Spinal Cord and Spinal Nerves PDF

NERVOUS SYSTEM
16 O U T L I N E
16.1 Gross Anatomy of the Spinal Cord 487

16.2 Spinal Cord Meninges 489
16.3 Sectional Anatomy of the Spinal Cord 491
16.3a Location and Distribution of Gray Matter 491
16.3b Location and Distribution of White Matter 493
Spinal Cord 16.4 Spinal Nerves

16.4a
16.4b
16.4c
493
Spinal Nerve Distribution
Nerve Plexuses 495
Intercostal Nerves 496
493
and Spinal 16.4d

16.4e
16.4f
16.4g
Cervical Plexuses 496
Brachial Plexuses 499
Lumbar Plexuses 503
Sacral Plexuses 506
Nerves 16.5 Reflexes 510

16.5a Components of a Reflex Arc 510
16.5b Examples of Spinal Reflexes 512
16.5c Reflex Testing in a Clinical Setting 512
16.6 Development of the Spinal Cord 513
MODULE 7: NERVOUS SYSTEM
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Chapter Sixteen Spinal Cord and Spinal Nerves 487
he spinal cord provides a vital link between the brain and filum terminale is a thin strand of pia mater that helps anchor
T the rest of the body, and yet it exhibits some functional inde-
pendence from the brain. The spinal cord and its attached spinal
the conus medullaris to the coccyx. Figure 16.1c shows the conus
medullaris and the cauda equina.
nerves serve two important functions. First, they are a pathway for Viewed in cross section, the spinal cord is roughly cylin-
sensory and motor impulses. Second, the spinal cord and spinal drical, but slightly flattened both posteriorly and anteriorly. Its
nerves are responsible for reflexes, which are our quickest reactions external surface has two longitudinal depressions: A narrow
to a stimulus. In this chapter, we describe the anatomy of the spinal groove, the posterior (or dorsal) median sulcus, dips internally
cord and the integrative activities that occur there. on the posterior surface, and a slightly wider groove, the anterior
(or ventral) median fissure, is observed on its anterior surface.
Cross-sectional views of the spinal cord vary, depending
upon the part from which the section was taken (table 16.1).
16.1 Gross Anatomy These subtle differences make identifying specific spinal cross
of the Spinal Cord sections a bit easier. For example, the diameter of the spinal
cord changes along its length because the amount of gray
Learning Objectives: matter and white matter and the function of the cord vary in
1. Describe the structure of the spinal cord. different parts. Therefore, the spinal cord parts that control
2. Explain the basic functions of the spinal cord. the upper and lower limbs are larger because more neuron
cell bodies are located there, and more space is occupied by
A typical adult spinal cord ranges between 42 and 45 centi-
axons and dendrites. The cervical enlargement, located in the
meters (cm) (16 to 18 inches) in length. It extends inferiorly from the
inferior cervical part of the spinal cord, contains the neurons
brain through the foramen magnum and then through the vertebral
that innervate the upper limbs. The lumbosacral enlargement
canal and ends at the level of the L1 vertebra. The spinal cord may be
extends through the lumbar and sacral parts of the spinal cord
subdivided into the following parts (figure 16.1a):
and innervates the lower limbs.
■ The cervical part is the superiormost region of the The spinal cord is associated with 31 pairs of spinal nerves
spinal cord. It is continuous with the medulla oblongata. that connect the CNS to muscles, receptors, and glands. Spinal
The cervical part contains motor neurons whose axons nerves are considered mixed nerves because they contain both
contribute to the cervical spinal nerves and receives motor and sensory axons. Spinal nerves are identified by the first
input from sensory neurons through these spinal nerves letter of the spinal cord part to which they attach combined with
(figure 16.1b). a number. Thus, each side of the spinal cord contains 8 cervi-
■ The thoracic part lies inferior to the cervical part. It cal nerves (called C1–C8), 12 thoracic nerves (T1–T12), 5 lumbar
contains the neurons for the thoracic spinal nerves. nerves (L1–L5), 5 sacral nerves (S1–S5), and 1 coccygeal nerve
■ The lumbar part is a shorter segment of the spinal cord (Co1). Spinal nerve names can be distinguished from cranial nerve
that contains the neurons for the lumbar spinal nerves. names (discussed in chapter 15) because cranial nerves are desig-
■ The sacral part lies inferior to the lumbar part and contains nated by CN followed by a Roman numeral.
the neurons for the sacral spinal nerves.
■ The coccygeal (kok-sij ́ē-a ̆l) part (not shown in figure
16.1) is the most inferior “tip” of the spinal cord. (Some
texts consider this part a portion of the sacral part of the
spinal cord.) One pair of coccygeal spinal nerves arises Study Tip!
from this region. With one exception, the number of spinal nerves matches the num-
Note that the different parts of the spinal cord do not match ber of vertebrae in that region. For example, there are 12 pairs of thoracic
up exactly with the vertebrae of the same name. For example, the spinal nerves and 12 thoracic vertebrae. The sacrum is formed from
lumbar part of the spinal cord is actually closer to the inferior 5 fused sacral vertebrae, and there are 5 pairs of sacral spinal nerves.
thoracic vertebrae than to the lumbar vertebrae. This discrepancy The coccygeal vertebrae tend to fuse into one structure, and there is
is due to the fact that the growth of the vertebrae continued longer 1 pair of coccygeal nerves. The only exception to this rule is that there
than the growth of the spinal cord itself. Thus, the spinal cord in are 8 pairs of cervical spinal nerves, but only 7 cervical vertebrae,
an adult is shorter than the vertebral canal that houses it. because the first cervical pair emerges between the atlas (the first
The tapering inferior end of the spinal cord is called the cervical vertebra) and the occipital bone.
conus medullaris (kōn ú s̆ med-oo-la r̆ ́ is; kōnos = cone, medulla =
middle). The conus medullaris marks the official “end” of the
spinal cord proper (usually at the level of the first lumbar ver-
tebra). Inferior to this point, groups of axons collectively called W H AT D I D Y O U L E A R N?
the cauda equina (kaw ́da ̆ ē-kwı̄ ń a )̆ project inferiorly from the
spinal cord. These nerve roots are so named because they resemble ●
1 Identify the spinal cord enlargements. What is their function?
a horse’s tail (cauda = tail, equus = horse). Within the cauda equina ●
2 List the specific names of spinal nerves according to their region
is the filum terminale (fı̄ ́lum ̆ ter ḿ i-na ̆l; terminus = end). The and the total number of pairs of spinal nerves.
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488 Chapter Sixteen Spinal Cord and Spinal Nerves
Atlas
C1
Cerebellum
Cervical plexus C2
C3
Cervical part
C4
C5
Cervical enlargement C6 Spinal cord
C7
C8 Posterior
Brachial plexus T1 vertebra rootlets
T1
T2
T3
T4
Posterior
T5 median Denticulate
Thoracic part
sulcus ligaments
T6
T7 (b) Cervical part
T8
T9 Spinal
cord
T10
T11
Lumbosacral
enlargement
L1 vertebra T12 Lumbar part
Conus medullaris Sacral part Posterior
L1 rootlets
Conus
medullaris
L2
Lumbar plexus
L3
Cauda equina
L4
L5 Posterior
root Posterior
Sacral plexus S1 root ganglion
Cauda
S2
equina
S3
S4
Filum terminale
S5
Co1 Filum
terminale
(a) Posterior view (c) Conus medullaris and cauda equina
Figure 16.1
Gross Anatomy of the Spinal Cord. The spinal cord extends inferiorly from the medulla oblongata through the vertebral canal. (a) The vertebral
arches have been removed to reveal the anatomy of the adult spinal cord and its spinal nerves. (b) Cadaver photo of the cervical part of the spinal
cord. (c) Cadaver photo of the conus medullaris and the cauda equina.
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Table 16.1 Cross Sections of Representative Parts of the Spinal Cord

Spinal Cord Part General Size General Shape White Matter/Gray Other
(Diameter) Matter Ratio Characteristics
Cervical Largest of all spinal cord Oval; slightly flattened Large proportion of In superior segments
parts (13–14 mm in on both anterior and white matter compared (C1–C5), anterior horns
Posterior transverse diameter) posterior surfaces to gray matter are relatively small,
and posterior horns are
relatively large
Posterior In inferior segments
median (C6–C8), anterior horns
sulcus are larger and posterior
horns are even more
Anterior enlarged
median
fissure
Anterior
Thoracic Smaller than the Oval; still slightly Larger proportion of Anterior and posterior
cervical part (9–11 mm flattened anteriorly and white matter than gray horns are enlarged
Posterior in transverse diameter) posteriorly matter only in first thoracic
segment; small lateral
horns are visible
Anterior
Lumbar Slightly larger than the Less oval, almost Relative amount of Anterior and posterior
thoracic part (11–13 mm circular white matter is reduced horns are very large;
Posterior in transverse diameter) both in proportion to small lateral horns
gray matter and in present in first two
comparison to cervical sections of lumbar part
part only
Anterior
Sacral Very small Almost circular Proportion of gray Anterior and posterior
matter to white matter horns relatively large
Posterior is largest in this spinal compared to the size of
cord part the cross section
Anterior
tebra, and houses areolar connective tissue, blood vessels, and

16.2 Spinal Cord Meninges adipose connective tissue. It is in this space that an epidural
Learning Objective: anesthetic is given. Deep to the epidural space is the most exter-
nal of the meninges, the dura mater. Although the cranial dura
1. Compare and contrast the arrangement and functions of
mater has an outer periosteal layer and an inner meningeal layer,
the spinal meninges.
the spinal dura mater consists of just one meningeal layer. The
The spinal cord is protected and encapsulated by spinal dura mater provides stability to the spinal cord. In addition, at
cord meninges, which are continuous with the cranial meninges each intervertebral foramen, the dura mater extends between
described in chapter 15. In addition, spaces between some of the adjacent vertebrae and fuses with the connective tissue layers
meninges have clinical significance. The structures and spaces that surround the spinal nerves.
(both real and potential) that encircle the spinal cord, listed from
outermost to innermost, are as follows: vertebra, epidural space,
dura mater, subdural space, arachnoid mater, subarachnoid space, W H AT D O Y O U T H I N K ?
and pia mater (figure 16.2). ●
1 Why doesn’t the spinal dura mater have two layers as the cranial
The epidural (ep-i-doo ŕ a ̆l) space lies between the dura dura mater does? What structures that are formed from cranial
mater and the periosteum covering the inner walls of the ver- dura mater must be missing around the spinal cord?
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Posterior
Spinous process
of vertebra
Epidural space
Dura mater
Spinal nerve
Subdural space
Arachnoid mater
Subarachnoid space
Intervertebral foramen
Pia mater
Spinal cord Body of vertebra
Anterior
(a) Cross section of vertebra and spinal cord
White matter
Gray matter
Posterior median sulcus

Central canal
Posterior rootlets Anterior median fissure
Pia mater
Posterior root
Posterior root ganglion
Spinal nerve
Anterior root Subarachnoid space

Arachnoid mater
Anterior rootlets
Subdural space
Dura mater
(b) Anterior view
Figure 16.2
Spinal Meninges and Structure of the Spinal Cord. (a) A cross section of the spinal cord shows the relationship between the meningeal layers
and the superficial landmarks of the spinal cord and vertebral column. (b) Anterior view shows the spinal cord and meninges.
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CLINICAL VIEW
Lumbar Puncture Skin

Subcutaneous
(Spinal Tap) layer
Back muscles
It is sometimes necessary to analyze the cerebrospinal fluid (CSF) to Ligamentum L3
determine if there is an infection or disorder of the central nervous flavum
system. The clinical procedure for obtaining CSF is known as a lumbar Epidural space
puncture (commonly referred to as a spinal tap). The surface anatomy Dura mater and
arachnoid mater
landmarks and the procedure for performing a lumbar puncture are
Lumbar puncture
discussed in a Clinical View in chapter 13. Recall that the adult spinal needle
cord typically ends at the level of the L1 vertebra, so it is safe to
insert the needle between the L 3 and L4 vertebrae or between the L4
and L5 vertebrae. The needle must be inserted through the skin, the Subarachnoid L4
subcutaneous layer, back muscles, and ligamentum flavum. Then, the space
Cauda equina
needle must pass through the epidural space, dura mater, arachnoid
mater, and enter the subarachnoid space. Here, approximately 3 to
9 milliliters of CSF are taken and then analyzed to determine the nature Vertebral canal
of the nervous system ailment. Site of needle insertion for a lumbar puncture.
In most anatomic and histologic preparations, a narrow

subdural space separates the dura mater from the arachnoid Study Tip!
mater. This space is found only in tissue preparations, and in
Use this analogy to remember the location of somatic motor neu-
life it is merely a potential space. Deep to the arachnoid mater is
rons: The anterior horns contain the somatic motor neurons, just as the
the subarachnoid space, which is a real space filled with cere-
anterior part of a car houses the motor.
brospinal fluid (CSF). The pia mater, deep to the subarachnoid
space, is a delicate, innermost meningeal layer composed of
elastic and collagen fibers. This meninx directly adheres to the
16.3a Location and Distribution of Gray Matter
spinal cord and supports some of the blood vessels supplying
The gray matter in the spinal cord is centrally located, and its
the spinal cord. Denticulate (den-tik ū́ -lāt; dentatus = toothed)
shape resembles a letter H or a butterfly. The gray matter may be
ligaments are paired, lateral triangular extensions of the spinal
subdivided into the following components: anterior horns, lateral
pia mater that attach to the dura mater. These ligaments help
horns, posterior horns, and the gray commissure (see table 16.1
suspend and anchor the spinal cord laterally to the dura mater
and figure 16.3).
(see figure 16.1b).
Anterior horns are the left and right anterior masses of
gray matter. The anterior horns primarily house the cell bod-
W H AT D I D Y O U L E A R N? ies of somatic motor neurons, which innervate skeletal muscle.
Lateral horns are found in the T1–L2 parts of the spinal cord
●
3 What is the function of the denticulate ligaments? only. The lateral horns contain the cell bodies of autonomic motor
neurons, which innervate cardiac muscle, smooth muscle, and
glands. Posterior horns are the left and right posterior masses
16.3 Sectional Anatomy of gray matter. The axons of sensory neurons and the cell bodies
of interneurons are located in the posterior horns. (Note that the
of the Spinal Cord cell bodies of these sensory neurons are not found in the poste-
Learning Objectives: rior horns; rather, they are located in the posterior root ganglia,
which are mentioned later in this chapter.) The gray commis-
1. Describe the internal anatomy of the spinal cord.
sure (kom ́ i-shū r; commissura = a seam) is a horizontal bar of
2. Identify and explain the distribution of gray matter and
gray matter that surrounds a narrow central canal. The gray
white matter in the spinal cord.
commissure primarily contains unmyelinated axons and serves
3. Compare and contrast how gray matter and white matter
as a communication route between the right and left sides of the
process information.
gray matter.
The spinal cord is partitioned into an inner gray matter Within these regions of gray matter are various functional
region and an outer white matter region (figure 16.3). The gray groups of neuron cell bodies called nuclei (noo ́ k lē-ı̄) (fig-
matter is dominated by the dendrites and cell bodies of neurons ure 16.4). Sensory nuclei in the posterior horns contain inter-
and glial cells and unmyelinated axons, whereas the white matter neuron cell bodies. Somatic sensory nuclei receive information
is composed primarily of myelinated axons. from sensory receptors, such as pain or pressure receptors in the
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Posterior
White matter Central canal Posterior median sulcus Gray matter
Posterior horn
Posterior funiculus
Gray commissure
Lateral funiculus
Lateral horn
White commissure Anterior horn
Anterior funiculus
Anterior median fissure

Anterior
(a) Gray and white matter
Posterior
Figure 16.3
Posterior horn
Gray Matter and White Matter Organization in the Spinal Cord.
Gray matter
(a) The gray matter is centrally located, and the white matter is
externally located. (b) Histology of a transverse section of the White matter
spinal cord.
Central canal
Lateral horn
Anterior horn
Gray
commissure
Anterior
(b) Transverse section
Posterior root Posterior horn

(sensory) (interneurons and sensory axons)
Posterior root Somatic

ganglion
Somatic sensory neuron Sensory nuclei
Visceral
Visceral sensory neuron Lateral horn
Components within (autonomic Autonomic
a typical spinal nerve Autonomic motor neuron
motor Motor nuclei
Somatic motor neuron neurons) Somatic
Spinal nerve
(sensory and motor)
Anterior root
(motor)
Anterior horn (somatic motor neurons)
Figure 16.4
Neuron Pathways and Nuclei Locations. The collections of neuron cell bodies within the CNS form specific nuclei. Neurons are color-coded on
the left side of the drawing, while their respective nuclei are color-coded on the right side of the drawing.
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skin, while visceral sensory nuclei receive information from epineurium (see figure 14.12). Motor axons in a spinal nerve orig-
sensory receptors such as the stretch receptors in the smooth inate from the spinal cord (see figures 16.2 and 16.4). Anteriorly,
muscle walls of viscera. Motor nuclei in the anterior and lateral multiple anterior rootlets arise from the spinal cord and merge
horns contain motor neuron cell bodies that send nerve impulses to form a single anterior root (or ventral root), which contains
to muscles and glands. The somatic motor nuclei in the anterior motor axons only. These motor axons arise from cell bodies in
horns innervate skeletal muscle, while the autonomic motor the anterior and lateral horns of the spinal cord. Likewise, the
nuclei in the lateral horns innervate smooth muscle, cardiac posterior aspect of the spinal cord contains multiple posterior
muscle, and glands. rootlets that enter the posterior aspect of the spinal cord. These
rootlets were derived from a single posterior root (or dorsal root),
16.3b Location and Distribution of White Matter which contains sensory axons only. The cell bodies of these sen-
The white matter of the spinal cord is external to the gray matter. sory neurons are located in a posterior root ganglion, which is
White matter on each side of the cord is also partitioned into three attached to the posterior root (see figures 16.2b and 16.4).
regions, each called a funiculus (fū-nik ū́ -lŭs; pl., funiculi,1 fū- Each anterior root and its corresponding posterior root unite
nik ū́ -lı̄; funis = cord) (see figure 16.3a). A posterior funiculus lies within the intervertebral foramen to become a spinal nerve. Thus,
between the posterior gray horns on the posterior side of the cord a spinal nerve contains both motor axons (from the anterior root)
and the posterior median sulcus. The white matter region on each and sensory axons (from the posterior root). You can compare a
lateral side of the spinal cord is the lateral funiculus. The anterior spinal nerve to a cable composed of multiple wires. The “wires”
funiculus is composed of tracts of white matter that occupy the within a spinal nerve are the motor and sensory axons.
space on each anterior side of the cord between the anterior gray The anterior and posterior roots merge to form a spinal nerve
horns and the anterior median fissure; the anterior funiculi are within an intervertebral foramen that is superior or inferior to the
interconnected by the white commissure. vertebra of the same number. For example, the second cervical
The axons within each white matter funiculus are organized spinal nerve exits the vertebral canal through the intervertebral
into smaller structural units called tracts (tractus = a drawing foramen between the C1 and the C2 vertebrae. The eighth cervical
out) or fasciculi (fa -̆ sik ū́ -lı̄; fascis = bundle), to be described in spinal nerve is the exception; it leaves the intervertebral foramen
chapter 17. Individual tracts conduct either sensory impulses between the C7 and T1 vertebrae. The spinal nerves inferior to C8
(ascending tracts from the spinal cord to the brain) or motor com- exit below the vertebra of the same number. So, for example, the
mands (descending tracts from the brain to the spinal cord) only. second thoracic spinal nerve exits the vertebral canal through the
Each funiculus region (posterior, lateral, and anterior) contains intervertebral foramen between the T2 and T3 vertebrae.
both ascending and descending tracts. Thus, each funiculus con- Because the spinal cord is shorter than the vertebral canal,
tains both motor and sensory axons. the roots of the lumbar and sacral spinal nerves have to travel
inferiorly to reach their respective intervertebral foramina through
W H AT D I D Y O U L E A R N? which they pass before they can merge and form a spinal nerve.
●
4 Describe the arrangement of gray matter and white matter in the
Thus, the anterior and posterior roots of the lumbar and sacral
spinal nerves must be much longer than the roots of the other
spinal cord.
spinal nerves.
●
5 Compare the components of the anterior horns and the posterior
horns of the spinal cord.
16.4a Spinal Nerve Distribution
●
6 What are the three groups of funiculi in the white matter of the
After leaving the intervertebral foramen, a typical spinal nerve
spinal cord?
almost immediately splits into branches, termed rami (figure 16.5).
The posterior (dorsal ) ramus (rā m
́ ŭs; pl., rami, rā m
́ ı̄; branch) is
the smaller of the two main branches. It innervates the deep muscles
16.4 Spinal Nerves of the back (e.g., erector spinae and transversospinalis) and the
skin of the back. The anterior (ventral ) ramus is the larger of the
Learning Objectives:
two main branches. The anterior ramus splits into multiple other
1. Describe spinal nerve formation. branches, which innervate the anterior and lateral portions of the
2. List the number of spinal nerve branches. trunk, the upper limbs, and the lower limbs. Many of the anterior
3. Define the concept of a dermatome, and explain the rami go on to form nerve plexuses, which are described in the
clinical importance of a dermatome. next section. Additional rami, called the rami communicantes,
4. Compare and contrast the structure, distribution, and are also associated with spinal nerves. These rami contain axons
innervation patterns of the spinal nerve plexuses. associated with the autonomic nervous system. Each set of rami
The 31 pairs of spinal nerves connect the central nervous communicantes extends between the spinal nerve and a ball-like
system to muscles, glands, and receptors. Recall from chapter structure called the sympathetic trunk ganglion. These ganglia
14 that a spinal nerve is formed from the union of thousands of are interconnected and form a beaded necklace–like structure
motor and sensory axons, and contains three types of successive called the sympathetic trunk. The rami communicantes, the sym-
connective tissue wrappings: endoneurium, perineurium, and pathetic trunk, and the rest of the autonomic nervous system are
described in detail in chapter 18.
1
Note: Anterior and lateral funiculi were formerly called columns. The W H AT D O Y O U T H I N K ?
Federative Committee on Anatomical Terminology (FCAT) now states that
the term “column” refers to structures within the gray matter of the spinal ●
2 Why is an anterior ramus so much larger than a posterior ramus?
cord, while “funiculus” refers to the white matter regions. (Hint: Think about what structures each innervates.)
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Posterior
Spinous process
Deep muscles of back
Posterior root
Posterior ramus Spinal cord
Anterior ramus Spinal nerve
Anterior root
Rami
communicantes
Sympathetic trunk
ganglion
Figure 16.5
Spinal Nerve Branches. The major
branches of a spinal nerve are the Body of vertebra
posterior ramus and the anterior Anterior
ramus.
CLINICAL VIEW
Shingles
Some adults experience a reactivation of their childhood chickenpox
infection, a condition termed shingles (shing ǵ lz). During the initial
infection, the chickenpox virus (varicella-zoster) sometimes leaves the
skin and invades the posterior root ganglia of the spinal cord. There,
the virus remains latent until adulthood, when it becomes reactivated
and proliferates, traveling through the sensory axons to the dermatome.
(The word shingles is derived from the Latin word cingulum, meaning
“girdle,” reflecting the dermatomal pattern of its spread.) Within the
dermatome, the virus continues to proliferate in the skin, giving rise
to a rash and blisters, which are often accompanied by intense burn-
ing or tingling pain. Sometimes the pain precedes the development
of the visible skin changes. Shingles patients are contagious as long
as they have the blisters.
About 10% of adults will experience shingles during their lifetime,

most after the age of 50. Psychological stress, other infections (such
as a cold or the flu), and even a sunburn can trigger the development
of shingles. Shingles is usually a self-limiting condition, although the
disease can recur, and for some patients, dermatomal pain may last
long after the skin changes have resolved.
A classic dermatomal spread of a shingles infection on the right upper torso.
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C2
Trigeminal nerve (CN V)
C2 C3
C4
C5
C3 C6
C4 C7
C8
C5 T1
T1 T2
T2 C5 C5
T3
T3
T4
T2 T4 T2
T5 T5
T6
T1 T6 T1
T7
T7
T8
T8
T9
T9 T10
C7 T11 C7
T10 T12
C6 C8 C8 C6
C5 T11 C5 L1
L2
T12 L3
L1 L1 L4
S2 S3
S4
S3 S5
C6 C6 Co
L2 L2
C7 C8 C8 C7 L5 L5
L1
S1 S1
L3 L3 S2 S2
L2 L2
L4 L4
Figure 16.6
L3 Dermatome Maps. A dermatome is an area of
skin supplied by a single spinal nerve. These
L5 L5 diagrams only approximate the dermatomal
distribution.
S1 S1
L4
S1 S1
L5 L5
Anterior view Posterior view
Dermatomes 16.4b Nerve Plexuses

A dermatome (der m ́ a -̆ tōm; derma = skin, tome = a cutting) is a A nerve plexus (plek ś us̆ ; a braid) is a network of interweaving ante-
specific segment of skin supplied by a single spinal nerve. All spi- rior rami of spinal nerves. (Note: The posterior rami of spinal nerves
nal nerves except C1 innervate a segment of skin, and so each of are smaller than their anterior counterparts and do not form plexuses,
these nerves is associated with a dermatome. Thus, the skin of the but tend to follow a segmental pattern as they innervate the deep
body may be divided into sensory segments that collectively make muscles and skin of the neck and back.) The anterior rami of most
up a dermatome map (figure 16.6). For example, the horizontal spinal nerves form nerve plexuses on both the right and left sides
segment of skin around the umbilicus (navel) region is supplied by of the body. These nerve plexuses then split into multiple “named”
the anterior ramus of the T10 spinal nerve. The dermatome map nerves that innervate various body structures. The principal
follows a segmental pattern along the body. Dermatomes are clini- plexuses are the cervical plexuses, brachial plexuses, lumbar
cally important because they can indicate potential damage to one plexuses, and sacral plexuses (see figure 16.1).
or more spinal nerves. For example, if a patient experiences anes-
thesia (numbness) along the medial side of the arm and forearm,
W H AT D O Y O U T H I N K ?
the C8 spinal nerve may be damaged.
Dermatomes are also involved in referred visceral pain, ●
3 What is the benefit of having an intricate nerve plexus, rather
a phenomenon in which pain or discomfort from one organ is than a single nerve that innervates a structure?
mistakenly referred to a dermatome. For example, the appendix Nerve plexuses are organized such that axons from each
is innervated by axons from the T10 regions of the spinal cord, anterior ramus extend to body structures through several dif-
so appendicitis typically causes referred visceral pain to the T10 ferent branches. In addition, each terminal branch of the plexus
dermatome in the umbilicus region rather than in the abdomino- houses axons from several different spinal nerves. Most of the
pelvic region of the appendix itself. Thus, pain in a dermatome named nerves from a plexus are composed of axons from multi-
may arise from an organ nowhere near the dermatome. Referred ple spinal nerves. Thus, damage to a single segment of the spinal
visceral pain is explored further in chapter 19. cord or damage to a single spinal nerve generally does not result
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Spinal nerve
Posterior ramus
Posterior root
Anterior ramus
Anterior root
Rami communicantes
Sympathetic trunk ganglion
Sympathetic trunk
Figure 16.7
Intercostal Nerves. Intercostal nerves are the anterior
rami of the T1–T11 spinal nerves. They are typically
distributed as shown here.
in complete loss of innervation to a particular muscle or region

of skin. Study Tip!
Most of the thoracic spinal nerves, as well as nerves S5–Co1,
This mnemonic will help you remember the nerves that innervate
do not form plexuses. We discuss the thoracic spinal nerves (called
the diaphragm: C three, four, and five keep the diaphragm alive.
intercostal nerves) first, followed by the individual nerve plexuses.
16.4c Intercostal Nerves

The anterior rami of spinal nerves T1–T11 are called intercostal
nerves because they travel in the intercostal space sandwiched
between two adjacent ribs (figure 16.7). (T12 is called a subcos- 16.4d Cervical Plexuses
tal nerve, because it arises below the ribs, not between two ribs.) The left and right cervical plexuses are located deep on each
The innervation pattern of the T1–T12 nerves is as follows: With side of the neck, immediately lateral to cervical vertebrae C1–C 4
the exception of T1, the intercostal nerves do not form plexuses. (figure 16.8). They are formed primarily by the anterior rami of
A portion of the anterior ramus of T1 helps form the brachial spinal nerves C1–C4. The fifth cervical spinal nerve is not con-
plexus, but a branch of it travels within the first intercostal space. sidered part of the cervical plexus, although it contributes some
The anterior ramus of nerve T2 emerges from its intervertebral axons to one of the plexus branches. Branches of the cervical
foramen and innervates the intercostal muscles of the second plexuses innervate anterior neck muscles as well as the skin of
intercostal space. Additionally, a branch of T2 conducts sensory the neck and portions of the head and shoulders. The branches of
impulses from the skin covering the axilla and the medial sur- the cervical plexuses are described in detail in table 16.2.
face of the arm. Anterior rami of nerves T3–T6 follow the costal One important branch of the cervical plexus is the phrenic
grooves of the ribs to innervate the intercostal muscles and receive (fren ́ i k; phren = diaphragm) nerve, which is formed primarily
sensations from the anterior and lateral chest wall. Anterior rami from the C4 nerve and some contributing axons from C3 and C5.
of nerves T7–T12 innervate not only the inferior intercostal spaces, The phrenic nerve travels through the thoracic cavity to innervate
but also the abdominal muscles and their overlying skin. the diaphragm.
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Figure 16.8
Anterior rami Cervical Plexus. Anterior rami
Cervical plexus branches of nerves C1–C4 form the cervical
Other nerves (not part plexus, which innervates the
of cervical plexus)
skin and many muscles of
the neck.
C1
Atlas
Hypoglossal nerve (XII)

Accessory nerve (XI) C2
Axis
C3
Lesser occipital nerve
Great auricular nerve

Transverse cervical nerve C4
Superior root
Ansa cervicalis
Inferior root C5
Branch to brachial plexus
Supraclavicular nerves
Phrenic nerve
Table 16.2 Branches of the Cervical Plexuses

Nerves Anterior Rami Innervation
MOTOR BRANCHES
Ansa cervicalis Geniohyoid; infrahyoid muscles (omohyoid, sternohyoid, sternothyroid, and thyrohyoid)
Superior root C1, C2
Inferior root C3, C4
Phrenic C3–C5 (primarily C4) Diaphragm
Segmental branches C1–C4 Anterior and middle scalenes
CUTANEOUS BRANCHES
Greater auricular C2, C3 Skin on ear; connective tissue capsule covering parotid gland
Lesser occipital C2 Skin of scalp superior and posterior to ear
Supraclavicular C3, C4 Skin on superior part of chest and shoulder
Transverse cervical C2, C3 Skin on anterior part of neck
Note: While CN XII (hypoglossal) travels with the nerves of the cervical plexus, this cranial nerve is not considered part of the plexus.
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C5
C5 vertebra
T1 vertebra
C6
Nerve to subclavius
Anterior rami: C5, C6, C7, C8, T1
Trunks: superior, middle, inferior Superior trunk
Anterior divisions
Posterior divisions C7
Cords: posterior, lateral, medial
Terminal branches Middle trunk
Lateral pectoral nerve C8
Subscapular nerves
Lateral cord
T1
Posterior cord
Musculocutaneous nerve Long thoracic nerve

Inferior trunk
Medial pectoral nerve
Median nerve Thoracodorsal nerve
Axillary nerve Medial cord
Radial nerve Ulnar nerve
(a) Anterior view
Lateral cord
Posterior cord
Axillary artery
Musculocutaneous
nerve
Axillary nerve
Medial cord
Radial nerve
Median nerve
Ulnar nerve
Long thoracic
nerve
(b) Right axilla, anterior view
Figure 16.9
Brachial Plexus. Anterior rami of nerves C5–T1 form the brachial plexus, which innervates the upper limb. (a) Rami, trunks, divisions, and cords
form the subdivisions of this plexus. (b) A cadaver dissection identifies major nerves from the right brachial plexus. (c) Complete pathways of main
brachial plexus branches in the right upper limb.
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16.4e Brachial Plexuses

The left and right brachial plexuses are networks of nerves that
supply the upper limb. Each brachial plexus is formed by the
anterior rami of spinal nerves C5–T1 (figure 16.9). The com-
Clavicle ponents of the brachial plexus extend laterally from the neck,
pass superior to the first rib, and then continue into the axilla.
Lateral cord
Each brachial plexus innervates the pectoral girdle and the entire
Posterior cord upper limb of one side.
Structurally, each brachial plexus is more complex than a
Medial cord
Scapula
cervical plexus and composed of anterior rami, trunks, divisions,
Axillary nerve and cords when examined from a medial to lateral perspective.
The anterior rami (sometimes called roots) of the brachial plexus
Musculocutaneous
nerve are simply the continuations of the anterior rami of spinal nerves
C5–T1. These rami emerge from the intervertebral foramina and
Humerus
Radial nerve travel through the neck. The five roots unite to form the superior,
middle, and inferior trunks in the posterior triangle of the neck.
Ulnar nerve Nerves C5 and C6 unite to form the superior trunk; nerve C7
Median nerve remains as the middle trunk; and nerves C8 and T1 unite to form
the inferior trunk. Portions of each trunk divide inferior to the
clavicle into an anterior division and a posterior division, which
primarily contain axons that innervate the anterior and posterior
parts of the upper limb, respectively.
Superficial branch
of radial nerve
Study Tip!
Deep branch Ulna In general, nerves from the anterior division of the brachial plexus
of radial nerve tend to innervate muscles that flex the parts of the upper limb. Nerves
Ulnar nerve
from the posterior division of the brachial plexus tend to innervate
muscles that extend the parts of the upper limb. So, if you know a nerve
Median nerve
Radius
is a branch of the anterior division of the brachial plexus, the nerve
likely innervates a group of flexor muscles!
Upon reaching the axilla, the anterior and posterior divi-

Deep branch sions converge to form three cords, which are named with respect
of ulnar nerve
Recurrent branch to their position near the axillary artery. The posterior cord is
of median nerve Superficial branch
of ulnar nerve
posterior to the axillary artery and is formed by the posterior
divisions of the superior, middle, and inferior trunks; therefore, it
Digital branch contains portions of C5–T1 nerves. The medial cord is medial to
Digital branch of ulnar nerve the axillary artery and is formed by the anterior division of the
of median nerve inferior trunk; it contains portions of nerves C8–T1. The lateral
cord is lateral to the axillary artery and is formed from the ante-
(c) Right upper limb, anterior view rior divisions of the superior and middle trunks; thus, it contains
portions of nerves C5–C7.
Finally, five major terminal branches emerge from the
three cords: the axillary, median, musculocutaneous, radial, and
ulnar nerves (table 16.3). The axillary nerve traverses through
the axilla and posterior to the surgical neck of the humerus. The
axillary nerve emerges from the posterior cord of the brachial
plexus and innervates both the deltoid and teres minor muscles.
It receives sensory information from the superolateral part of the
arm. The median nerve is formed from branches of the medial
and lateral cords of the brachial plexus. This nerve travels along
the midline of the arm and forearm, and deep to the carpal tunnel
in the wrist. It innervates most of the anterior forearm muscles,
the thenar muscles, and the lateral two lumbricals. It receives
sensory information from the palmar side of the lateral 3-1/2 fin-
gers (thumb, index finger, middle finger, and the lateral half of
the ring finger) and from the dorsal tips of these same fingers.
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Table 16.3 Branches of the Brachial Plexus

Terminal Branch Anterior Motor Innervation Cutaneous Innervation
Rami
Axillary Nerve C5, C6 Deltoid (arm abductor) Superolateral arm
Formed from posterior cord, posterior division of the brachial Teres minor (lateral rotator of arm)
plexus
Posterior cord
Axillary nerve
Teres minor
Deltoid
Median Nerve C5–T1 Most anterior forearm muscles Palmar aspects and dorsal tips of
Formed from medial and lateral cords, anterior division of the (pronators, flexors of wrist, digits) lateral 3-1/2 digits (thumb, index
brachial plexus Flexor carpi radialis finger, middle finger, and 1/2 of
ring finger)
Flexor digitorum superficialis
Lateral cord Pronator teres
Posterior cord Pronator quadratus
Medial cord Lateral 1/2 of flexor digitorum
profundus
Flexor pollicis longus
Thenar (thumb) muscles (move
Median nerve thumb)
Flexor pollicis brevis
Abductor pollicis brevis
Opponens pollicis
Lateral two lumbricals (flex MP
Pronator teres joints and extend PIP and DIP joints)
Flexor carpi radialis
Palmaris longus
Flexor digitorum
Flexor pollicis superficialis
longus Flexor digitorum
profundus
Pronator
(lateral half)
quadratus
Thenar muscles
Lateral two
lumbricals
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Table 16.3 Branches of the Brachial Plexus (continued)

Rami
Musculocutaneous Nerve C5–C7 Anterior arm muscles (flex Lateral region of forearm
Formed from the lateral cord, anterior division of the brachial humerus, flex elbow joint, supinate
plexus forearm)
Coracobrachialis
Biceps brachii
Brachialis
Lateral cord
Coracobrachialis
Musculocutaneous
nerve
Biceps brachii
Brachialis
Radial Nerve C5–T1 Posterior arm muscles (extend Posterior region of arm
Formed from the posterior cord, posterior division of the forearm) Posterior region of forearm
brachial plexus Triceps brachii Dorsal aspect of lateral three digits
Anconeus (except their distal tips)
Lateral cord Posterior forearm muscles (supinate
forearm, extend wrist, digits,
one muscle that abducts thumb)
Posterior cord Supinator
Extensor carpi radialis muscles
Medial cord
Extensor digitorum
Radial nerve
Extensor carpi ulnaris
Lateral head of Extensor pollicis longus
Long head of triceps brachii Extensor pollicis brevis
triceps brachii
Abductor pollicis brevis
Extensor digiti minimi
Medial head of
Extensor indicis
triceps brachii
Brachioradialis Brachioradialis (flexes forearm)
Anconeus
Extensor carpi
Supinator radialis
Extensor carpi ulnaris Abductor

pollicis longus
Extensor digiti minimi
Extensor digitorum
Extensor pollicis
longus and brevis
Extensor indicis
(continued on next page)
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Table 16.3 Branches of the Brachial Plexus (continued)

Rami
Ulnar Nerve C8–T1 Anterior forearm muscles (flexors Dorsal and palmar aspects of medial
Formed from the medial cord, anterior division of the brachial of wrist and digits) 1-1/2 digits (little finger, medial aspect
plexus Medial half of flexor digitorum of ring finger)
profundus
Lateral cord Flexor carpi ulnaris
Intrinsic hand muscles
Posterior cord
Hypothenar muscles
Medial cord
Palmar interossei (adduct
fingers)
Dorsal interossei (abduct fingers)
Ulnar nerve Adductor pollicis (adducts
thumb)
Medial two lumbricals ( flex MP
joints and extend PIP and DIP
joints)
Flexor carpi ulnaris
Flexor digitorum profundus

(medial half)
Hypothenar muscles
Adductor
pollicis Medial two lumbricals
Dorsal and
palmar interossei
Smaller Branches of the Brachial Plexus Anterior Motor Innervation Cutaneous Innervation
Rami
Dorsal scapular C5 Rhomboids, levator scapulae
Long thoracic C5–C7 Serratus anterior
Lateral pectoral C5–C7 Pectoralis major
Medial pectoral C8–T1 Pectoralis major
Pectoralis minor
Medial cutaneous nerve of arm C8–T1 Medial side of arm
Medial cutaneous nerve of forearm C8–T1 Medial side of forearm
Nerve to subclavius C5–C6 Subclavius
Suprascapular C5–C6 Supraspinatus, infraspinatus
Subscapular nerves C5–C6 Subscapularis, teres major
Thoracodorsal C6–C8 Latissimus dorsi
The musculocutaneous (mus̆ ́kū-lō-kū-tā ń ē-us̆ ) nerve arises muscles (forearm extensors) and the posterior forearm muscles
from the lateral cord of the brachial plexus. It innervates the ante- (extensors of the wrist and digits and the supinator of the forearm).
rior arm muscles (coracobrachialis, biceps brachii, and brachialis), It receives sensory information from the posterior arm and forearm
which flex the humerus and flex the forearm. It also receives surface and the dorsolateral side of the hand.
sensory information from the lateral surface of the forearm. The The ulnar nerve arises from the medial cord of the brachial
radial nerve arises from the posterior cord of the brachial plexus. It plexus and descends along the medial side of the arm. It wraps pos-
travels along the posterior side of the arm and then along the radial terior to the medial epicondyle of the humerus and then runs along
side of the forearm. The radial nerve innervates the posterior arm the ulnar side of the forearm. It innervates some of the anterior
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CLINICAL VIEW:
IEW: In Depth
Brachial Plexus Injuries passage. Additionally, the nerve may be injured by any deep lacera-
tion of the wrist. Median nerve injury often results in paralysis of
Injuries to parts of the brachial plexus are fairly common, especially the thenar group of muscles. The classic sign of median nerve injury
in individuals aged 18–22. Minor plexus injuries are treated by simply is the “ape hand” deformity, which develops over time as the thenar
resting the limb. More severe brachial plexus injuries may require eminence wastes away until the hand eventually resembles that of
nerve grafts or nerve transfers; for very severe injuries, no effective an ape (apes lack well-developed thumb muscles). The lateral two
treatment exists. Various nerves of the brachial plexus may be injured. lumbricals are also paralyzed, and sensation is lost in the part of
the hand supplied by the median nerve.
AXILLARY NERVE INJURY
The axillary nerve can be compressed within the axilla, or it can be ULNAR NERVE INJURY
damaged if the surgical neck of the humerus is broken (recall that the The ulnar nerve may be injured by fractures or dislocations of the elbow
axillary nerve travels posterior to the surgical neck of the humerus). A because of this nerve’s close proximity to the medial epicondyle of the
patient whose axillary nerve is damaged has great difficulty abducting humerus. When you “hit your funny bone,” you have actually hit your
the arm due to paralysis of the deltoid muscle, as well as anesthesia ulnar nerve. Most of the intrinsic hand muscles are paralyzed (including
(lack of sensation) along the superolateral skin of the arm. the interossei muscles, the hypothenar muscles, the adductor pollicis,
RADIAL NERVE INJURY and the medial two lumbricals), so the person is unable to adduct or
The radial nerve is especially subject to injury during humeral shaft abduct the fingers. In addition, the person experiences sensory loss
fractures or in injuries to the lateral elbow. Nerve damage results in along the medial side of the hand. A clinician can test for ulnar nerve
paralysis of the extensor muscles of the forearm, wrist, and fingers. injury by having a patient hold a piece of paper tightly between the
A common clinical sign of radial nerve injury is “wrist drop,” meaning fingers as the doctor tries to pull it away. If the person has weak
that the patient is unable to extend his or her wrist. The patient also interossei muscles, the paper can be easily extracted.
experiences anesthesia along the posterior arm, the forearm, and the SUPERIOR TRUNK INJURY
part of the hand normally supplied by this nerve. The superior trunk of the brachial plexus can be injured by excessive
POSTERIOR CORD INJURY separation of the neck and shoulder, as when a person riding a motor-
The posterior cord of the brachial plexus (which includes the axillary cycle is flipped from the bike and lands on the side of the head. A
and radial nerves) is commonly injured in the axilla. One cause is superior trunk injury affects the C5 and C6 anterior rami, so any brachial
improper use of crutches, a condition called crutch palsy. Similarly, the plexus branch that has these nerves is also affected to some degree.
posterior cord can be compressed if a person drapes the upper limb
INFERIOR TRUNK INJURY
over the back of a chair for an extended period of time. Because this
The inferior trunk of the brachial plexus can be injured if the arm is
can happen if someone passes out in a drunken stupor, this condition
excessively abducted, as when a neonate’s arm is pulled too hard during
is also referred to as drunkard’s paralysis. Fortunately, full function of
delivery. Inferior trunk injuries also may happen when grasping some-
these nerves is often regained after a short period of time.
thing above the head to break a fall—for example, grabbing a branch to
MEDIAN NERVE INJURY keep from falling out of a tree. An inferior trunk injury involves the C8
The median nerve may be impinged on or compressed as a result of and T1 anterior rami, so any brachial plexus branch that is formed from
carpal tunnel syndrome because of the close confines of this narrow these nerves (such as the ulnar nerve) also is affected to some degree.
forearm muscles (the medial region of the flexor digitorum pro- 16.4f Lumbar Plexuses
fundus and all of the flexor carpi ulnaris). It also innervates most The left and right lumbar plexuses are formed from the anterior
of the intrinsic hand muscles, including the hypothenar muscles, rami of spinal nerves L1–L4 located lateral to the L1–L 4 vertebrae
the palmar and dorsal interossei, and the medial two lumbricals. It and along the psoas major muscle in the posterior abdominal
receives sensations from the skin of the dorsal and palmar aspects wall (figure 16.10). The lumbar plexus is structurally less com-
of the medial 1-1/2 fingers (the little finger and the medial half of plex than the brachial plexus. However, like the brachial plexus,
the ring finger). the lumbar plexus is subdivided into an anterior division and a
The brachial plexus also gives off numerous other nerves posterior d ivision. The primary nerves of the lumbar plexus are
that innervate portions of the upper limb and pectoral girdle. listed in table 16.4.
These branches are not as large as the terminal branches (see The main nerve of the posterior division of the lumbar
table 16.3). plexus is the femoral nerve. This nerve supplies the anterior thigh
muscles, such as the quadriceps femoris (knee extensor) and the
W H AT D O Y O U T H I N K ? sartorius and iliopsoas (hip flexors). It also receives sensory infor-
●
4 Which nerve might you have damaged if you have difficulty mation from the anterior and inferomedial thigh as well as the
abducting your arm and experience anesthesia (lack of sensation) medial aspect of the leg. The main nerve of the anterior division is
along the superolateral arm? the obturator nerve, which travels through the obturator foramen
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Anterior rami
Posterior divisions
Anterior divisions
L1
Iliohypogastric nerve
L2 Ilioinguinal nerve
Ilioinguinal nerve Genitofemoral nerve

L3
Genitofemoral nerve Femoral nerve
L4
Lateral femoral Lateral femoral
cutaneous nerve cutaneous nerve
L5
Femoral nerve
Obturator nerve
Lumbosacral trunk
Obturator nerve
(a) Anterior view
Saphenous nerve
(continuation of
Subcostal nerve femoral nerve)
Ilioinguinal nerve
Lateral femoral
cutaneous nerve
Genitofemoral nerve
Obturator nerve
Femoral nerve
(b) Right pelvic region, anterior view (c) Right lower limb, anterior view
Figure 16.10
Lumbar Plexus. (a) Anterior rami of nerves L1–L4 form the lumbar plexus. (b) Cadaver photo shows the components of the lumbar plexus.
(c) Pathways of lumbar plexus nerves.
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Table 16.4 Branches of the Lumbar Plexus

Main Branch Anterior Motor Innervation Cutaneous Innervation
Rami
Femoral Nerve L2–L4 Anterior thigh muscles Anterior thigh
Quadriceps femoris (knee Inferomedial thigh
L2 extensor)
L3 Medial side of leg
L4 Iliopsoas (hip flexor) Most medial aspect of foot
Iliacus Sartorius (hip and knee flexor)
Femoral nerve Psoas major Pectineus1
Sartorius Pectineus
Rectus femoris
Vastus Vastus medialis
intermedius
Sartorius
Vastus lateralis
Obturator Nerve L2–L4 Medial thigh muscles (adductors Superomedial thigh

of thigh)
L2 Adductors
L3
L4 Gracilis
Pectineus1
Obturator nerve Obturator externus (lateral rotator
of thigh)
Obturator externus
Adductor longus
Adductor brevis
Adductor longus
Adductor magnus Gracilis
1
Pectineus may be innervated by the femoral nerve, obturator nerve, or branches from both nerves.
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Table 16.4 Branches of the Lumbar Plexus (continued)

Smaller Branches of the Lumbar Plexus Anterior Motor Innervation Cutaneous Innervation
Rami
Iliohypogastric L1 Partial innervation to abdominal Superior lateral gluteal region
muscles (flex vertebral column) Inferior abdominal wall
Ilioinguinal L1 Partial innervation to abdominal Inferior abdominal wall

muscles (flex vertebral column) Scrotum (males) or labia majora
(females)
Genitofemoral L1, L2 Small area in anterior superior thigh

Scrotum (males) or labia majora
(females)
Lateral femoral cutaneous L2, L3 Anterolateral thigh
to the medial thigh. There, the nerve innervates the medial thigh plantar muscles of the foot and conduct sensory impulses from the
muscles (which adduct the thigh) and receives sensory informa- skin covering the sole of the foot. The common fibular (common
tion from the superomedial skin of the thigh. Smaller branches of peroneal) nerve is formed from the posterior division of the sciatic
each lumbar plexus innervate the abdominal wall, the scrotum nerve. As the common fibular division of the sciatic nerve, it sup-
and the labia, and the inferior portions of the abdominal muscles plies the short head of the biceps femoris muscle. Along the lateral
(table 16.4). knee, as it wraps around the neck of the fibula, this nerve splits
into two main branches: the deep fibular nerve and the superficial
fibular nerve.
W H AT D O Y O U T H I N K ?
●
5 Which nerve of the lumbar plexus might you have damaged if you
have difficulty extending your knee?
16.4g Sacral Plexuses Anterior rami

The left and right sacral plexuses are formed from the anterior Posterior divisions
rami of spinal nerves L4–S4 and are located immediately inferior Anterior divisions L4
to the lumbar plexuses (figure 16.11). The lumbar and sacral
plexuses are sometimes considered together as the lumbosacral L5
plexus. The nerves emerging from a sacral plexus innervate the
gluteal region, pelvis, perineum, posterior thigh, and almost all
of the leg and foot.
The anterior rami of the sacral plexus organize themselves
into an anterior division and a posterior division. The nerves aris- S1
ing from the anterior division tend to innervate muscles that flex Superior gluteal nerve
(or plantar flex) parts of the lower limb, while the posterior divi-
sion nerves tend to innervate muscles that extend (or dorsiflex) Inferior gluteal nerve S2
part of the lower limb. Table 16.5 lists the main and smaller
nerves of the sacral plexus. Nerve to piriformis
S3
The sciatic (sı̄-at ́ik) nerve, also known as the ischiadic
(is-kē-at ́ik; hip joint) nerve, is the largest and longest nerve in the Common fibular division
Sciatic nerve S4
body. This nerve projects from the pelvis through the greater sciat- Tibial division
ic notch of the os coxae and extends into the posterior region of the
thigh. The sciatic nerve is actually composed of two divisions—the Posterior femoral cutaneous nerve
tibial division and the common fibular division—wrapped in a
common sheath. Just superior to the popliteal fossa, the two divi- Pudendal nerve
sions of the sciatic nerve split into two nerves. The tibial nerve is (a) Anterior view
formed from the anterior divisions of the sciatic nerve. In the pos-
terior thigh, the tibial division of the sciatic nerve innervates the Figure 16.11
hamstrings (except for the short head of the biceps femoris) and
Sacral Plexus. Anterior rami of nerves L4, L5, and S1–S4 form the
the hamstring part of the adductor magnus. It travels in the poste- sacral plexus. (a) The sacral plexus has six rami and both anterior
rior compartment of the leg, where it supplies the plantar flexors and posterior divisions. (b) A posterior view shows the distribution
of the foot and the toe flexors. In the foot, the tibial nerve splits of nerves of the sacral plexus. (c, d) Cadaver photos reveal the major
into the lateral and medial plantar nerves, which innervate the sacral plexus nerves of the right gluteal and popliteal regions.
mck78097_ch16_486-517.indd 506 2/14/11 3:36 PM

Superior gluteal Gluteus medius

nerve (cut)
Inferior gluteal Gluteus minimus
nerve Gluteus maximus
Pudendal nerve Superior gluteal
(cut)
Sciatic nerve nerve
Posterior femoral
cutaneous nerve Inferior gluteal
nerve
Sacrotuberous
ligament
Sciatic nerve
Posterior femoral
cutaneous nerve
Pudendal nerve Gluteus maximus

(cut)
(c) Right gluteal region
Common fibular
nerve
Gracilis Biceps femoris

Tibial nerve
Lateral sural
cutaneous nerve
Tibial nerve
Semimembranosus
Semitendinosus Common fibular
nerve
Popliteal artery
Plantaris
Sural nerve
Medial sural
cutaneous nerve Gastrocnemius,
lateral head
Gastrocnemius, Lateral sural
medial head cutaneous nerve
Medial plantar
Lateral plantar
nerve
nerve
(b) Right lower limb, posterior view (d) Right popliteal region
The deep fibular (deep peroneal ) nerve travels in the flexors). It also conducts sensory impulses from most of the dor-
anterior compartment of the leg and terminates between the sal surface of the foot and the anteroinferior part of the leg.
first and second toes. It supplies the anterior leg muscles (which
dorsiflex the foot and extend the toes) and the muscles on the
dorsum of the foot (which extend the toes). In addition, this nerve
receives sensory innervation from the skin between the first and
W H AT D I D Y O U L E A R N?
second toes on the dorsum of the foot. The superficial fibular ●
7 Where is a posterior root ganglion located, and what does it
(superficial peroneal) nerve travels in the lateral compartment contain?
of the leg. Just proximal to the ankle, this nerve becomes
superficial along the anterior part of the ankle and dorsum of
●8 Identify the nerve plexuses, from superior to inferior.
the foot. The superficial fibular nerve innervates the lateral ●9 What nerves form the brachial plexus?
compartment muscles of the leg (foot evertors and weak plantar ●
10 What are the main nerves of the lumbar and sacral plexuses?
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Table 16.5 Branches of the Sacral Plexus

Main Branch Anterior Rami Motor Innervation Cutaneous Innervation
Sciatic Nerve L4–S3 (See tibial and common fibular (See tibial and common fibular
(Composed of tibial and common fibular divisions nerves) nerves)
wrapped in a common sheath)
Tibial Nerve L4–S3 Posterior thigh muscles (extend Branches to the heel, and via its
L4 thigh and flex leg) medial and lateral plantar nerve
L5 Long head of biceps femoris branches (which supply the sole of
S1 the foot)
Semimembranosus
S2
S3 Tibial division Semitendinosus
of sciatic nerve Part of adductor magnus
Adductor Posterior leg muscles (plantar
Biceps femoris magnus flexors of foot, flexors of knee)
(long head)
Flexor digitorum longus
Semitendinosus
Semimembranosus Flexor hallucis longus
Gastrocnemius
Tibial nerve Soleus
Popliteus
Gastrocnemius Tibialis posterior (inverts foot)
Popliteus Plantar foot muscles (via medial
and lateral plantar nerve branches)
Soleus
Tibialis posterior
Flexor digitorum
longus
Flexor hallucis
longus
Medial plantar Lateral plantar

nerve nerve
Common Fibular Nerve L4–S2 Short head of biceps femoris (knee (See deep fibular and superficial
(Divides into deep fibular and superficial fibular flexor); see also deep fibular and fibular nerves)
branches) superficial fibular nerves
L4
L5
S1
S2
S3
Common fibular
division of
sciatic nerve
Biceps femoris
short head
Common fibular
nerve
Fibularis longus
Fibularis brevis Tibialis anterior
Superficial fibular Deep fibular

nerve nerve
Extensor digitorum Extensor hallucis
longus longus
Fibularis tertius
Extensor digitorum
brevis Extensor hallucis
brevis
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Table 16.5 Branches of the Sacral Plexus (continued)

Main Branch Anterior Rami Motor Innervation Cutaneous Innervation
Deep Fibular Nerve L4–S1 Anterior leg muscles (dorsiflex foot, Dorsal interspace between first and
extend toes) second toes
Tibialis anterior (inverts foot)
Extensor hallucis longus
Extensor digitorum longus
Common fibular
nerve Fibularis tertius
Dorsum foot muscles (extend toes)
Tibialis anterior Extensor hallucis brevis
Superficial fibular Extensor digitorum brevis
Deep fibular
nerve nerve
Extensor digitorum Extensor hallucis
longus longus
Fibularis tertius
Extensor digitorum
brevis Extensor hallucis
brevis
Superficial Fibular Nerve L5–S2 Lateral leg muscles (foot evertors Anteroinferior part of leg; most of
and plantar flexors) dorsum of foot
Fibularis longus
Fibularis brevis
Common fibular
nerve
Fibularis longus
Fibularis brevis
Superficial
fibular nerve
Smaller Branches of the Sacral Plexus Anterior Rami Motor Innervation Cutaneous Innervation
Inferior gluteal nerve L5–S2 Gluteus maximus (thigh extensor)
Superior gluteal nerve L4–S1 Gluteus medius, gluteus minimus,
and tensor fasciae latae (abductors
of thigh)
Posterior femoral cutaneous nerve S1–S3 Skin on posterior thigh
Pudendal nerve S2–S4 Muscles of perineum, external Skin on external genitalia
anal sphincter, external urethral
sphincter
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CLINICAL VIEW
Sacral Plexus Nerve Injuries The common fibular nerve is especially prone to injury due to fracture
of the neck of the fibula or compression from a leg cast that is too
Some branches of the sacral plexus are readily subject to injury. For example, tight. Compression of the nerve compromises it and its branches
a poorly placed gluteal intramuscular injection can injure the superior (superficial fibular, deep fibular), paralyzing the anterior and lateral
or inferior gluteal nerves, and in some cases even the sciatic nerve (see leg muscles and leaving the person unable to dorsiflex and evert
Clinical View in chapter 13). Additionally, a herniated intervertebral disc the foot. One classic sign of fibular nerve injury is “foot drop.” As a
may impinge on the nerve branches that form the sciatic nerve. Injury to person lifts the affected foot to take a step, the lack of innervation
the sciatic nerve produces a condition known as sciatica (sı̄-at ́ i-kă), which of the anterior and lateral leg muscles causes the foot to fall into
is characterized by extreme pain down the posterior thigh and leg. This the plantar-flexed position. Because the person can’t dorsiflex the
pain does not go away unless the injury to the sciatic nerve is remedied. foot to walk normally, he or she compensates by flexing the hip to
For example, repairing a herniated disc will alleviate the compression on lift the affected area and keep from tripping or stubbing the toes.
the sciatic nerve.
16.5 Reflexes 3. Information from nerve impulse is processed in the

integration center by interneurons. More complex reflexes
Learning Objectives: may use a number of interneurons within the CNS to
1. Identify and describe the properties of a reflex. integrate and process incoming sensory information and
2. List the structures and steps involved in a reflex arc. transmit information to a motor neuron. The simplest
3. Explain how reflexes are used as diagnostic indicators. reflexes do not involve interneurons; rather, the sensory
neuron synapses directly on a motor neuron in the anterior
Reflexes are rapid, automatic, involuntary reactions of mus- gray horn of the spinal cord.
cles or glands to a stimulus. All reflexes have similar properties: 4. Motor neuron transmits nerve impulse to effector. The
■ A stimulus is required to initiate a response to sensory motor neuron transmits a nerve impulse through the anterior
input. root and spinal nerve to the peripheral effector organ.
■ A rapid response requires that few neurons be involved and 5. Effector responds to nerve impulse from motor
synaptic delay be minimal. neuron. An effector (ē-fek t́ ŏr, -tōr; producer) is a peripheral
■ An automatic response occurs the same way every time. target organ that responds to the impulse from the motor
■ An involuntary response requires no intent or pre-awareness neuron. This response is intended to counteract or remove
of the reflex activity. Thus, reflexes are usually not the original stimulus.
suppressed. Awareness of the stimulus occurs after the
reflex action has been completed, in time to correct or avoid Reflex arcs may be ipsilateral or contralateral. A reflex arc is
a potentially dangerous situation. termed ipsilateral (ip-si-lat é r-a ̆l; ipse = same, latus = side) when
both the receptor and effector organs of the reflex are on the same
An example of a reflex occurs when you accidentally touch side of the spinal cord. For example, an ipsilateral effect occurs when
a hot burner on a stove. Instantly and automatically, you remove the muscles in your left arm contract to pull your left hand away from
your hand from the stimulus (the hot burner), even before you are a hot object. A reflex arc is contralateral (kon-tră-lat ́er-ăl; contra =
completely aware that your hand was touching something extremely opposite) when the sensory impulses from a receptor organ cross
hot. A reflex is a survival mechanism; it allows us to quickly over through the spinal cord to activate effector organs in the
respond to a stimulus that may be detrimental to our well-being opposite limb. For example, a contralateral effect occurs when you
without having to wait for the brain to process the information. step on a sharp object with your left foot and then contract the
muscles in your right leg to maintain balance as you withdraw
16.5a Components of a Reflex Arc
your left leg from the damaging object.
A reflex arc is the neural “wiring” of a single reflex. It always Reflexes may also be monosynaptic or polysynaptic
begins at a receptor in the PNS, communicates with the CNS, and (figure 16.13). A monosynaptic (mon ́ō-si-nap t́ ik; monos = single)
ends at a peripheral effector, such as a muscle or gland cell. The reflex is the simplest of all reflexes. The sensory axons synapse
number of intermediate steps varies, depending on the complexity directly on the motor neurons, whose axons project to the effector.
of the reflex. Generally, five steps are involved in a simple reflex Interneurons are not involved in processing this reflex. Very minor
arc, as illustrated in figure 16.12 and described here: synaptic delay is incurred in the single synapse of this reflex arc,
1. Stimulus activates receptor. Sensory receptors (dendritic resulting in a very prompt reflex response. An example of a mono-
endings of a sensory neuron) respond to both external and synaptic reflex is the patellar (knee-jerk) reflex, which physicians
internal stimuli, such as temperature, pressure, or tactile use to assess the functioning of the spinal cord. By tapping the
changes. patellar ligament with a reflex hammer, the muscle spindles in
2. Nerve impulse travels through sensory neuron to the CNS. the quadriceps muscles are stretched. The brief stimulus causes a
Sensory neurons conduct impulses from the receptor into the reflexive contraction that occurs unopposed and produces a notice-
spinal cord. able kick of the leg.
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1 Stimulus activates 2 Nerve impulse travels through

receptor sensory neuron to the spinal cord
Skin 3 Nerve impulse is processed in the
integration center by interneurons
Interneuron
Spinal cord
4 Motor neuron transmits

nerve impulse to effector
5 Effector responds to impulse from motor neuron
Figure 16.12
Reflex Arc. A reflex arc is a nerve pathway composed of neurons that control rapid, unconscious, automatic responses to a stimulus.
Monosynaptic reflex: Polysynaptic reflex:

Sensory (stretch) receptor Direct communication between Interneuron facilitates
sensory and motor neuron sensory-motor communication
Spinal cord
Sensory receptor
Sensory Sensory
neuron neuron
Interneuron
Effector organ
Effector organ
Motor neuron Motor neuron
Figure 16.13
Monosynaptic and Polysynaptic Reflexes. (Left) The minimal number of neurons and the pathways of a monosynaptic reflex are compared to
(right) those of a polysynaptic reflex.
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Polysynaptic (pol ́ē-si-nap t́ ik; polys = many) reflexes have more Motor

complex neural pathways that exhibit a number of synapses involving Sensory
interneurons within the reflex arc. Because this reflex arc has more
components, there is a more prolonged delay between stimulus and Muscle stretch stimulates
response. An example of a polysynaptic reflex is the crossed-extensor sensory nerve impulse
reflex, which is the reflex that supports postural muscle activity when to travel to the CNS
you withdraw your foot from a painful stimulus, as in the previous
example. Contraction of the extensor muscles in the other limb occurs
Muscle spindle
by polysynaptic reflexes to enable you to maintain balance.
16.5b Examples of Spinal Reflexes Sensory nerve

endings
Some common spinal reflexes are the withdrawal reflex, the
stretch reflex, and the Golgi tendon reflex. Motor nerve
A withdrawal (flexor) reflex is a polysynaptic reflex arc endings
that is initiated by a painful stimulus, such as touching something Muscle
very hot. Stimulation of a receptor organ causes the transmission
of sensory information to the spinal cord. Interneurons receive the
sensory information and stimulate motor neurons to direct flexor
muscles to contract in response. Simultaneously, antagonistic
(extensor) muscles are inhibited so that the traumatized body part Stretch
may be quickly withdrawn from the harmful stimulation.
The stretch reflex is a monosynaptic reflex that monitors and Figure 16.14
regulates skeletal muscle length. Stretch in a muscle is monitored Stretch Reflexes. A stretch reflex is a simple monosynaptic reflex
by a stretch receptor called a muscle spindle. When a stimulus involving two neurons. A stretching force detected by a muscle
results in the stretching of a muscle, that muscle reflexively spindle results in the contraction of that muscle.
contracts (figure 16.14). The patellar (knee-jerk) reflex is an
example of a stretch reflex. The stimulus (the tap on the patellar
ligament) stretches the quadriceps femoris muscle and initiates
contraction of the muscle, thereby extending the knee joint.
Muscle
The Golgi tendon reflex is a polysynaptic reflex that prevents
skeletal muscles from tensing excessively. Golgi tendon organs are Muscle contraction
nerve endings located within tendons near a muscle–tendon junc- stimulates sensory
nerve impulses that
tion (figure 16.15). As a muscle contracts, force is exerted on its travel to the CNS
associated tendon, resulting in increased tension in the tendon and Axon of
activation of the Golgi tendon organ. Nerve impulses in the Golgi sensory neuron
tendon organ signal interneurons in the spinal cord, which in turn
inhibit the actions of the motor neurons. When the motor neurons
that cause the muscle contraction are inhibited, the associated
muscle is allowed to relax, thus protecting the muscle and tendon Tendon
from excessive tension damage.
16.5c Reflex Testing in a Clinical Setting

Reflexes can be an important diagnostic tool. Clinicians use them
to test specific muscle groups and specific spinal nerves or seg- Figure 16.15
ments of the spinal cord (table 16.6). Although some variation Golgi Tendon Reflex. Contraction of a muscle generates tension on
in reflexes is normal, a consistently abnormal reflex response may its tendons, and may cause a tendon reflex response. This illustration
indicate damage to the nervous system or muscles. shows a Golgi tendon organ, which detects the contraction force and
A reflex response may be normal, hypoactive, or hyper- results in the relaxation of that muscle.
active. The term hypoactive reflex means that a reflex response
is diminished or absent. A hypoactive reflex may indicate damage
to a segment of the spinal cord, or it may suggest muscle disease
or damage to the neuromuscular junction. A hyperactive reflex W H AT D I D Y O U L E A R N?
refers to an abnormally strong response. It may indicate damage
somewhere in either the brain or spinal cord, especially if it is ●
11 List the five steps in a reflex arc.
accompanied by clonus (klō n ́ u s̆ ; tumult), rhythmic oscillations ●
12 What is the major difference between monosynaptic reflexes and
between flexion and extension when the muscle reflex is tested. polysynaptic reflexes?
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Table 16.6 Some Clinically Important Reflexes

Reflex Spinal Nerve Segments Tested Normal Action of Effector
Biceps reflex C5, C6 Flexes elbow when biceps brachii tendon is tapped
Triceps reflex C6, C7 Extends elbow when triceps brachii tendon is tapped
Abdominal reflexes T8–T12 Contract abdominal muscles when one side of the abdominal wall is briskly stroked
Cremasteric reflex L1, L2 Elevates testis (due to contraction of cremaster muscle in scrotum) when medial side of
thigh is briskly stroked
Patellar (knee-jerk) reflex L2–L4 Extends knee when patellar ligament is tapped
Ankle (Achilles) reflex S1, S2 Plantar flexes ankle when calcaneal tendon is tapped
Plantar reflex L5, S1 Plantar flexes foot; flexes toes when plantar side of foot is briskly stroked1
1
This is the normal reflex response in adults; in adults with spinal cord damage and in normal infants, the Babinski sign occurs, which is extension of the great toe and
fanning of the other toes.
16.6 Development of the Spinal Cord limitans (lim ́ i-tanz; limes = boundary) forms in the lateral walls
of the central canal (figure 16.16b). The sulcus limitans also rep-
Learning Objective: resents a dividing point in the neural tube as two specific regions
1. Explain how the spinal cord and spinal nerves develop in become evident on each side: the basal plates and the alar plates.
the embryo. The basal plates lie anterior to the sulcus limitans. The basal
plates develop into the anterior and lateral horns, motor structures
Recall from previous chapters that the central nervous sys-
of the gray matter. They also form the anterior part of the gray
tem forms primarily from the embryonic neural tube, while the
commissure. The alar (ā ́ la r̆ ; ala = wing) plates lie posterior to the
cranial and spinal nerves form primarily from neural crest cells
sulcus limitans. By about the ninth week of development, the alar
that have split off from the developing neural tube. The cranial
plates develop into posterior horns, sensory structures of the gray
(superior) part of the neural tube expands and develops into the
matter. They also form the posterior part of the gray commissure.
brain, while the caudal (inferior) part of the neural tube forms the
During the embryonic period, the spinal cord extends the
spinal cord. The following discussion focuses on the caudal part of
length of the vertebral canal. However, during the fetal period, the
the neural tube and its nearby neural crest cells.
growth of the vertebral column (and its vertebral canal) outpaces
As the caudal part of the neural tube differentiates and spe-
that of the spinal cord. By the sixth fetal month, the spinal cord is
cializes, the spinal cord begins to develop (figure 16.16). However,
at the level of the S1 vertebra, while a newborn’s spinal cord ends
this developmental process is much less complex than that for the
at about the L3 vertebra. By adulthood, the spinal cord length
brain. A hollow neural canal in the neural tube develops into
extends only to the level of the L1 vertebra. This disproportionate
the central canal of the spinal cord. Note that the neural canal
growth explains why the lumbar, sacral, and coccygeal regions
doesn’t “shrink” in size; rather, the neural tube around it grows
of the spinal cord and its associated nerve roots do not lie next to
at a rapid rate. Thus, as the neural tube walls grow and expand,
their respective vertebrae.
the neural canal in the newborn appears as a tiny hole called the
central canal.
During the fourth and fifth weeks of embryonic develop- W H AT D I D Y O U L E A R N?
ment, the walls of the neural tube start to grow rapidly and
unevenly. Part of the neural tube forms the white matter of the ●
13 From what embryonic structures do most components of the
spinal cord, while other components form gray matter. By the cranial and spinal nerves form?
sixth week of development, a horizontal groove called the sulcus ●
14 What structures develop from the alar plates?
mck78097_ch16_486-517.indd 513 2/14/11 3:36 PM

Neural crest
Neural canal
Neural tube
(a) Week 4
Alar plate
Sensory neuron
cell bodies
Sulcus limitans
Basal plate
Motor neuron
cell bodies
(b) Week 6: Basal and alar plates form
Gray commissure Posterior root
Sensory axons
Posterior horn Posterior root

ganglion
Gray matter Lateral horn
Central
canal
Anterior horn
Spinal nerve
Interneuron
Motor axons
White matter Anterior root
(c) Week 9: Gray horns form from basal and alar plates
Figure 16.16
Spinal Cord Development. The spinal cord begins development as a tubular extension of the brain. (a) A cross section shows the structures of the
neural tube of an embryo in week 4 of development. Transverse sections show (b) the formation of the basal and alar plates at week 6 and
(c) the developing spinal cord at week 9.
Clinical Terms
hemiplegia (hem-ē-plē ́jē-ă; hemi = one-half, plege = stroke) paraplegia (par-ă-plē ́jē-ă) Paralysis that results in loss of motor
Paralysis of the upper and lower limbs on one side of the control in both lower limbs.
body only, usually as a result of a stroke (cerebrovascular quadriplegia (kwah ́dri-plē ́jē-ă; quattor = four) Paralysis of both
accident). the upper and the lower limbs.
myelitis (mı̄-ĕ-lı̄ ́tis; myelos = medulla, marrow) Inflammation of
the spinal cord.
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Chapter Summary
■ The spinal cord and its attached spinal nerves serve as a pathway for sensory and motor impulses and are responsible
for reflexes.
16.1 Gross Anatomy ■ The adult spinal cord extends inferiorly from the brain through the vertebral canal and ends at the level of the L1
of the Spinal vertebra.
Cord 487 ■ Thirty-one pairs of spinal nerves connect the spinal cord to the body: 8 pairs of cervical nerves, 12 pairs of thoracic
nerves, 5 pairs of lumbar nerves, 5 pairs of sacral nerves, and 1 pair of coccygeal nerves.
16.2 Spinal Cord ■ An outer epidural space separates the tough dura mater membrane from the inner walls of the vertebral canal.
Meninges 489 ■ The subarachnoid space, which is internal to the arachnoid mater, houses the cerebrospinal fluid.
■ The pia mater is the innermost meningeal layer. It is bound laterally to the spinal dura mater by paired denticulate
ligaments.
16.3 Sectional ■ Gray matter is centrally located and H-shaped; peripheral to the gray matter is the white matter, which is composed
Anatomy of the primarily of myelinated axons.
Spinal Cord 491
16.3a Location and Distribution of Gray Matter 491
■ Gray matter is composed of three horns: anterior (cell bodies of somatic motor neurons), lateral (cell bodies of
autonomic motor neurons), and posterior (sensory axons and interneurons).
■ The gray commissure connects the left and right sides of the gray matter and contains the axons of interneurons that
extend between opposite sides of the spinal cord.
16.3b Location and Distribution of White Matter 493
■ The white matter is organized into three pairs of funiculi, each composed of specific tracts. Sensory information moves
through ascending tracts to the brain, and motor information is carried by descending tracts from the brain to the
spinal cord.
16.4 Spinal ■ Spinal nerves originate from anterior and posterior rootlets.
Nerves 493
16.4a Spinal Nerve Distribution 493
■ Spinal nerves have two branches: a posterior ramus innervates the skin and deep muscles of the back, and an anterior
ramus innervates the anterior and lateral portions of the trunk and the limbs.
16.4b Nerve Plexuses 495
■ A nerve plexus is a network of interwoven anterior rami.
16.4c Intercostal Nerves 496
■ The anterior rami of spinal nerves T1–T11 form the intercostal nerves. Nerve T12 is called a subcostal nerve.
16.4d Cervical Plexuses 496
■ The cervical plexus is formed from the anterior rami of C1–C4. It innervates the neck and portions of the head and
shoulders.
16.4e Brachial Plexuses 499
■ The brachial plexus innervates the upper limb and is formed from the anterior rami of C5–T1.
16.4f Lumbar Plexuses 503
■ The lumbar plexus innervates the anterior and medial thigh and the skin of the medial leg. It is formed from the anterior
rami of L1–L4.
16.4g Sacral Plexuses 506
■ The sacral plexus innervates most of the lower limb and is formed from the anterior rami of L4–S4.
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Chapter Summary (continued)

16.5 Reflexes 510 ■ A reflex is a rapid, automatic, involuntary motor response of muscles or glands to a stimulus.
16.5a Components of a Reflex Arc 510
■ The five steps involved in a reflex arc are (1) activation of a receptor by a stimulus, (2) impulse conduction to the CNS,
(3) integration and processing of information by interneurons, (4) stimulation of a motor neuron, and (5) effector organ
response.
■ The simplest reflex arc is a monosynaptic reflex, in which the sensory neuron synapses directly with the motor neuron.
A polysynaptic reflex involves a sensory neuron, a motor neuron, and at least one interneuron connecting the sensory
and motor neurons.
16.5b Examples of Spinal Reflexes 512
■ A withdrawal reflex is polysynaptic and activates flexor muscles to immediately remove a body part from a painful
stimulus.
■ A stretch reflex is monosynaptic and regulates skeletal muscle length and tone.
■ A Golgi tendon reflex is polysynaptic and prevents excessive tension in a muscle by inhibiting the contraction of the
muscle, allowing it to relax.
16.5c Reflex Testing in a Clinical Setting 512
■ Testing differentiates between hypoactive and hyperactive reflexes, and can help diagnose nervous system or muscular
disorders.
16.6 Development ■ The neural tube forms basal plates and alar plates. The basal plates form the anterior horns, lateral horns, and the
of the Spinal anterior part of the gray commissure, while the alar plates form the posterior horns and the posterior part of the gray
Cord 513 commissure.
Challenge Yourself
Matching c. cauda equina.
Match each numbered item with the most closely related lettered d. posterior root.
item. ______ 2. The anterior root of a spinal nerve contains
______ 1. sacral plexus a. strand of pia mater that a. axons of both motor and sensory neurons.
anchors spinal cord to coccyx b. axons of sensory neurons only.
c. interneurons.
______ 2. posterior root b. innervates infrahyoid muscles d. axons of motor neurons only.
______ 3. filum terminale c. forms anterior and lateral horns ______ 3. Identify the meningeal layer immediately deep to
______ 4. white matter d. contains axons of sensory the subdural space.
neurons a. pia mater
b. arachnoid mater
______ 5. cervical plexus e. contains cell bodies of c. epidural space
autonomic motor neurons d. dura mater
______ 6. basal plate f. a segment of skin supplied by a ______ 4. Axons cross from one side of the spinal cord to the
spinal nerve other through a region called the
______ 7. reflex g. innervates gluteal region and a. lateral horn.
most of lower limb b. posterior horn.
c. gray commissure.
______ 8. lateral horn h. innervates anterior thigh d. anterior horn.
muscles
______ 5. The radial nerve originates from the ______ plexus.
______ 9. dermatome i. composed of tracts and funiculi a. cervical
______ 10. femoral nerve j. rapid, involuntary motor b. lumbar
reaction of a muscle c. sacral
d. brachial
Multiple Choice ______ 6. Which structure provides motor innervation to the
deep back muscles and receives sensory information
Select the best answer from the four choices provided. from the skin of the back?
______ 1. The tapered inferior end of the spinal cord is called a. anterior ramus
the b. anterior root
a. conus medullaris. c. posterior ramus
b. filum terminale. d. posterior root
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______ 7. Lower limbs are supplied by neurons from the addition, list which types of nuclei (motor or sensory) are
______ of the spinal cord. located in each horn.
a. lumbosacral enlargement 4. Where are the cervical plexuses located, and what do they
b. thoracic region innervate?
c. cervical enlargement
5. What are the main terminal branches of the brachial plexus,
d. All of these are correct.
and what muscles do these terminal branches innervate?
______ 8. The subarachnoid space contains ______, and the 6. What anterior rami form the lumbar plexus, and what are
epidural space contains ______. some nerves formed from this plexus?
a. CSF; fat, connective tissue, and blood vessels
7. What muscles do the tibial and common fibular nerves
b. fat, connective tissue, and blood vessels; blood
innervate?
c. CSF; pia mater
d. fat, connective tissue, and blood vessels; CSF 8. What is a reflex? How does it differ from a muscle
movement that you consciously control, as when you
______ 9. The white matter of the spinal cord is composed consciously contract your biceps brachii muscle?
primarily of
9. What are the differences between withdrawal, stretch, and
a. unmyelinated axons.
Golgi tendon reflexes?
b. neurolemmocytes and satellite cells.
c. myelinated axons. 10. Where are the basal plates of the neural tube, and what
d. cell bodies of neurons. does each form?
______ 10. Which statement is true about intercostal nerves? Developing Critical Reasoning
a. They are formed from the posterior rami of spinal
1. Arthur dove off a small cliff into water that was shallower
nerves.
than he expected and hit his head on a submerged object.
b. They form a thoracic plexus of nerves.
He is now a quadriplegic, meaning that both his upper and
c. They originate from the thoracic part of the
lower limbs are paralyzed. Approximately where is the
spinal cord.
location of his injury? What is the likelihood that Arthur
d. They innervate the deep back muscles of the
will recover from this injury? (You may want to review parts
thoracic region.
of chapter 14 to answer the latter question.)
Content Review 2. Jessica was knocked off her bicycle and fractured the
medial epicondyle of her elbow. The neurologist detected
1. Identify the spinal cord parts, which spinal nerves are
swelling and increased pressure around Jessica’s injury, and
associated with them, and their relationship to the
suspected that a nerve might be damaged as well. What
corresponding vertebrae.
nerve is likely damaged, and what other symptoms would
2. Where is the epidural space? What is housed there? the neurologist expect as a result of this injury?
3. List the three gray matter horns on each side of the spinal
cord, and discuss the neuronal composition of each. In
Answers To “What Do You Think?”
1. The two layers of the cranial dura mater split to form the 3. A nerve plexus houses axons from several different spinal
dural venous sinuses, which are large veins that drain nerves. Thus, damage to a single segment of the spinal cord
blood away from the brain. The spinal cord lacks dural or damage to a single spinal nerve generally does not result
venous sinuses, but has smaller veins that travel in the in complete loss of innervation to a particular muscle or
epidural space around the spinal cord. region of skin.
2. An anterior ramus is larger than a posterior ramus because 4. Anesthesia along the upper lateral arm and difficulty
the posterior rami only innervate deep back muscles and abducting the arm indicate damage to the axillary nerve.
the skin of the back, while the anterior rami innervate 5. Difficulty extending the knee indicates damage to the
almost all other body structures (e.g., the limbs and the femoral nerve.
anterior and lateral trunk).
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Spinal Cord and Spinal Nerves PDF

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What are the main parts of the spinal cord and their functions?

What are the main parts of the spinal cord and their functions?

What are the main types of spinal nerves and what do they innervate?

What are the main types of spinal nerves and what do they innervate?

NERVOUS SYSTEM

16.1 Gross Anatomy of the Spinal Cord 487

Spinal Cord 16.4 Spinal Nerves

and Spinal 16.4d

Nerves 16.5 Reflexes 510

MODULE 7: NERVOUS SYSTEM

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mck78097_ch16_486-517.indd 487 2/14/11 3:35 PM

(a) Posterior view (c) Conus medullaris and cauda equina

mck78097_ch16_486-517.indd 488 2/14/11 3:35 PM

Table 16.1 Cross Sections of Representative Parts of the Spinal Cord

tebra, and houses areolar connective tissue, blood vessels, and

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Spinal cord Body of vertebra

(a) Cross section of vertebra and spinal cord

Posterior median sulcus

Anterior root Subarachnoid space

(b) Anterior view

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Lumbar Puncture Skin

In most anatomic and histologic preparations, a narrow

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Anterior median fissure

(a) Gray and white matter

(b) Transverse section

Posterior root Posterior horn

Posterior root Somatic

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mck78097_ch16_486-517.indd 493 2/14/11 3:35 PM

Deep muscles of back

Posterior root ganglion

Posterior ramus Spinal cord

Anterior ramus Spinal nerve

About 10% of adults will experience shingles during their lifetime,

A classic dermatomal spread of a shingles infection on the right upper torso.

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Anterior view Posterior view

Dermatomes 16.4b Nerve Plexuses

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in complete loss of innervation to a particular muscle or region

16.4c Intercostal Nerves

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Hypoglossal nerve (XII)

Great auricular nerve

Branch to brachial plexus

Table 16.2 Branches of the Cervical Plexuses

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Lateral pectoral nerve C8

Musculocutaneous nerve Long thoracic nerve

(a) Anterior view

(b) Right axilla, anterior view

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16.4e Brachial Plexuses

Upon reaching the axilla, the anterior and posterior divi-

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