Inferior gluteal nerve

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Inferior gluteal nerve
Gray828.png
Plan of sacral and pudendal plexuses (inferior gluteal nerve labeled at middle left)
Posterior Hip Muscles 3.PNG
The gluteus medius and nearby muscles
Details
From Sacral plexus (L5–S2)
Innervates Gluteus maximus
Identifiers
Latin nervus gluteus inferior
TA98 A14.2.07.032
TA2 6544
FMA 16511
Anatomical terms of neuroanatomy

The inferior gluteal nerve is the main motor neuron that innervates the gluteus maximus muscle. It is responsible for the movement of the gluteus maximus in activities requiring the hip to extend the thigh, such as climbing stairs. Injury to this nerve is rare but often occurs as a complication of posterior approach to the hip during hip replacement. When damaged, one would develop gluteus maximus lurch, which is a gait abnormality which causes the individual to 'lurch' backwards to compensate lack in hip extension.

Contents

Anatomy

The largest muscle of the posterior hip, gluteus maximus, is innervated by the inferior gluteal nerve. [1] It branches out and then enters the deep surface of the gluteus maximus, the principal extensor of the thigh, and supplies it.

Origin

The muscle is supplied by the inferior gluteal nerve which arises from the dorsal branches of the ventral rami of the fifth (L5), the first (S1) and second (S2) sacral nerves. [2]

The lumbosacral trunk, which is made up of L5 and a small branch of L4, effectively connects the lumbar and sacral plexuses. [3] The lower branches of the L4 and the L5 nerves enter the sacral plexus.

The sacral plexus is formed by the lumbosacral trunk, the first to third sacral ventral rami, and part of the fourth, the remainder of the last joining the coccygeal plexus. The sacral plexus is formed in the pelvis in front of the piriformis muscle. [3]

The sacral plexus is formed anterior to the piriformis muscle and gives rise to the sciatic nerve, the superior and inferior gluteal nerves, and the pudendal and posterior femoral cutaneous nerves. [3]

However, most of the sacral plexus nerves are scarcely recognizable, because they leave the pelvis through the greater sciatic foramen. From the pelvis, the anterior primary branches of the nerves entering the plexus (the first sacral nerve being a particularly large one) and a mass of nerves on the piriformis can be recognized. [4]

Course

The inferior gluteal nerve leaves the pelvis through the greater sciatic foramen, passing inferior to the piriformis muscle. [5] It then divides into muscular branches to supply the gluteus maximus that pass posteriorly into the deep surface of the gluteus maximus muscle. [6]

The inferior gluteal nerve is superficial to the sciatic nerve. It has been described as having multiple branches with subsequent innervation of the overlying gluteus maximus. [1]

The inferior gluteal nerve entered the deep surface of gluteus maximus very inferiorly. At the lower border of the piriformis muscle, the nerve turns backward and divides into upward and downward diverging branches, which enter the gluteus maximus. The nerve may also send a branch to the posterior femoral cutaneous nerve. [3]

The inferior gluteal nerve reliably emerged inferior to the piriformis muscle. The branching characteristics of the nerve falls into two broad categories.One category is short stalks which came under the piriformis and then gave rise to all of the terminal branches of the nerve which spanned the muscle of the gluteus maximus. The number of branches from the stalk ranged from four to six. [1] The second category occurs as a partial split of the stalk that occurred proximal to the coverage of the piriformis. There were two to three divisions of the inferior gluteal nerve under the piriformis that would further divide close to the insertion of the nerve into the actual muscle belly. [1]

The nerve was always seen close to and medial to the sciatic nerve when it left the sacral plexus inferior to the piriformis. In all specimens, the nerve entered the deep surface of gluteus maximus approximately 5 cm from the tip of the greater trochanter of the femur and entered the deep surface of gluteus maximus over the inferior one-third of the muscle belly. [2]

The inferior gluteal nerve is accompanied by the inferior gluteal artery, a branch of the anterior trunk of the internal iliac artery. [2]

However the relationship between the inferior gluteal nerve and artery was found to be unpredictable. [1] No consistent relationship between the inferior gluteal artery and the inferior gluteal nerve was observed in current studies.

There is a relationship between the common stalk of the inferior gluteal nerve and external anatomic landmarks. The targeted region should be aimed inferior to the most prominent aspect of the greater trochanter, and medial to the landmark of the ischial tuberosity, at the depth of the posterior border of the proximal femur. Triangulating using these three coordinates, one can reliably reach the source of the inferior gluteal nerve. This will result in maximal stimulation of the gluteus maximus musculature when using electrical stimulation for the purpose of prevention of pressure ulcers. [1]

The sciatic nerve (L4 to S3), the largest nerve of the body, immediately leaves the pelvis through the greater sciatic foramen, below the piriformis. The superior gluteal nerve passes backward through the greater sciatic foramen, above the piriformis: the inferior gluteal nerve also passes backward through the greater sciatic foramen but below the piriformis." [4]

Function

The major function of the gluteus maximus is to extend the flexed thigh and bring it inline with the trunk. It may prevent the forward momentum of the trunk from producing flexion at the supporting hip during bipedal gait. It is intermittently active in the walking cycle and in climbing stairs and continuously active in strong lateral rotation and abduction of the thigh and also stabilizes the femur on the tibia when the knee extensors are relaxed. In addition to this, the gluteus maximus has an important role during some activities like running or standing up. [6]

The gluteus maximus, a large muscle with numerous attachments, is a powerful extensor of the thigh or of the trunk lower limbs are in a fixed position. The gluteus maximus is also a strong hip stabilzer. It extends thigh at the hip, assists in laterally rotating the thigh. [7] It contracts at heel-strike, slowing forward motion of trunk by arresting flexion of the hip and initiating extension. This movement prevents trunk from falling forward. [7] [8]

Surprisingly, however, the gluteus maximus is not important posturally, is relaxed when one is standing, and is little used in walking. It is employed in running, climbing, and rising from a sitting or stooped position. It also controls flexion at the hip upon sitting down. [7]

Injury

From hip replacement

Inferior gluteal entrapment neuropathy is rarely reported but is recognized as a complication of the posterior approach to hip arthroplasty. Injuries to the peripheral nerves occur in 0.5% to 8% of patients undergoing total hip replacement. [2]

The posterior approach has been assessed most widely and is perhaps the most frequently used, but it is also the one most likely to be associated with damage to the inferior gluteal nerve since this structure is not usually seen. Direct abnormalities of the nerve may be difficult to detect due to the small size of the nerve, although signal intensity alterations in the gluteus maximus may be encountered [3]

Diagnostic imaging of peripheral nerves about the hip is a challenging task due to the complex regional anatomy, the small size and intricate course of many nerves. There are also a variety of clinical situations leading to local disturbances in the nerve function the positioning of the inferior gluteal nerve makes it vulnerable to iagtrogenic injury during posterior and posterior approaches to the hip [9]

It is subject to injury by compression and ischemia in sedentary individuals, resulting in difficulty in rising from a sitting position and difficulty climbing stairs. [10]

The incidence of damage to the inferior gluteal nerve after replacement of the hip is still uncertain. Peripheral nerve injury may occur during operations on the hip as a result of operative trauma associated with stretching and retraction of the nerve. Few studies have focused on damage to the inferior gluteal nerve during hip replacement. [6]

In ten other patients who had a posterior approach, nine had abnormal electromyographic findings in inferior gluteal innervated muscles and eight of the ten also had abnormalities in superior gluteal innervated muscles. They suggested that abnormalities of gait after the operation may be due to injury to these nerves. [6]

The reduction in walking speed and persistently abnormal gait, sometimes seen in patients one year after total hip replacement, were associated with a decrease in the extensor moment with a resultant decrease in the range of extension of the hip and a reduction in the abductor moment. [11]

When a muscle-splitting incision is made across gluteus maximus as part of the classical posterior approach and the muscle parted by hand-held or self-retaining retractors, the likelihood of damage to the inferior gluteal nerve is high. The nerve enters the deep surface of the muscle and is not easily visualised and differentiated from other structures running with it, such as the blood vessels. Parting the muscle damages the nerve further by stretching or even rupturing its branches which run superiorly on its deep surface. [2]

Entrapment neuropathy is an underrecognized cause of pain and functional impairment caused by acute or chronic injury to peripheral nerves. [9]

Although nerves may be injured anywhere along their course, they are more prone to compression, entrapment, or stretching as they traverse anatomically vulnerable regions, such as superficial or geographically constrained spaces. Subclinical electromyographic abnormalities of both the superior and inferior gluteal nerves have been described in up to 77% of patients after total hip replacement, regardless of the surgical approach. [9]

The posterior approach is the most common and practical of those used to expose the hip joint. The posterior approaches allow excellent visualization of the femoral shaft, thus are popular for revision joint replacement surgery in cases in which the femoral component needs to be replaced. The likelihood of damage to the inferior gluteal nerve is reported to be high when a muscle-splitting incision is made across the gluteus maximus as a part of the classical posterior approach to the hip. [6]

This may cause selective denervation of the gluteus maximus since the inferior gluteal nerve courses along the deep surface of the muscle and is not easily visualized and differentiated from other structures running with it, such as blood vessels. [3]

Gluteus maximus lurch

Injury to this nerve leads to a gluteus maximus lurch. When gluteus maximus is weak/injured, trunk extends (lean back) on heel-strike on weakened side. This compensates for weakness of hip extension.

Damage to the inferior gluteal nerve causes loss of extension at hip, and causes the buttock to waste.

The normal gluteus maximus gait is when the gluteus maxims begins to contract at moment of heel-strike, slowing forward motion of trunk by arresting flexion of hip and initiating extension. When gluteus maximus is weak, trunk lurches backward (gluteus maximus lurch) at heel-strike on weakened side to interrupt forward motion of the trunk. [12]

There is great difficulty in preventing the flexion of the trunk heel strike so the person may use trunk extension before heel strike to maintain balance causing a backwards lurch. [7] The trunk lurches back on the stance phase side hyperextending. The backwards trunk lurch persists throughout the stance to maintain the gravitational force line behind the hip axis locking the hip into extension. There is an apparent forward protrusion of the affected hip due to exaggerated hip motion and the person may also hold the shoulders backward to keep the center of gravity behind the joint. The hamstring muscles often compensate for the gluteus maximus weakness resulting in a near normal gait pattern but most often these muscles are affected together. [8]

See also

Related Research Articles

<span class="mw-page-title-main">Human leg</span> Lower extremity or limb of the human body (foot, lower leg, thigh and hip)

The leg is the entire lower limb of the human body, including the foot, thigh or sometimes even the hip or buttock region. The major bones of the leg are the femur, tibia, and adjacent fibula. The thigh is between the hip and knee, while the calf (rear) and shin (front) are between the knee and foot.

<span class="mw-page-title-main">Sciatic nerve</span> Large nerve in humans and other animals

The sciatic nerve, also called the ischiadic nerve, is a large nerve in humans and other vertebrate animals which is the largest branch of the sacral plexus and runs alongside the hip joint and down the lower limb. It is the longest and widest single nerve in the human body, going from the top of the leg to the foot on the posterior aspect. The sciatic nerve has no cutaneous branches for the thigh. This nerve provides the connection to the nervous system for the skin of the lateral leg and the whole foot, the muscles of the back of the thigh, and those of the leg and foot. It is derived from spinal nerves L4 to S3. It contains fibers from both the anterior and posterior divisions of the lumbosacral plexus.

<span class="mw-page-title-main">Gluteus medius</span> One of the three gluteal muscles

The gluteus medius, one of the three gluteal muscles, is a broad, thick, radiating muscle. It is situated on the outer surface of the pelvis.

<span class="mw-page-title-main">Gluteus minimus</span> Smallest of the three gluteal muscles

The gluteus minimus, or glutæus minimus, the smallest of the three gluteal muscles, is situated immediately beneath the gluteus medius.

<span class="mw-page-title-main">Piriformis muscle</span> One of six small hip muscles in the lateral rotator group

The piriformis muscle is a flat, pyramidally-shaped muscle in the gluteal region of the lower limbs. It is one of the six muscles in the lateral rotator group.

<span class="mw-page-title-main">Gluteal sulcus</span> Fold separating the thigh from the buttock

The gluteal sulcus is an area of the body of humans and anthropoid apes, described by a horizontal crease formed by the inferior aspect of the buttocks and the posterior upper thigh. The gluteal sulcus is formed by the posterior horizontal skin crease of the hip joint and overlying fat and is not formed by the lower border of the gluteus maximus muscle, which crosses the fold obliquely. It is one of the major defining features of the buttocks. Children with developmental dysplasia of the hips are born with uneven gluteal folds and can be diagnosed with a physical examination and sonogram.

The biceps femoris is a muscle of the thigh located to the posterior, or back. As its name implies, it consists of two heads; the long head is considered part of the hamstring muscle group, while the short head is sometimes excluded from this characterization, as it only causes knee flexion and is activated by a separate nerve.

<span class="mw-page-title-main">Sacral plexus</span> Nerve plexus

In human anatomy, the sacral plexus is a nerve plexus which provides motor and sensory nerves for the posterior thigh, most of the lower leg and foot, and part of the pelvis. It is part of the lumbosacral plexus and emerges from the lumbar vertebrae and sacral vertebrae (L4-S4). A sacral plexopathy is a disorder affecting the nerves of the sacral plexus, usually caused by trauma, nerve compression, vascular disease, or infection. Symptoms may include pain, loss of motor control, and sensory deficits.

<span class="mw-page-title-main">Tensor fasciae latae muscle</span> Muscle of the thigh

The tensor fasciae latae is a muscle of the thigh. Together with the gluteus maximus, it acts on the iliotibial band and is continuous with the iliotibial tract, which attaches to the tibia. The muscle assists in keeping the balance of the pelvis while standing, walking, or running.

<span class="mw-page-title-main">Internal iliac artery</span> Main artery of the pelvis

The internal iliac artery is the main artery of the pelvis.

<span class="mw-page-title-main">Posterior cutaneous nerve of thigh</span> Sensory nerve that supplies the back of the thigh, leg, buttock, and perineum

The posterior cutaneous nerve of the thigh is a sensory nerve of the thigh. It is a branch of the sacral plexus. It supplies the skin of the posterior surface of the thigh, leg, buttock, and also the perineum.

<span class="mw-page-title-main">Superior gluteal nerve</span> Nerve on the pelvis and leg

The superior gluteal nerve is a mixed nerve of the sacral plexus that originates in the pelvis. It provides motor innervation to the gluteus medius, gluteus minimus, tensor fasciae latae, and piriformis muscles; it also has a cutaneous branch.

<span class="mw-page-title-main">Superior gluteal artery</span>

The superior gluteal artery is the terminal branch of the posterior division of the internal iliac artery. It exits the pelvis through the greater sciatic foramen before splitting into a superficial branch and a deep branch.

<span class="mw-page-title-main">Inferior gluteal artery</span>

The inferior gluteal artery is a terminal branch of the anterior trunk of the internal iliac artery. It exits the pelvis through the greater sciatic foramen. It is distributed chiefly to the buttock and the back of the thigh.

<span class="mw-page-title-main">Nerve to obturator internus</span> Human nerve

The nerve to obturator internus is a mixed nerve providing motor innervation to the obturator internus muscle and gemellus superior muscle, and sensory innervation to the hip joint. It is a branch of the sacral plexus. It is one of the group of deep gluteal nerves.

<span class="mw-page-title-main">Nerve to quadratus femoris</span>

The nerve to quadratus femoris is a nerve of the sacral plexus that provides motor innervation to the quadratus femoris muscle and gemellus inferior muscle, and an articular branch to the hip joint. The nerve leaves the pelvis through the greater sciatic foramen.

<span class="mw-page-title-main">Greater sciatic notch</span>

The greater sciatic notch is a notch in the ilium, one of the bones that make up the human pelvis. It lies between the posterior inferior iliac spine (above), and the ischial spine (below). The sacrospinous ligament changes this notch into an opening, the greater sciatic foramen.

<span class="mw-page-title-main">Posterior compartment of thigh</span> One of the fascial compartments that contains the knee flexors and hip extensors

The posterior compartment of the thigh is one of the fascial compartments that contains the knee flexors and hip extensors known as the hamstring muscles, as well as vascular and nervous elements, particularly the sciatic nerve.

<span class="mw-page-title-main">Outline of human anatomy</span> Overview of and topical guide to human anatomy

The following outline is provided as an overview of and topical guide to human anatomy:

<span class="mw-page-title-main">Hip bone</span> Bone of the pelvis

The hip bone is a large flat bone, constricted in the center and expanded above and below. In some vertebrates it is composed of three parts: the ilium, ischium, and the pubis.

References

  1. 1 2 3 4 5 6 Skalak, A. F., et al. "Relationship of Inferior Gluteal Nerves and Vessels: Target for Application of Stimulation Devices for the Prevention of Pressure Ulcers in Spinal Cord Injury." Surgical and Radiologic Anatomy 30.1 (2008): 41-45. Print.
  2. 1 2 3 4 5 Ling, Z. X., and V. P. Kumar. "The Course of the Inferior Gluteal Nerve in the Posterior Approach to the Hip." Journal of Bone and Joint Surgery-British Volume 88B.12 (2006): 1580-83. Print.
  3. 1 2 3 4 5 6 Petchprapa, C. N., et al. "Mr Imaging of Entrapment Neuropathies of the Lower Extremity Part 1. The Pelvis and Hip." Radiographics 30.4 (2010): 983-1000. Print.
  4. 1 2 Mirilas, P., and J. E. Skandalakis. "Surgical Anatomy of the Retroperitoneal Spaces, Part Iv: Retroperitoneal Nerves." American Surgeon 76.3 (2010): 253-62. Print.
  5. ↑ Moore, Keith L.; Dalley, Arthur F.; Agur, Anne M. R. (2017). Essential Clinical Anatomy. Lippincott Williams & Wilkins. p. 586. ISBN   978-1496347213.
  6. 1 2 3 4 5 Apaydin, N., et al. "The Course of the Inferior Gluteal Nerve and Surgical Landmarks for Its Localization During Posterior Approaches to Hip." Surgical and Radiologic Anatomy 31.6 (2009): 415-18. Print.
  7. 1 2 3 4 Delisa, Joel A. (1998). Gait Analysis In The Science Of Rehabilitation. Diane Pub Co. pp. 8, 9. ISBN   0756700213.
  8. 1 2 Hoppenfeld, Stanley (2000). Treatment and rehabilitation of fractures. Philadelphia [u.a.]: Lippincott Williams & Wilkins. pp. 39, 259, 277. ISBN   0781721970.
  9. 1 2 3 Tagliafico Alberto, et al. "Imaging Of Neuropathies About The Hip." European Journal of Radiology (n.d.): ScienceDirect. Web. 16 Nov. 2012
  10. ↑ Dejong, P. J., and T. W. Vanweerden. "Inferior and Superior Gluteal Nerve Paresis and Femur Neck Fracture after Spondylolisthesis and Lysis - a Case-Report." Journal of Neurology 230.4 (1983): 267-70. Print.
  11. ↑ Mondelli, M., et al. "Mononeuropathies of Inferior and Superior Gluteal Nerves Due to Hypertrophy of Piriformis Muscle in a Basketball Player." Muscle & Nerve 38.6 (2008): 1660-62. Print.
  12. ↑ Wheeless, Clifford R. "Gait" . Retrieved 2012-11-26.
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