YOSEPH A. N.13 .144

FKUPNVJ 2013

Inervasi Lumbal

PLEXUS LUMBAL

Lumbal

Fungsi Inervasi Lumbal

(L1) Iliohypogastric & Ilio-inguinal

Cabang utama L1 memanjang melewati pinggiran lateral dari otot Psoas Mayor

Cabang utama ini bercabang lagi menjadi iliohypogastric dan ilio-inguinal

Cabang Iliohipograstrik

Melewati bagian permukaan depan otot quadratus lumborum, dan bagian belakang ginjal

Berfungsi motorik pada otot transversus abdominis dan berlanjut lewat bagian depan sekeliling tubuh di antara otot transversus abdominis dan otot oblique internal

Lateral cutaneous branch (cabang lateral) yang berada di atas iliac crest mempersarafi otot oblique internal dan eksternal, serta mensuplai daerah posterolateral kulit gluteus

Cabang Iliohipograstrik

Anterior cutaneous branch (cabang anterior) berlanjut dari bagian depan, mempersarafi otot oblique internal ke arah bawah tengah

Semakin dekat ke kulit, saraf memanjang pada superfisial dari inguinal ring setelah melewati aponeurosis pada otot oblique eksternal

Lalu mempersarafi bagian kulit pada regio pubis

Cabang Ilio-inguinal

Cabang ilio-inguinal berukuran lebih kecil dan posisinya lebih posterior dari iliohypogastric

Jalur yang dilewati cabang ini lebih curam dari iliohypogastric dan menyebrangi otot iliaka untuk sampai ke iliac crest

Dekat bagian akhir anterior dari iliac crest, cabang ini mempersarafi otot transversus abdominis, lalu otot oblique internal, setelah itu memasuki inguinal canal

Cabang Ilio-inguinal

Kemudian cabang ini melewati superficial inguinal ring bersamaan dengan spermatic cord dan menginervasi bagian selangkangan, akar penis, serta permukaan depan scrotum pada pria, mons pubis dan labium majus pada wanita

(L1 & L2) Genitofemoral Nerve

Berasal dari percabangan L1 dan L2Berjalan ke arah bawah melewati otot psoas

mayor sampai bagian permukaan depannyaKemudian turun di permukaan otot, pada

bagian retroperitoneal, melewati bagian belakang sampai pada ureter

Biasanya terbagi menjadi cabang genital dan femoral

Cabang Genital

Cabang genital terus mengarah turun dan masuk melewati kanal inguinal dan inguinal ring

Pada Pria, mempersarafi otot cremasteric dan berakhir pada kulit bagian atas anterior dari skrotum

Pada Wanita, beriringan dengan ligamen uterus dan berakhir pada kulit mons pubis dan labium majus

Cabang Femoral

Cabang Femoral memanjang turun pada sisi samping arteri iliaka eksterna dan melewati ligamen inguinal bagian posterior, memasuki sarung femoral lateral sampai ke arteri femoral

Mempersarafi kulit bagian anterior atas daerah selangkangan

(L2 & L3) Lateral Cutaneous Nerve of Thigh

Berasal dari L2 and Memanjang dari tepi lateral otot psoas

mayor, curam ke bawah melewati otot iliakaKemudian melewati bagian posterior sampai

ke ligamen inguinal dan memasuki daerah selangkangan

Mempersarafi kulit daerah anterior dan lateral selangkangan sampai pada lutut

(L2 L4) Obturator Nerve

Berasal dari percabangan L2 sampai L4 Ke arah bawah melewati otot psoas mayor,

berjalan terus melewati dinding lateral rongga pelvis dan memasuki kanal obturator untuk mempersarafi bagian medial daerah selangkangan

(L2 L4) Obturator Nerve

Pada kanal obturator, saraf ini terbagi menadi cabang anterior dan posterior

Ketika memasuki daerah selangkangan, dua cabang ini terbagi oleh otot obturator eksternus dan adductor brevis, kedua cabang ini mempersarafi: Cabang persendian paha Cabang otot ke obturator externus, pectineus, adductor

longus, gracilis, adductor brevis, and adductor magnus Cabang daerah medial selangkangan Bersamaan dengan saraf saphenous, mempersarafi

bagian atas kaki dan persendian lutut

(L2 L4) Femoral Nerve

Percabangan dari L2 sampai L4Cabang ke arah bawah melewati otot psoas mayor

pada bagian samping tepi bawahSaraf femoral berada di antara tepi lateral psoas

mayor dan permukaan anterior otot iliaka, makin ke dalam melewati bagian lateral arteri femoral dan melewati bagian posterior dari ligamen inguinal, lalu memasuki bagian depan dari selangkangan

Ketika memasuki daerah selangkangan, saraf ini terbagi menjadi beberapa cabang

Saraf Saphenous mempersarafi permukaan medial kaki

PLEXUS SAKRAL

Sakral

Sciatic Nerve

The sciatic nerve is the largest nerve of the body and carries contributions from L4 to S3. It:

forms on the anterior surface of the piriformis muscle and leaves the pelvic cavity through the greater sciatic foramen inferior to piriformis

passes through the gluteal region into the thigh, where it divides into its two major branches, the common fibular nerve (common peroneal nerve) and the tibial nerve-dorsal divisions of L4, L5, S1, and S2 are carried in the common fibular part of the nerve and the ventral divisions of L4, L5, S1, S2, and S3 are carried in the tibial part

innervates muscles in the posterior compartment of the thigh and muscles in the leg and foot

carries sensory fibers from the skin of the foot and lateral leg

Pudendal nerve

The pudendal nerve forms anteriorly to the lower part of piriformis muscle from ventral divisions of S2 to S4. It:

leaves the pelvic cavity through the greater sciatic foramen, inferior to the piriformis muscle, and enters the gluteal region

courses into the perineum by immediately passing around the sacrospinous ligament, where the ligament joins the ischial spine, and through the lesser sciatic foramen (this course takes the nerve out of the pelvic cavity, around the peripheral attachment of the pelvic floor, and into the perineum)

is accompanied throughout its course by the internal pudendal vessels

innervates skin and skeletal muscles of the perineum, including the external anal and external urethral sphincters

Other branches

The superior gluteal nerve, formed by branches from the dorsal divisions of L4 to S1, leaves the pelvic cavity through the greater sciatic foramen superior to piriformis muscle and supplies muscles in the gluteal region-gluteus medius, gluteus minimus, and tensor fasciae latae (tensor of fascia lata) muscles

The inferior gluteal nerve, formed by branches from the dorsal divisions of L5 to S2, leaves the pelvic cavity through the greater sciatic foramen inferior to the piriformis muscle and supplies the gluteus maximus, the largest muscle in the gluteal region

Both superior and inferior gluteal nerves are accompanied by corresponding arteries.

Other branches

The nerve to the obturator internus and the associated superior gemellus muscle originates from the ventral divisions of L5 to S2 and leaves the pelvic cavity through the greater sciatic foramen inferior to the piriformis muscle. Like the pudendal nerve, it passes around the ischial spine and through the lesser sciatic foramen to enter the perineum and supply the obturator internus muscle from the medial side of the muscle, inferior to the attachment of the levator ani muscle.

Other branches

The nerve to the quadratus femoris muscle and the inferior gemellus muscle, and the posterior cutaneous nerve of the thigh (posterior femoral cutaneous nerve) also leave the pelvic cavity through the greater sciatic foramen inferior to the piriformis muscle and course to muscles and skin, respectively, in the lower limb.

Other branches

Unlike most of the other nerves originating from the sacral plexus, which leave the pelvic cavity through the greater sciatic foramen either above or below the piriformis muscle, the perforating cutaneous nerve leaves the pelvic cavity by penetrating directly through the sacrotuberous ligament and then courses to skin over the inferior aspect of the buttocks.

Other branches

The nerve to the piriformis and a number of small nerves to the levator ani and coccygeus muscles originate from the sacral plexus and pass directly into their target muscles without leaving the pelvic cavity.

Other branches

The obturator nerve (L2 to L4) is a branch of the lumbar plexus. It passes inferiorly along the posterior abdominal wall within the psoas muscle, emerges from the medial surface of the psoas, passes posteriorly to the common iliac artery and medially to the internal artery at the pelvic inlet, and then courses along the lateral pelvic wall. It leaves the pelvic cavity by traveling through the obturator canal and supplies the adductor region of the thigh.

Coccygeal plexus

The small coccygeal plexus has a minor contribution from S4 and is formed mainly by the anterior rami of S5 and Co, which originate inferiorly to the pelvic floor. They penetrate the coccygeus muscle to enter the pelvic cavity and join with the anterior ramus of S4 to form a single trunk, from which small anococcygeal nerves originate. These nerves penetrate the muscle and the overlying sacrospinous and sacrotuberous ligaments and pass superficially to innervate skin in the anal triangle of the perineum.

Autonomic nerve

Sympathetic Diagram

Thoracolumbar Outflow All preganglionic fibers of sympathetic division arise from

cell bodies of preganglionic neurons located in spinal cord segments T1-L2

Preganglionic sympathetic neurons in grey matter of spinal cord produces lateral horns Sympathetic neurons leave spinal cord via the ventral root and

passes through white ramus communicans (rami communicantes) to enter paravertebral ganglion (forms part of sympathetic trunk)

Once a preganglionic axon reaches a paravertebral ganglion it can...... Synapse with a post ganglionic neuron within the same ganglion Ascend/descend within sympathetic trunk to synapse with

another paravertebral ganglion Pass through the ganglion and emerge from the sympathetic

chain without synapsing

Sympathetic Diagram

Synapses in Paravertebral (sympathetic chain) Ganglion: Postganglionic axons enter the ventral ramus of the joining spinal nerves via communicating branches called gray rami communicantes

 Preganglionic fiber serving head, neck, and thorax emerge from spinal cord segments T1-T6 and ascend the sympathetic chain to synapse with postganglionic neurons within cervical ganglia (inferior, middle, and superior) Superior cervical ganglion:

Stimulates dilator muscles of irises Inhibits nasal and salivary glands Stimulates copious sweating Stimulates arrector pili muscle to contract Causes blood vessel vasodilation Provides branches to carotid body (oxygen sensor) and larynx & pharynx

Middle cervical ganglia - innervates heart and skin Inferior cervical ganglia (stellate ganglion) innervates heart, aorta, dilates

bronchioles, constrict esophageal sphincter

Sympathetic Diagram

Synapses in Prevertebral (Collateral) Ganglion: Preganglionic fibers of T5-L2 synapse in prevertebral ganglia. Fibers enter and leave without synapsing and form several nerves collectively called splanchnic nerves (greater, lesser, and lumbar)

Splanchnic nerves synapse at abdominal aortic plexus that clings to surface of abdominal aorta

Synapses occur at ganglia of plexus: Greater splanchnic nerve

Celiac ganglion - innervates stomach (decrease muscle activity/constricts pyloric sphincter), adrenal medulla (secretes epinephrine/norepinephrine), liver (epinephrine stimulates liver to release glucose), kidney (vasoconstriction, decrease urine output), intestine (decrease smooth muscle activity)

Lesser splanchnic nerve Superior mesenteric (via celiac) ganglion - innervates small intestine

Lumbar splanchnic nerve Inferior mesenteric ganglion - innervates large intestine

Lumbar splanchnic nerve  Hypogastric ganglion - innervates bladder and urethra (causes relaxation of smooth

muscle of bladder wall and constricts urethral sphincter/inhibits voiding), genitalia (causes ejaculation in males and vaginal contractions in females)

Parsympathetic Diagram(Craniosacral Division)

Oculomotor nerve (III) Preganglionic fibers from oculomotor nuclei in the midbrain synapses in the

ciliary ganglion (in eye), postganglionic fiber innervates smooth muscle of eye  Pupil constriction and lens movement to cause focusing

Facial nerve (VII) Preganglionic fibers from lacrimal nuclei in the pons synapses in the

pterygopalatine ganglia, postganglionic fiber innervates lacrimal glands of eye Lubrication of eye and tear formation

Preganglonic fibers from superior salivatory nuclei in the pons synapses in the submandibular ganglia, postganglionic fibers innervate submandibular and sublingual salivary glands Production of saliva and secretion of salivary enzymes

Glossopharyngeal nerve (IX) Preganglionic fibers from the inferior salivary nuclei in the medulla synapses

in the otic ganglia, postganglionic fibers innervate the parotid salivary glandCranial Outflow

Parsympathetic Diagram(Craniosacral Division)

Vagus nerve (X) Preganglionic fibers from the dorsal motor nuclei of

the medulla synapses in terminal ganglia located within the walls of the target organ Intramural ganglia ....effects:

Heart -decreases/steadies heart rate and constricts coronary veins

Lung - constricts bronchioles Gall bladder - expel bile Stomach - stimulates secretion of enzymes Intestines - increase motility (peristalsis) and relaxes

sphincters Cranial Outflow

Parsympathetic Diagram(Craniosacral Division)

Preganglionic fibers from lateral gray matter of spinal cord in segments S2-S4 synapse in terminal ganglia within walls of the target organ Intramural ganglia....effects:

Distal large intestines - relaxes sphincters Bladder - contraction of smooth muscle of bladder wall;

relaxes urethral sphincter - promotes voiding Genitalia - causes penile and clitoral erection

Sacral Outflow

Referensi

Gray’s Anatomy for Students, 2nd ed., 2009Snell, Richard S.: Clinical Anatomy by

Regions, 9th ed. 2012