cranialdal part dorsally crossed the cranial part before reach- most roots of the inferior gluteal nerve. In the present
study, within the same segment the superior gluteal
ing the glutei medius and minimus (Fig. 7).
nerve arose proximal to the inferior gluteal nerve. And
DISCUSSION
as Eisler (1892) stated, some roots of the superior glu1. The Segmental Composition and Dorsoventral
teal nerve were found to cross behind roots of the infeRelationship of the Superior and Inferior Gluteal Nerves
rior gluteal nerve (see Fig. 1).Taken together, it can be
Although there are numerous reports on the mor- concluded that the superior gluteal nerve lies dorsal to
phology of the sacral plexus, the details of the descrip- the inferior gluteal nerve.
tion of each nerve from the plexus have not signifi11. The Stratification of fhe Dorsaf Division of the
cantly progressed since the reports of Paterson (1887)
Sacral Plexus
and Eisler (1891, 1892).
According to Paterson (1887) the superior gluteal
In general, it is accepted that the presence of the
nerve arises from L4 to S1, and the inferior gluteal longitudinal strata in the limb plexus corresponds to
nerve from S1 to S2. Eisler (1891) reported that the the portions occupied by nerve fibers to the flexor mussuperior gluteal nerve arises from L4 to S1 (the furcal cle group or the extensor muscle group (e.g., Schwalbe
nerve being L4) or from L5 to S2 (the furcal nerve being 1881; Bolk 1898, 1902). Recently, the motor pool posiL5), and the inferior gluteal nerve arises from L5 t o S2. tions of individual muscles have been mapped in variVarious textbooks (Table 3) state that the superior glu- ous animals. Hollyday (1980) mentioned that each
from the trunk of S2 between the origins of the superior
and inferior gluteal nerves.
639
STRATIFICATION OF THE SACRAL PLEXUS
TABLE 2. Segmental composition of the cranial and caudal parts of the superior
gluteal nerve
Specimen
1
2
3
4
5
6
7
8
9
10
11
12
Cadaver
Side
1
1
2
2
3
3
4
4
5
5
6
7
R
L
R
L
R
L
R
L
R
L
L
L
N. gluteus
Sex
F
F
M
M
M
M
M
M
M
M
M
M
adult motoneuron pool is a continuous, although distorted, representation of muscle precursor position on
the original sheets of dorsal and ventral muscle mass.
Nicolopoulos-Stournaras and Iles (1983) mentioned
that the relative positions of the column of the motoneuron pools supplying different muscles and their
transverse location in the spinal cord are very consistent between individual rats. And, Hollyday and Jacobson (1990) reported that muscles innervated by
nerves diverging from common nerve trunks have
neighboring motor pools. Therefore, the columns of motor pools in the spinal cord form the stratum-structure,
and the stratum-structure of the plexus is recognized
as the amplification of that in the spinal cord. The
stratiform relationship in the limb plexus which corresponds to that of the motoneuron pools in the spinal
cord should be noted. For the convenience of the classification of the plexus, the authors postulate that the
cutaneous branches run along the routes of the muscular branches, and the strata of the cutaneous branches
correspond to the strata of the muscular branches.
Tosney and Landmesser (1984) reported that neurites could make correct and specific decisions in the
plexus region in the absence of all tissues distal t o the
pelvic girdle. And Phelan and Hollyday (1990)reported
that axons are capable of making an appropriate choice
at the dorsalhentral branch point in the absence of
their target. Therefore the stratification of the plexus
is one of the most fundamental elements in limb formation.
In a gross anatomical study, Kida (1987, 1990) investigated in detail the human cervical plexus, and
emphasized that the stratum-structure of the spinal
nerves is also recognized in the nerves of the trunk
musculature. The presence of the stratum-structure of
the motoneuron pools of the axial musculature was
suggested by Smith and Hollyday (1983) and Fetcho
(1986, 1987).
Akita (1992a, 1992b) reported that the muscle layers
ventral to the tibia1 nerve stratum appear to descend in
the cranio-caudal direction concomitant with the caudalward shift of the cloaca. Therefore, the stratum
might be considered to migrate in the cranio-caudal
direction during the embryonic stage.
As mentioned earlier, the superior gluteal nerve lies
dorsal t o the inferior gluteal nerve. The fact that the
superior gluteal nerve does not contribute to the for-
suDerior
Part
Cranial
Caudal
L4,L5
L5,Sl
L4,L5,s1
s1
L5,Sl
s1,s2
L5,Sl
Sl,S2
L5,Sl
s1,s2
L4,L5,Sl
S1,S2
s1
L4,L5,Sl
L4,L5,Sl
s1
L4,L5,Sl
s1
L5,Sl
S1,S2
s1
L4,L5,Sl
*** Undivided ***
mation of the nerve to the biceps femoris suggests that
the superior and inferior gluteal nerves are situated in
different strata. The proximal part of the dorsal division of the sacral plexus can be divided into three
strata from dorsal to ventral (Fig. 8): 1)stratum of the
superior gluteal nerve, 2 ) stratum of the inferior gluteal nerve, and 3) stratum of the common peroneal
nerve.
The nerve to the short head of the biceps femoris is
situated between the inferior gluteal nerve and the
common peroneal nerve. According to Bardeen (19061,
both the short head of the biceps and the gluteus maximus are represented in urodeles by the ilio-(femoralfibularis and in reptiles by the ilio-fibularis muscle
which is supplied by the peroneal portion of the sciatic
nerve. Therefore, the nerve to the short head of the
biceps femoris can be primarily considered a part of the
stratum of the inferior gluteal nerve.
In this study, no branch of the superior gluteal nerve
was found to contribute to the formation of the posterior femoral cutaneous nerve which is in agreement
with the findings of Nakanishi et al. (1976). We previously reported the existence of cutaneous branches of
the superior gluteal nerve (Akita et al., 1991); these
branches indicate the need for re-evaluation of the
stratification of the cutaneous branches of the lateral
and posterior thigh.
111. The Nerves to the Piriformis
In the morphology of the muscles and nerves of the
thigh and buttock, the piriformis muscle itself is of
great positional significance. Interestingly however,
few reports discuss the innervation of the piriformis. In
the past, this innervation has been customarily called
the “nerve to the piriformis” (e.g., Gray’s Anatomy,
[Williams et al., 19891). However, as numerous
branches to the piriformis were found in this study, we
have adopted the terminology, “nerves t o the piriformis”. Regarding the origin of the nerves to the piriformis, according to Gray’s Anatomy textbooks (Clemente, 1985; Williams et al., 1989) these nerves arise
from the dorsal portions of S2 or from S1 and S2. In
many textbooks the origin of the nerves to the piriformis is located proximal to that of the superior gluteal nerve. In general, the nerves to the piriformis are
thought to arise from the dorsal surfaces of the sacral
nerve trunks. But, Sat0 and Sat0 (1987) reported that
640
K. AKITA ET AL.
Fig. 7. Schematic presentation of the relationship between the superior gluteal nerve and the pelvic
bones in the erect posture (lateral aspect).
in detail on their first and second types of branches.
Nerves supplying the piriformis arose from numerous
nerves in addition to the caudalmost root of the supeN. duteus
rior gluteal nerve. Interestingly, as shown in Figure 8,
Superior
Inferior
these nerves arose from all three strata of the dorsal
L5,Sl,S2
Sl,S2 division of the sacral plexus. Therefore, the nerves to
Rauber-Kopsch (Kopsch, 1909)
L4,L5,Sl,(S2) (L4),L5,Sl,S2 the piriformis are not simply the dorsalmost branches
Spalteholz (1929)
L4,L5,Sl
L5,Sl,S2 of the sacral plexus, and the piriformis should be conMorris (Schaeffer, 1953)
Cunningham (Romanes, 1981)
L4,L5,S1
L5,Sl,S2 sidered a compound muscle rather than a single musL4,L5,Sl
L5,Sl,S2 cle.
Gray (Clemente, 1985)
Grav (Williams et al.. 1989)
L4,L5.S1
L5,Sl,S2
In the future it will be necessary to study the positional relationship between the piriformis and the scithe branches innervating the piriformis are classified atic nerve in order t o make a comparison with the
into four types: 1) the branches arising from the dorsal present findings and to obtain a complete overall unsurface of the dorsal division of the sacral plexus, 2) the derstanding of these complicated nerves.
branches from the ventral surface of the dorsal diviACKNOWLEDGMENTS
sion, 3) the branches from the dorsal surface of the
We thank Dr. Hiroshi Sasaki of the 3rd Department
ventral division, and 4) the branches from the ventral
surface of the ventral division. In this study, we report of Anatomy, Faculty of Medicine, Tokyo Medical and
TABLE 3. Textbook descriptions of the segmental
composition of the superior and inferior gluteal nerves
STRATIFICATION OF THE SACRAL PLEXUS
641
Fig. 8. Schematic presentation of the relationship among the nerves of the dorsal division of the sacral
plexus (dorsal aspect) showing the stratification and the various origins of the nerves to the piriformis.
Dental University, for helpful comments on the manuscript. This work was partly supported by Grants-inAid for Scientific Research (No.03670005) from the
Japan Ministry of Education, Science, and Culture.
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772 Кб
Теги
division, piriformis, dorsal, sacra, nerve, stratification, main, among, relationships, innervation, plexus
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