The femoral nerve (n. Femoralis) is formed from the fibers of the dorsal branches of the front primary division of Lii -LIV spinal nerves, sometimes Li. Starting at the Li level, it is first located behind a large lumbar muscle, then comes out of its outer edge. Next, the nerve is in the furrow (groove) between the iliac and large lumbar muscles. Here it is covered on top of the iliac fascia. The fascial leaflets located above the femoral nerve are divided into four plates: iliac, precurative, transverse and peritoneal. There may be up to three bags containing a small amount of connecting and adipous tissue between these plates. Since the femoral nerve is located in a close and fixed gap between the pelvis bones and the iliac fascia, in this place it can easily be squeezed with hemorrhage with the formation of hematoma. The cavity of the pelvis Nerve leaves, passing through a bone-fibrous tunnel, formed by a groove bunch (in front), branches of the lane and iliac bone. Under the bunch of the nerve passes through muscle lacuna. Upon exit to the hip, the nerve is located under the sheets of wide fascia of the thigh covering the iliac and scallop muscle. Here it is located in a femoral triangle, limited at the top of the groin bale, outside - tailoring and inside - long leading muscles. With the lateral side of the femoral triangle, a deep leaflet of the widespread hip fascia goes into iliac fascia, covering m. iliopsoas. MEDIALLY NERVA is a femoral artery. At this level, the femoral nerve may also squeeze the hematoma.
Above the groove bundle from the femoral nerve, branches are departed to iliac, large and small lumbar muscles. These muscles are flexing the thigh in the hip joint, moving its duck; With a fixed thigh, the lumbar part of the spinal column is bent, tilting the torso ahead.
Tests to determine the strength of these muscles:
- in the position lying on the back, the examined raises the straightened lower limb up; The survey has resistance to this movement, resting his palm in the middle of the hip region;
- in a position sitting at the stage, the surveyed bends down the lower limb in the hip joint; The survey prevents this movement, having resistance at the level of the lower third of the thigh;
- from the position lying on the back (on a rigid surface), the surveyed is offered to sit down without the help of the upper limbs with the lower limbs fixed to bed.
Under the groin bale or distal, the femoral nerve is divided into motor and sensitive branches. Of these, the first is supplied with a comb, tailoring and four-headed muscles, second-skin, subcutaneous tissue and fascia in the field of the lower two-thirds of the anterior and annex the surface of the thigh, the front of the tight surface, sometimes the inner edge of the foot from the medial ankle.
Great Muscle (m. Pectineus) bends, leads and rotates the thigh dust.
The tailoring muscle (m. Sartorius) bends down the lower limb in the hip and knee joints, rotating the thigh duck.
Test for determining the strength of the tailort muscle: the surveyed in the position lying on the back is offered to moderately bend the lower limb in the knee and hip joints and rotate the hip dweller; The explore has resistance to this movement and palprates abbreviated muscle. A similar test can be explored and in the position of the surveyed sitting on the stool.
Fouring the thigh muscle (m. Quadriceps Femoris) bends thigh in the hip joint and extensions the shin in the knee joint.
Test to determine the strength of the four-headed muscle:
- in the position of lying on the tire, the lower limb bends in the hip and knee joints, the examined suggests the bottom limb to break; The survey has resistance to this movement and examines abbreviated muscles;
- sitting on a chair, the examined extension of its lower limb in the collar joint; The survey has resistance to this movement and palprates abbreviated muscle.
The presence of hypotrophy of this muscle can be determined when measuring the hip circle on strictly symmetrical levels (usually 20 cm above the top edge of the patella.
The femoral nerve is amazed at injury (including traumatic and spontaneous hematoma in its course, for example, with hemophilia, anticoagulant treatment, etc.), inhabivable lymphadenitis, appendicular abscess, etc.
The clinical picture of the defeat of the femur nerve in the field of furrow between the iliac and lumbar muscles or in the femoral triangle is almost identical. Initially, there is pain in the groin area. This pain is irradiating into the lumbar region and on the thigh. Quickly rapids the intensity of pain to a strong and constant.
The hip joint is usually kept in the position of flexia and outdoor rotation. Patients take a characteristic position in bed. They often lie on the affected side, with a spine bent in the lumbar section, hip and knee joints - a bending contracture in the hip joint. Extension in the hip joint enhances pain, but other movements are possible if the lower limb remains in a bent position.
In case of hemorrhage at the level of the iliac muscle, paralysis of the muscles, which are supplied with a femoral nerve, arises, but this happens. In the formation of hematoma, only a femoral nerve is usually affected. In very rare cases, the lateral skin nerve of the thigh can be involved. The defeat of the femoral nerve is usually manifested by a pronounced pares of thigh flexors and extensors of the leg, the loss of the knee reflex. Standing, walking, running, and especially the rise in the stairs. Compensate the fence of the function of the four-headed muscle patients are trying due to the reduction of the muscle, straining the wide fascia of the thigh. Walking on a flat surface is possible, but the gait becomes peculiar; The lower limb is excessively extended in the knee joint, as a result of which the shin is excessively thrown forward and the stop becomes the entire sole. Patients avoid bending the lower limb in the knee joint, as it cannot be accelerated. The patella is not fixed, it can be passively shifted in different directions.
For a neuralgic embodiment of the femoral nerve, the symptom of Wasserman is characteristic: the patient lies on the stomach; The survey raises the straightened limb up, and the pain on the front surface of the thigh and in the groin area appears. The same will be when flexing in the knee joint (symptom of Matskevich). The pain is also intensified in the standing position while tilting the body. Sensitivity disorders are localized in the lower two-thirds of the front and the front of the surface of the thigh, the apparent surface of the lower leg, the inner edge of the foot. Vasomotor and trophic disorders can be connected.
Content:Introduction. The femoral neuropathy refers to fairly frequent mononeuropathies of the lower extremities. Although the femoral neuropathy is known for a long time (for the first time the disease was described almost 200 years ago, under the name "Front Rough Nertarius" Deskartes (Descartes, 1822)), it remains a relatively little-known disease, and the number of publications devoted to this problem in neurological literature is relatively small. In this regard, they do not cause surprise of often observed diagnostic errors.
Causes of frequent errors in the diagnosis of femoral neuropathy:
- there is not enough good awareness of practical doctors about the causes and clinical manifestations of the defeat of the femoral nerve (Nervus Femoralis);
- an explicit tendency to the hyperdiagnosis of reflex and compression vertebrogenic syndromes (with which they currently often associate any pain syndromes, sensitivity disorders and paresses in the limbs).
In any case, incorrect diagnosis leads to partially or completely incorrect therapy, which, naturally, adversely affects the course of the disease and contributes to its chronicization. Meanwhile, the overwhelming majority of cases of femoral neuropathy, subject to timely principles and adequacy of therapeutic measures, are potentially curboral. Eliminating the causes of damage to the femoral nerve and early pathogenetic therapy make it possible to avoid potentially disabled outcomes, including hard-fermented complex pelvic belt painsee and the front group of the thigh muscle group with persistent violations of the walking function.
Literature: According to the materials of the article: "High Neuropathy" T.V. Zimakova, F.A. Habirov, T.I. Khaibullin, N.N. Babicheva, E.V. Pomegranates, L.A. Averyanova; Kazan State Medical Academy, Republican Clinical Hospital of Recovery Treatment of MZ RT, Kazan; Magazine "Practical Medicine" №2 (57) April 2012.
Additional Information: Article: "Clinical variants of femoral nerve syndrome" T.V. Zimakova, Republican clinical hospital of reducing treatment of MD RT, Kazan; Magazine Practical Medicine "№1 (66) April 2013. [ to read ]
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The subcutaneous nerve (n. Saphenus) is the final and longest branch of the femoral nerve, derivative Lii - LIV spinal roots. After removing from the femoral nerve at the level of the groove bunch or above it, it is located laterally of the femoral artery in the rearranged part of the femoral triangle. Further, it enters along with the femoral vein and the artery in the leading channel (sub-primorial, or gunter channels), which has a triangular shape in cross section. The two sides of the triangle form the muscles, and the roof of the channel forms a dense intermuncture sheet of fascia, which is stretched between the medial wide muscle of the thigh and the long leading muscle in the upper channel of the channel. At the bottom of the channel, this fascial leafle is attached to a large leading muscle (it is called the removal fascia). The tailoring muscle arrives from above to the roof of the canal and moves relative to it. It changes the degree of its tension and the magnitude of the lumen for the nerve, depending on the reduction of the medial wide and the thrust muscles. Usually, before leaving the channel, the subcutaneous nerve is divided into two branches - sublovers and downward. The latter accompanies the long hidden vein and goes down on the shin. Nerves can penetrate through the right-minded fascia together or through separate holes. Next, both nerves are located on the fascia under the tailoring muscle and then go under the skin, the screw-like rich tendon of this muscle, and sometimes proceeding it. More dramatically changes the direction of the fifth branch than descending. It is located along the long axis of the hip, but in the lower third of the hip can change its direction by 100 ° and heading almost perpendicular to the axis of the limb. This nerve supplies not only the skin of the medial surface of the knee joint, but also its inner capsule. Dutching branches to the skin of the inner surface of the leg and the inner edge of the foot are departed from the downward branch. Presents practical interest a small twig that passes between the surface and deep part of the tibial (internal) collateral ligament. It may be injured (squeezed) with a felling meniscus, hypertrophied bone spurs along the edges of the joint, with surgery,
The defeat of the subcutaneous nerve occurs in persons over 40 years without prior injury. At the same time, they detect significant fat deposits on the hips and some degree of O-shaped configuration of the lower extremities (Genu Varum). With the syndrome of damage to this nerve often combines internal ink (rotation around the axis) of the tibia. Inraarticular and periarticular changes in the knee joint are not uncommon. Therefore, it is often explained by the STI symptoms only by the lesion of the joint, not assuming the possible neurogenic nature of pain. Direct hip injury at this neuropathy is rare (only from football players). In some patients, the history has damage to the knee joint, usually caused by a non-direct injury, but by transferring a combination of angular and torsion influences to the joint. This type of injuries can cause the separation of internal meniscus at the site of attachment or ripping cartilage. Usually, with refrigerated disorders or hypersobility of the joint, which impede movements, it is not assumed to be a neurogenic basis for permanent pains and a function disorders. However, such changes can be anatomical cause of chronic trauma of the subcutaneous nerve.
The clinical picture of the lesion of the subcutaneous nerve depends on the joint or isolated damage to its branches. When the sublitting branch is affected, pain and possible sensitivity disorders will be limited to the area of \u200b\u200bthe inner part of the knee joint. Under the defeat of the descending branch, such symptoms will refer to the inner surface of the lower leg and foot. Neuropathy is characterized by increasing pain when the limb to be extension in the knee joint. It is very important for the diagnosis of the symptom of the finger compression, if, when it is performed, the upper level of the provocation of paresthesia or pain in the zone of supplying the subcutaneous nerve corresponds to the nerve outlet point from the leading channel. This point is approximately 10 cm above the inner dish of the hip. Search for this point is as follows. The fingertips are superimposed at this level on the front-internal part of the medial wide muscles of the thigh and then slide the stop to contact with the edge of the tailoring muscle. The opening of the subcutaneous nerve outlet is at this point.
With a differential diagnosis, the area of \u200b\u200bdistribution of painful sensations should be taken into account. If the pains (paresthesias) are felt along the inner surface of the lower limb from the knee joint down to the first finger, the high level of damage to the femoral nerve from the neuropathy of its final branch is the subcutaneous nerve. In the first case, the pains are also distributed on the front surface of the thigh, and it is also possible to reduce or loss of the knee reflex. In the second case, the feeling of pain is usually localized not higher than the knee joint, there is no knee reflex loss and sensitive disorders on the front surface of the thigh, and the point of provocation of pain with the finger squeezing corresponds to the site of the subcutaneous nerve from the channel. If the painful sensations are limited to the inner part of the knee joint, the neuropathy of the subcutaneous nerve should be distinguished from such, for example, the position of the knee joint, as the inflammation of the tibial collateral ligament or acute damage to the meniscus. The presence of these disorders and disorders of the joint function is easy to assume on the basis of intensive pain, the pain of the inner surface of the knee joint and harsh pain in it. The final diagnosis of the neuropathy of the sublovered branch of the subcutaneous nerve contributes to the detection of the top level of the provocation of painful sensations with the finger compression. This level corresponds to the location of the nerve. The diagnostic value has at least a temporary weakening of pain after the injection of the hydrocortisone at this point, as well as the detection of sensitive disorders in the skin area of \u200b\u200bthe inner surface of the knee joint.
For prepatellular neuralgia characteristic: the presence in history of a direct injury of the patella, usually when falling on her knees; Immediate or delayed for a few weeks from the moment of injury to the emergence of neuralgic pain under the patella; Detection of a painful point during palpation only at the middle of the inner edge of the patella; the inability due to the gain of pain stand on the knees, to flex the lower limbs in the knee joints, climb up the stairs and, in some cases, generally go; Full cessation of pain after the operational removal of a neurosistrate beam, which supplies pre-trained bags. All these symptoms are not characteristic of the damage to the subcutaneous nerve.
Content:Introduction. The femoral neuropathy refers to fairly frequent mononeuropathies of the lower extremities. Although the femoral neuropathy is known for a long time (for the first time the disease was described almost 200 years ago, under the name "Front Rough Nertarius" Deskartes (Descartes, 1822)), it remains a relatively little-known disease, and the number of publications devoted to this problem in neurological literature is relatively small. In this regard, they do not cause surprise of often observed diagnostic errors.
The Mulberian nerve is an outer bifurcation of the branch of the sedellastic nerve, taking its beginning to the upper angle of the poning, then the guide down and outward towards the head of the Metober bone. The participation of an external patellied sedlication nerve is the most common protuce syndrome in the lower limb, but remains much less common than the median creek tunnel.
He comes to the neck of the Metobers, taking usually flattened by an appearance of about 40 mm, attracting at high inserts of the Mulobers muscles, which are at this level a muscular bone clamp with a mulberry bone. He then passes through a small -com tunnel gap the passage between the inserts of the Metobers muscle on the Maloberstarny bone, quickly divided into a small -com nerve and a small -com nerve. Further down, on the rise, the nerve moves with the front tibial artery under the front ring bundle, separating it into two end branches. - The side branch of the engine, innervating pedal muscle, is a sensitive middle branch, ending at the front end of the first interdimensional space and providing sensory innervation of the first interpal space.
Causes of frequent errors in the diagnosis of femoral neuropathy:
- there is not enough good awareness of practical doctors about the causes and clinical manifestations of the defeat of the femoral nerve (Nervus Femoralis);
- an explicit tendency to the hyperdiagnosis of reflex and compression vertebrogenic syndromes (with which they currently often associate any pain syndromes, sensitivity disorders and paresses in the limbs).
In any case, incorrect diagnosis leads to partially or completely incorrect therapy, which, naturally, adversely affects the course of the disease and contributes to its chronicization. Meanwhile, the overwhelming majority of cases of femoral neuropathy, subject to timely principles and adequacy of therapeutic measures, are potentially curboral. Eliminating the causes of damage to the femoral nerve and early pathogenetic therapy make it possible to avoid potentially disabled outcomes, including hard-fermented complex pelvic belt painsee and the front group of the thigh muscle group with persistent violations of the walking function.
At this level, it pierces the surface and becomes subcutaneous fascia to divide into two final branches are sensitive, one internal and other external, responsible for the innervation of the back of the foot behind its edges, except the side. As a touch nerve, it is responsible for the innervation of the outer surface of the calf and the dorsal surface of the foot. Paines are rare and etiologically dependent, while moderate sensory disorders are limited to an oval area covering the front two-thirds of the leg and the back of the foot.
From the very beginning it is necessary to distinguish a sharp form from the progressive form. - an acute form installed within a few hours or days where the engine is most often happening, but discrete sensory signs; - On the contrary, the progressive form causes a deficit of an incomplete engine and dissociates with more acute sensory disorders on the back leg, the presence of pain before directly to the characteristic or external compressive, because the nerve. Clinical inspection includes, of course, the balance of motor skills and the sensitivity of the legs and feet.
Management and results of abdominal nerve lesions. Peripheral traps of the neuropathy of the lower limb. Perley's capture of the nerve at the runners. Paralysis of the lower nerves after an intermittent consistent pneumatic compression. Paralysis of the lower nerves as a result of osteochondroma of a small-terror head. Peroneal paralysis due to the hematoma in the total mulberry shell after the distal torsion fracture and the ankle stretching. Damage to the total small nerve: diagnostic and therapeutic approach.
Pressing the nerve with a mucoid pseudocyst: about 23 cases. Paralysis of the lower nerves after treatment with acupuncture. Study of common neuropathy associated with foreign pauses. Two cases of localized hypertrophic neurofibrosis. The blood supply to the sedellastic nerve and his popliteal division in humans. Decompression to capture the crotch nerve. The nerve biopsy is an invasive examination, which is usually not fulfilled as part of neuropathy. The biopsy then will allow him to better understand the mechanisms that cause it damage to the peripheral nerve, measure the severity and especially find the cause and, possibly, treatment.
The nerve trunk is similar to a stranded cable, in which individual fibers are isolated from each other myelin - a shell consisting of specialized cells. The myelin shell provides insulation of the nerve fiber, as well as their nutrition. Outside, the nervous trunk is shrouded with a connective tissue. Throughout he is blood supply to small arteries.
Biopsid nerve is always selected in the area where sensitivity is achieved. In all cases, this is a small sensitive branch that eliminates any engine deficiency, secondary to biopsy. The proximal Safenoic nerve is most often selected, but other nerves can be collected based on clinical symptoms.
The patient is usually hospitalized within a few days to carry out this biopsy in good conditions and receives sufficient postoperative medical observation. The sample is taken into the operating room or in a separate room in strict aseptic conditions. The operation lasts about 30 minutes and is carried out under local anesthesia. After cutting the skin size from 5 to 8 cm centimeters and small painless dissection to clean the nerve of nearby structures, it is divided that at this moment a very temporary sensation of the electric discharge can cause.
The processes of nerve cells emerging from the spinal cord - spinal roots - leaving the holes between the vertebrae, "confused" among themselves, forming the so-called plexus. The branches of peripheral nerves extend from the plexuses. At the same time, the twigs of one nerve are formed from several spinal roots. This ensures reliability in the work of the nervous system. There are such plexus on three levels:
If necessary, the patient was informed in consultation or during hospitalization, and his preliminary agreement was requested. The scar of the nervous biopsy is then sewn surgical wire and covered with a bandage. To prevent problems with the scars of the skin, local bleeding or infection, care recommendations and hygiene are provided to the patient, which also gets the necessary recipes to ultimately change the release and remove the seams after healing. full.
Before proceeding to the nerve biopsy, it is necessary to indicate: - the use of anticoagulants or platelet anti-aggregants - any pathologies that may occur as a result of the risk of bleeding is allergic to iodine or to anesthetic. After a biopsy, keep the care recommendations provided by the health team after removing the seams for changing and removing seams. When biopsy is carried out on the lower limb, it is important not to step on the ground for ten days in order not to risk the re-opening of the scar.
- shaven;
- lumbar;
- sleeps.
The fibers of the femoral nerve occur from lumbar plexus. The branches of the lumbar plexus are also the iliac-grade nerve, the iliac-groove, femoral-sex nerve, the lateral skin nerve of the thigh and the locking nerve.
However, the patient can move with reed in English. In addition to possible problems of scarring skin, local bleeding or superinfection of the already mentioned wound, the main complications for the report are:. - The risk of re-opening the scar. - The emergence of anesthesia area in relation to the skin area, usually innervated by a remote nerve. It may be an impression of discomfort, but there is no bound pain. - The emergence of uncomfortable electrical discharges when contacting a biopsy scar.
This complication remains rare and is associated with the formation of non-violence in biopsid nerve. The removal of nerves is carried out by specialist specialists in the laboratory of neuroanatopathology. The acquired fragment is cutting in different thickness, which should be studied in an optical microscope or an electronic specialist in the field of neuropathology of peripheral nerve. Different coloring and tests are also performed depending on the intended disease. All these milestones are long and explain why biopsy results are available only in a few weeks.
Anatomy: Where are the branches of the femoral nerve
The femoral nerve comes from II-IV lumbar spinal roots. Three beams with which it begins are going to the common trunk and descend down between the two muscles of the lower back: large lumbar and iliac. These muscles are attached to the upper part of the femoral bone. They lead the thigh to the stomach and unfold it out, and in a vertical position tip the torso ahead. Both of these muscles are innervated by motor sprigs of the femoral nerve.
Stubborn pains against which there are no effective funds. It consists of so-called neuropathic pains. As a result of injury or dysfunction of the nervous system, they affect at least once in their lives of about 7% of Switzerland's population without any treatment, which can facilitate their satisfactory.
Neuropathic pain is the hypersensitivity of the somatosensory nervous system, which may arise after injury of neurons, "explains Cedric Ladermann, a researcher of the Analgesia Center, the first author of the article, and who has just defended the dissertation on the exact item. These pains can be observed during the hernia of the disk, the neuralgia of the trigeminal nerve, zones, diabetic neuropathies or those that are induced by chemotherapy in patients with cancer.
Going below, the nerve barrel envelopes the lumbar muscle in front and through a narrow space under the groin bunch penetrates into the femoral triangle area. The anatomy of the femoral triangle is such that there is a deepening of a triangular shape, covered by fascia between the muscles of the thigh on the front of its surface. Here, the trunk of the femur nerve is divided into branches. Short motor twigs innervate thigh flexor muscles: tailoring, swing, four-headed thigh muscle. Sensitive branches provide skin sensitivity from groin folds to the knee.
Three categories of chronic pain
Chronic pain affects about 20% of the population. They can be divided into three categories. The first is inflammatory pain, which is caused by an excess of painful inflow into the nervous system as a result of the damage to the peripheral tissue. This pain should disappear after the healing of the fabric.
The second is neuropathic pain. These are those associated with lesions or diseases of the central or peripheral somatosensory system. The third group includes dysfunctional pains, that is, all those that cannot be classified in the first two categories and the causes of which are not identified. Like fibromyalgia, some parts of the nervous system responsible for painful information are sensitized, but they cannot find a biological explanation, despite extensive medical research.
The longest sensitive branch is lowered down on the shin and stop. It is called subcutaneous nerve. The subcutaneous nerve is responsible for the sensitivity of the skin sites, located in front, from the knee to the foot, as well as the inner edge of the leg and foot. It goes down on the shin through the muscular Gunters channel, which is reported to the patented straw. Here, a small twig is separated from him - the sublovers of the nerve, the innervation zone of which is the inner surface of the knee.
The anatomy of the femoral nerve makes it possible to understand the mechanisms of its damage and the symptoms that the femoral nerve is manifested are manifested.
Neuropathy Development Prerequisites
Long nerve fibers, a few dozen centimeters who are bonded from the body of the cell, are vulnerable to external influences. Injury or compression can cause impairment of nervous fiber. This is neuropathy.
Here are the most frequent reasons why neuropathy femoral nerve occurs:
- Spasm muscles of the lower back as a result of overvoltage (for example, athletes).
- Traumatic hemorrhage into the muscles of the lower back.
- Retrunisthed hematoma - blood cluster between the ileum-lumbar muscle and the peritoneum (thin shell, lining the abdominal cavity). Retrunien hematomas may occur after insignificant injuries in people with reduced blood clotting. These are patients with hemophilia, as well as patients who were prescribed anticoagulants - preparations that reduce blood clotting.
- Tumors of retroperitoneal space.
- Interpreting nerve and compression by its groin bunch. Such damage often occurs when a person is in forced position with widely divorced legs. For example, during operations on the vagina, removal of stones from the ureters and bladder. Also, the cause of damage can be an operation on the groin hernia or in the area of \u200b\u200bthe hip joint.
- Damage to the nervous trunk in the femoral triangle area. Such cases are found when the catheter is introduced into the femoral artery, as well as during operations about the femoral hernia.
- The diseases of the knee joint, accompanied by its deformation, cause pinching of nerve fibers in the muscular channel, along which they pass to the popliteal yam (Canal Gunter).
- Prolonged standing on the knees can lead to an isolated neuropathy by an underlovennikovy sprig.
- Varicose or thrombophlebitis subcutaneous veins of legs can cause pinches the twins innervating foot.
The neuropathy of the femoral nerve must be distinguished from states caused by diseases of the lumbar spine. The doctor will help in this careful inspection of the patient. ENMG - electroneuromiography, CT or MRI of retroperitoneal space is also important.
Early appeal to the doctor and an accurate description of the symptoms of the disease will help to make the correct diagnosis in a timely manner.
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