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Sacral plexus

The sacral plexus is a major nerve network in the peripheral nervous system, formed by the ventral (anterior) rami of spinal nerves L4 through S4, that provides motor and sensory innervation to the posterior thigh, most of the lower leg and foot, parts of the pelvis, perineum, and external genitalia.^[1]^[2] Located on the posterior pelvic wall, anterior to the piriformis muscle and posterior to the internal iliac vessels and ureter, the sacral plexus arises as a flat, triangular structure within the pelvis, often considered part of the broader lumbosacral plexus alongside the lumbar plexus.^[1]^[2] It is formed primarily by the lumbosacral trunk—contributing fibers from L4 and L5—and the anterior rami of S1 to S4, with these roots converging lateral to the sacral foramina before branching.^[1]^[2] The plexus gives rise to several key peripheral nerves, including the sciatic nerve (L4–S3), which is the largest branch and divides into the tibial and common peroneal (fibular) nerves to supply the posterior thigh muscles, leg, and foot; the pudendal nerve (S2–S4), responsible for sensory and motor functions in the perineum and genitalia; the superior gluteal nerve (L4–S1), innervating the gluteus medius, gluteus minimus, and tensor fasciae latae for hip abduction and medial rotation; and the inferior gluteal nerve (L5–S2), which powers the gluteus maximus for hip extension.^[1]^[2] Additional branches include the posterior femoral cutaneous nerve (S1–S3) for sensory input to the buttock and posterior thigh, and smaller nerves to pelvic floor muscles like the obturator internus and quadratus femoris.^[2] Functionally, the sacral plexus coordinates essential movements such as walking, hip stabilization, and pelvic organ control, while transmitting sensory information from the lower body; disruptions, often from trauma like pelvic fractures or compression by the piriformis muscle, can lead to conditions such as sciatica, foot drop, or perineal sensory loss, highlighting its clinical importance in neurology and orthopedics.^[1]^[2]

Overview

Formation

The sacral plexus originates from the ventral rami of spinal nerves L4 through S4. Specifically, it receives contributions from the lumbosacral trunk, which is formed by the ventral rami of L4 and L5 descending from the lumbar plexus, along with the ventral rami of S1, S2, S3, and S4.^[3]^[4] The lumbosacral trunk serves as a critical anatomical bridge, carrying fibers from the lumbar region to integrate with the sacral contributions, thereby linking the lumbar and sacral plexuses into the broader lumbosacral plexus system.^[2]^[5] Embryologically, the spinal nerves contributing to the sacral plexus develop during weeks 4 to 8 of gestation. This process involves neural crest cells, which migrate to form the sensory components of the peripheral nervous system, including dorsal root ganglia, and neuroectoderm of the neural tube, which gives rise to motor neurons and ventral roots.^[6]^[7] The ventral rami, which form the basis of the plexus, arise as these roots unite shortly after their emergence from the spinal cord. Anatomically, these ventral rami converge within the pelvis, anterior to the piriformis muscle, to form a flattened band of nerve fibers arranged in a flat, triangular configuration.^[8]^[9]^[10] This convergence allows for the subsequent division and distribution of fibers to the lower limb and pelvic structures.

Location

The sacral plexus is situated on the posterior pelvic wall, within the pelvis, immediately anterior to the piriformis muscle and the sacrum. It lies posterior to the internal iliac vessels and the ureter.^[8]^[2] The plexus spans vertically from the anterior sacral foramina at the S1 vertebral level, where the contributing ventral rami emerge, extending inferiorly to converge toward the lower portion of the greater sciatic foramen.^[8] Superiorly, it is defined by the joining lumbosacral trunk (derived from L4 and L5 roots), while inferiorly it incorporates contributions up to the S4 root; laterally, the plexus orients toward the gluteal region as its nerves exit the pelvis.^[3]^[11] In proximity to pelvic organs, the sacral plexus is positioned anterior to the rectum and near the urinary bladder, separated by the pelvic fascia.^[8]

Anatomy

Components

The sacral plexus is formed by the ventral rami of the spinal nerves L4 through S4, with each ventral ramus dividing into anterior and posterior divisions shortly after emerging from the intervertebral foramina.^[1] These divisions represent the primary internal organizational elements, allowing for the selective grouping of fibers destined for specific peripheral nerves; the anterior divisions generally contribute to flexor and adductor functions in the lower limb, while the posterior divisions supply extensor and abductor muscles.^[4] This bifurcation occurs within the pelvis, enabling the plexus to integrate contributions from both lumbar and sacral levels efficiently. The components of the sacral plexus consist of a mixture of motor, sensory, and autonomic nerve fibers derived from the contributing spinal segments. Motor fibers primarily originate from anterior horn cells and innervate skeletal muscles of the pelvis, perineum, and lower limb, while sensory fibers from dorsal root ganglia provide cutaneous and proprioceptive input from the same regions.^[1] Autonomic fibers, including parasympathetic components from S2-S4 via pelvic splanchnic nerves, are integrated into the plexus to regulate visceral functions such as bladder and bowel control.^[2] This heterogeneous composition ensures comprehensive innervation, with fibers from multiple spinal levels converging to form a unified network. As a complex network, the sacral plexus facilitates the intermingling and redistribution of fibers from its anterior and posterior divisions, allowing individual axons to travel through multiple rami before regrouping into terminal nerves.^[4] This rearrangement enhances functional efficiency by matching fiber origins to target distributions. The overall structure adopts a triangular form, with its base at the upper sacral levels tapering inferiorly toward the greater sciatic foramen.^[10]

Relations

The sacral plexus is situated on the posterior pelvic wall, with its anterior relations including the internal iliac artery and vein, the ureter, and the sigmoid colon on the left side (or distal ileal loops on the right).^[12]^[8] These structures lie in close proximity, potentially influencing the plexus during pelvic pathology or surgical interventions. The plexus receives its vascular supply from branches of the internal iliac artery, notably the superior and inferior gluteal arteries and their accompanying veins, which course alongside the plexus and its emerging nerves.^[8]^[12] Posteriorly, the sacral plexus lies directly against the anterior surface of the sacrum and coccyx, embedded within the pelvic fascia, and is covered by the piriformis muscle, which separates it from the gluteal region.^[2]^[5] This positioning allows the piriformis to serve as a key landmark, with the superior gluteal vessels passing between the lumbosacral trunk and the first sacral nerve root, while the inferior gluteal vessels traverse between the second and third sacral roots.^[12] Laterally, the sacral plexus relates to the obturator internus muscle and its tendon, as branches such as the nerve to the obturator internus emerge from the plexus and course toward this muscle near the greater sciatic foramen.^[12] The plexus converges laterally toward the greater sciatic foramen, where its major components exit the pelvis.^[8] Due to these spatial relationships, the sacral plexus is vulnerable to compression, particularly by the piriformis muscle in cases of piriformis syndrome, where anatomical variants may cause the sciatic nerve to pass through or above the muscle belly, leading to entrapment.^[8] Additionally, during childbirth, the fetal head at the pelvic brim can compress the plexus against the sacroiliac joint or surrounding structures.^[5]

Branches

Major Nerves

The major nerves arising from the sacral plexus include the sciatic nerve, pudendal nerve, superior gluteal nerve, inferior gluteal nerve, and nerve to the quadratus femoris. These nerves emerge primarily from the anterior rami of spinal nerves L4 through S4, exiting the pelvis via specific foramina to innervate muscles and structures of the lower limb, pelvis, and perineum.^[13]^[14] The sciatic nerve, the largest branch of the sacral plexus, originates from the ventral rami of spinal nerves L4 through S3 and represents the thickest nerve in the human body, with a diameter up to 2 cm. It forms within the pelvis anterior to the piriformis muscle and exits through the greater sciatic foramen inferior to that muscle, accompanied by the inferior gluteal artery. The nerve then descends along the posterior thigh, deep to the gluteus maximus, between the greater trochanter and ischial tuberosity, before dividing proximal to the popliteal fossa into its terminal branches: the tibial nerve and the common peroneal (fibular) nerve. This bifurcation typically occurs at the junction of the middle and lower thirds of the thigh, though variations exist where the split may occur higher, even within the pelvis. The sciatic nerve's dual composition reflects contributions from both posterior and anterior divisions of the lumbosacral plexus, enabling its extensive motor and sensory distributions.^[13] The pudendal nerve arises from the sacral plexus via the ventral rami of spinal nerves S2 through S4, forming a single trunk on the lateral pelvic wall. It exits the pelvis through the greater sciatic foramen inferior to the piriformis muscle, then hooks around the sacrospinous ligament and re-enters via the lesser sciatic foramen to travel through the pudendal canal (Alcock's canal) along the obturator internus muscle. This course positions it to supply the perineum, where it divides into three main branches: the inferior rectal nerve (innervating the external anal sphincter and perianal skin), the perineal nerve (supplying the perineal muscles and posterior vaginal wall or bulb of the penis), and the dorsal nerve of the penis or clitoris (providing sensation to the external genitalia). The pudendal nerve is primarily somatic, carrying motor fibers to pelvic floor muscles and sensory fibers from the perineal skin and mucosa.^[15] The superior gluteal nerve emerges from the posterior divisions of the L4, L5, and S1 roots of the sacral plexus, making it a pure motor nerve. It leaves the pelvis through the greater sciatic foramen superior to the piriformis muscle, along with the superior gluteal artery and veins, before branching immediately within the gluteal region. Its primary targets are the gluteus medius and gluteus minimus muscles, which it innervates via superficial and deep branches, and the tensor fasciae latae muscle, reached by a more distal ramus. These innervations support hip abduction and medial rotation, essential for pelvic stability during gait. The nerve's short course limits its vulnerability but requires precise surgical awareness in hip procedures.^[14] The inferior gluteal nerve originates from the dorsal branches of the ventral rami of L5, S1, and S2 within the sacral plexus, functioning exclusively as a motor nerve. It exits the pelvis through the greater sciatic foramen inferior to the piriformis muscle, posterior to the sciatic nerve, and accompanied by the inferior gluteal vessels. Upon entering the gluteal region, it penetrates the gluteus maximus muscle approximately 5 cm from the tip of the greater trochanter to provide its sole innervation, enabling powerful hip extension and lateral rotation critical for standing and climbing. The nerve's trajectory is relatively direct and superficial in the proximal gluteal area.^[16]^[17] The nerve to the quadratus femoris derives from the anterior divisions of the L4 and L5 roots via the lumbosacral trunk of the sacral plexus, often with minor contributions from S1. This mixed but predominantly motor nerve exits the greater sciatic foramen deep to the sciatic nerve and inferior to the piriformis, then courses anteriorly along the pelvic surface of the obturator internus tendon toward the posterior hip capsule. It supplies the quadratus femoris muscle, facilitating hip lateral rotation, and sends a branch to the inferior gemellus muscle, aiding in similar rotational movements. The nerve's path positions it adjacent to the hip joint, where it may communicate with other rotators like the obturator internus nerve.^[3]^[18]

Terminal Branches

The terminal branches of the sacral plexus consist of smaller nerves that emerge distally from the plexus, primarily providing targeted sensory and motor innervations to the skin and muscles of the posterior thigh, gluteal region, perineum, and pelvic floor. These branches arise from the anterior and posterior divisions of the ventral rami of spinal nerves L5 through S4, often exiting the pelvis via the greater or lesser sciatic foramina. Unlike the larger major nerves such as the sciatic, which serve as proximal trunks, the terminal branches are specialized for localized distributions.^[8]^[5] The posterior femoral cutaneous nerve originates from the posterior divisions of S1 and S2, along with the anterior divisions of S2 and S3. It exits the pelvis through the greater sciatic foramen inferior to the piriformis muscle, descending deep to the gluteus maximus muscle and along the posterior thigh beneath the fascia lata, eventually piercing the deep fascia near the knee. This nerve supplies the skin of the posterior thigh, upper posterior leg, perineum, and lower buttock via its perineal, inferior cluneal, and posterior thigh branches.^[8]^[4]^[19] The perforating cutaneous nerve arises from the posterior divisions of S2 and S3. It pierces the sacrotuberous ligament to reach the gluteal region, traveling superficially to supply the skin over the inferior and medial gluteal area, including the lower medial buttock fold.^[5]^[19]^[18] The nerve to the obturator internus emerges from the anterior divisions of L5 to S2. It leaves the pelvis via the greater sciatic foramen below the piriformis, crosses the ischial spine accompanied by the internal pudendal vessels, and re-enters through the lesser sciatic foramen to pierce the obturator internus muscle. This nerve supplies the obturator internus and superior gemellus muscles.^[8]^[5]^[18] Small direct branches from the sacral plexus, primarily the anterior divisions of S3 and S4, innervate the pelvic floor muscles, including the levator ani, coccygeus, and external anal sphincter. These branches arise within the pelvis and distribute to the respective muscles without exiting through the sciatic foramina.^[5]^[4]^[19] The sacral plexus integrates with the lumbar plexus through the lumbosacral trunk, formed by the anterior rami of L4 and L5, which contributes fibers to several terminal branches such as the nerve to the obturator internus.^[8]^[3]

Function

Motor Innervation

The sacral plexus provides motor innervation to the muscles of the pelvis, buttocks, and lower limb through its various branches, enabling essential movements such as hip stabilization, lower limb propulsion, and pelvic floor support. These efferent pathways originate primarily from the anterior rami of spinal nerves L4-S4, with specific contributions from the sacral segments S1-S4.^[20] The superior gluteal nerve (L4-S1) innervates the gluteus medius, gluteus minimus, and tensor fasciae latae muscles, facilitating hip abduction and medial rotation to maintain pelvic stability during gait.^[14] The inferior gluteal nerve (L5-S2), in contrast, supplies the gluteus maximus muscle, which is crucial for hip extension and lateral rotation, particularly during activities like rising from a seated position or climbing stairs.^[16] The sciatic nerve, a major terminal branch of the sacral plexus (L4-S3), divides into the tibial and common peroneal (fibular) nerves, each contributing to lower limb motor functions. The tibial division innervates the hamstrings (biceps femoris long head, semitendinosus, and semimembranosus), enabling knee flexion and assisting in hip extension.^[13] The common peroneal division supplies the anterior compartment muscles of the leg, such as the tibialis anterior, extensor hallucis longus, and extensor digitorum longus, which are responsible for ankle dorsiflexion and toe extension to prevent foot drop during walking.^[13] Deeper pelvic muscles receive targeted innervation for rotational movements: the nerve to the obturator internus (L5-S2) supplies the obturator internus and superior gemellus, promoting external rotation of the hip, while the nerve to the piriformis (S1-S2) innervates the piriformis muscle, further aiding in hip abduction and external rotation.^[21]^[22] The pudendal nerve (S2-S4) provides somatic motor innervation to the pelvic floor muscles, including the bulbospongiosus, ischiocavernosus, and external anal sphincter, which support continence and facilitate micturition and defecation.^[15] Additionally, the pelvic splanchnic nerves (S2-S4) carry parasympathetic fibers that contribute to autonomic motor control of the bladder detrusor muscle for urination and the distal colon for bowel motility.^[23]

Sensory Innervation

The sacral plexus provides sensory innervation to the skin of the lower limb, perineum, and pelvic viscera primarily through its anterior and posterior divisions, derived from spinal roots L4-S4. This afferent input includes cutaneous sensation via dermatomes and specific peripheral nerves, as well as visceral afferents from pelvic organs. Many of these nerves also carry motor fibers, though their efferent roles are detailed elsewhere. Dermatomes from the sacral roots S1-S3 supply sensory innervation to the posterior aspects of the thigh, leg, and sole of the foot, with S1 covering the lateral heel and sole, S2 the posterior thigh and popliteal fossa, and S3 contributing to the perianal region. These segmental patterns ensure overlapping coverage for tactile, proprioceptive, and nociceptive signals from the lower posterior body. The posterior femoral cutaneous nerve, arising from the posterior divisions of S1-S3, provides sensory innervation to the skin of the buttock, posterior thigh, and popliteal fossa, including inferior cluneal branches to the lower gluteal region. The pudendal nerve, formed from the anterior divisions of S2-S4, delivers sensory fibers to the perineum, external genitalia (including the penis or clitoris), and anal skin, facilitating sensations such as touch and pain in these areas. Branches of the sciatic nerve (L4-S3) further distribute sensory input to the lower leg and foot: the tibial division innervates the sole of the foot via its medial and lateral plantar branches, while the common peroneal division supplies the dorsum of the foot and anterior/lateral leg skin through its superficial and deep branches. These cover the posterolateral leg, lateral foot, and interdigital spaces, excluding the medial leg. Visceral sensory innervation from pelvic organs, including the bladder, rectum, and reproductive structures, is mediated by pelvic splanchnic nerves originating from S2-S4 roots, transmitting pain, distension, and other internal sensations to the spinal cord.

Clinical Aspects

Injuries

Injuries to the sacral plexus typically arise from high-energy trauma or compression, leading to disruption of the nerve network that innervates the lower limbs, pelvis, and perineum. These injuries can result in significant motor, sensory, and autonomic deficits, often requiring multidisciplinary management to optimize recovery.^[20] Common causes include pelvic fractures, which occur in approximately 0.7% of cases involving pelvic or acetabular trauma and up to 2% with sacral fractures specifically. Gunshot wounds, particularly to the abdomen or pelvis, frequently affect the lower lumbosacral trunk and sacral components due to their proximity. Prolonged labor during childbirth represents a compressive etiology, with obstetric sacral plexopathy reported in 1 in 2000 to 6400 deliveries, often from pressure by the fetal head or instruments. Additionally, sciatic nerve palsy—a major derivative of the sacral plexus—may stem from piriformis syndrome, where the piriformis muscle compresses the nerve in the gluteal region, or from iatrogenic injury during hip surgery, such as total hip arthroplasty.^[20]^[20]^[20]^[20]^[24] Manifestations of sacral plexus injuries vary by the extent and location of damage but commonly include lower limb weakness, particularly in hip extension, knee flexion, and ankle movements, potentially leading to foot drop. Sensory symptoms encompass perineal numbness and paresthesia along the posterior thigh and calf, while autonomic involvement may cause bowel or bladder dysfunction, such as urinary retention or incontinence, though this is rarer and often indicates severe sacral root involvement. Pain is frequently the initial complaint, radiating to the affected dermatomes.^[20]^[24]^[20] Diagnosis relies on clinical evaluation combined with electrophysiological and imaging studies. Electromyography (EMG) is essential for localizing the lesion, demonstrating axonal loss, reduced motor and sensory amplitudes, and fibrillation potentials while distinguishing plexopathy from radiculopathy. Magnetic resonance imaging (MRI) of the lumbosacral plexus, preferably with gadolinium contrast, visualizes edema, hemorrhage, or compression, providing critical anatomical detail for surgical planning.^[20]^[24]^[20] Treatment strategies depend on injury severity and etiology, beginning with conservative measures such as analgesia, physical therapy to maintain range of motion and strength, and ankle-foot orthoses for foot drop support. In cases of compressive lesions like hematomas or piriformis entrapment, urgent surgical decompression may be indicated to prevent irreversible damage. For traumatic disruptions from fractures or gunshot wounds, nerve repair or grafting is considered if deficits persist beyond 3-6 months, with rehabilitation playing a key role in functional recovery. Prognosis improves with early intervention, though complete resolution is uncommon in severe cases.^[20]^[24]^[20]

Variations and Disorders

The sacral plexus exhibits anatomical variations in up to 41% of individuals, as observed in cadaveric dissections of lumbosacral plexi.^[25] These variations often involve the level of neural root contributions or branching patterns, differing from the typical formation where anterior rami of S1-S4 spinal nerves converge ventral to the piriformis muscle. One common variation is the high division of the sciatic nerve, where the tibial and common fibular components separate proximal to the popliteal fossa, occurring in about 16.9% of cases based on meta-analysis of cadaveric and surgical data.^[25]^[26] This high division can arise within the pelvis or gluteal region, potentially altering the nerve's trajectory through the greater sciatic foramen. Another frequent variation is the absence of the perforating cutaneous nerve, reported in up to 20-33% of specimens, where its sensory supply to the inferior gluteal skin is instead provided by branches from the posterior femoral cutaneous nerve.^[27]^[28] Sacral plexopathy, a chronic disorder involving demyelination and axonal loss in the plexus, can arise in diabetic patients as part of lumbosacral radiculoplexus neuropathy, affecting approximately 1% of those with diabetes.^[29] Radiation-induced sacral plexopathy is another disorder, typically manifesting months to years after pelvic radiotherapy for cancers such as cervical or rectal tumors, with fibrosis causing progressive sensory loss and motor deficits in the distribution of S1-S4 roots.^[30] Tarlov cysts, fluid-filled perineural sacs along sacral nerve roots, particularly S2-S3, occur in up to 5% of the population, though symptomatic cases causing compression of the plexus are rare, resulting in chronic pain, radiculopathy, and autonomic dysfunction due to mechanical pressure on the dorsal root ganglia.^[31]^[32] Congenitally, spina bifida occulta or myelomeningocele disrupts the S2-S4 sacral roots in affected individuals, often leading to neurogenic bladder through impairment of the sacral micturition reflex arc and detrusor-sphincter dyssynergia.^[33] This condition, present in 1 in 2,500-3,000 live births, results in detrusor areflexia and urinary retention due to failed parasympathetic innervation from the sacral plexus.^[34] Surgical interventions near the sacral plexus carry specific risks, including inadvertent nerve injury during hip replacement procedures, where retraction or drilling can damage lumbosacral contributions, leading to postoperative foot drop or sensory deficits in 0.3-2% of cases.^[35] Similarly, tumor resections in the pelvic region, such as for sacral chordomas, pose anesthesia challenges, with regional blocks (e.g., sacral plexus blockade) risking hematoma or direct trauma to plexus branches, necessitating preoperative imaging to map variations.^[36]

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