Reexamination of the communicating branch between the sural and tibial nerves

Reexamination of communicating branches between the sural and tibial nerves ventral to the calcanean tendon was carried out on 52 legs of 26 Japanese cadavers which were used for ordinary dissection practices at the Niigata University School of Medicine. Communicating branches were found in 7 out of 52 dissections (13.5% of cases). In three of the 7 specimens, the communicating branch, the sural nerve and the tibial nerve with the deep crural fascia were removed from the legs and demonstrated by a modified Sihler's staining technique. Three types of communicating branches, Y, U and N, were distinguished on the basis of their shapes. In type Y, a medial branch from the sural nerve and a branch from the tibial nerve joined in Y-shape and become one terminal branch. In type U, the both branches formed a loop between the sural and tibial nerves. The type N communicating branch ran obliquely and medially to reach the tibial nerve distally. Only the Y type appeared in 5 specimens. Both the Y and U type and the Y and N types occurred in one specimen each. We assume that the communicating branch of the N type contains motor fibers which are derived from the sural nerve and innervate some plantar muscles, because this type is correspond to the communication type of some animals in which motor fibers have been demonstrated. Therefore, if the sural nerve biopsy is performed to examine a pure sensory nerve, removal of the more distal part of the sural nerve than a diverging point of a communicating branch is recommended. This study also indicated that the modified Sihler's staining technique is useful to examine distributions of cadaveric peripheral nerves after medical students' dissection course.     

Sural-tibial nerve communications in humans

We investigated the occurrence of a communication between the sural and tibial nerves in 49 legs of 28 Japanese cadavers. In front of the calcanean tendon, we found the communication in 7 legs (14.3%) or in 5 cadavers (18.9%). The sural nerve gave rise to a number of medial and lateral branches, including the lateral calcanean branch at the lateral side of the ankle. The communicating branch with the tibial nerve arose from the first medial branch and pierced the deep fascia of the leg. In 4 cases, the U-shaped communication was formed between the sural and tibial nerves, and in 3 cases, the Y-shaped communication. Electrophysiologi-cal evidence of an anomalous motor function of the sural nerve has been reported recently. We consider that the U-shaped communication between the sural and tibial nerves gives a morphological basis to the motor function of the sural nerve.     

Nerve conduction study of the medial and lateral plantar nerves

The medial and lateral plantar nerves may be evaluated through the recordings of the compound sensory nerve action potentials (CSNAP), compound mixed nerve action potentials (CMNAP) and compound muscular action potentials (CMAP). As some of these potentials are not easily and always obtainable in normal individuals, our purpose was to verify the consistency of these potentials for the study of these nerves. Fifty-one normal adult volunteers were examined. The CSNAP, CMNAP and CMAP, related to the medial and lateral plantar nerves were evaluated bilaterally. CSNAP were not obtained in 7.8% and in 17.6% from the medial and lateral plantar nerves respectively. CMNAP from the lateral plantar nerve were not obtained in 15.6%. CMNAP from the medial plantar nerves and CMAPs from the abductor hallucis and abductor digiti quinti were obtained for all nerves tested. Our results, therefore, suggest that these last 3 parameters are the ones more reliable for clinical application.     

Formation and distribution of the sural nerve based on nerve fascicle and nerve fiber analyses

The formation and distribution of the sural nerve are presented on the basis of an investigation of 31 legs of Japanese cadavers using nerve fascicle and fiber analyses. Nerve fibers constituting the medial sural cutaneous nerve were designated as 'T', whereas those constituting the peroneal communicating branch were designated as 'F'. In 74.2% of cases (23/31), the T and F fibers joined each other in the leg, whereas in 9.7% of cases (3/31) they descended separately. In 16.1% of cases (5/31), the sural nerve was formed of only the T fibers. The sural nerve gave off lateral calcaneal branches and medial and lateral branches at the ankle. The lateral calcaneal branches always contained T fibers. The medial branches consisted of only T fibers, whereas most of the lateral branches consisted of only F fibers (71.0%; 22/31). In addition to the T and F fibers, P fibers, which derived from the superficial and deep peroneal nerves, formed the dorsal digital nerves. The P fibers were entirely supplied to the medial four and one-half toes. However, they were gradually replaced by the T and F fibers in the lateral direction. The 10th proper dorsal digital nerve consisted of T fibers only (38.7%; 12/31), of F fibers only (19.4%; 6/31) or of both T and F fibers (38.7%; 12/31). These findings suggest that the T fibers are essential nerve components for the skin and deep structures of the ankle and heel rather than the skin of the lateral side of the fifth toe. The designation of the medial sural cutaneous nerve should be avoided and only the T fibers are appropriate components for naming as the sural nerve.     

足底内侧和外侧群肌的肌内神经整体分布模式及临床意义

目的 揭示足底内侧和外侧群肌的肌内神经整体分布模式,探讨其临床意义.方法 24具成年尸体,完整取下足底内侧和外侧群肌,采用改良Sihler染色显示肌内神经分布模式.结果 (足母)收肌的神经支从肌止端的深面入肌,而(足母)展肌、(足母)短屈肌、小趾展肌和小趾短屈肌的神经支常从肌起端的深面入肌.(足母)展肌中有1个半月形和...     

Lateromedial and dorsoplantar borders among supplying areas of the nerves innervating the intrinsic muscles of the foot.

The branching patterns of nerves supplying the intrinsic muscles of the foot were analyzed as a basis to confirm the muscle layer structure. Thirty-eight feet of 20 Japanese cadavers were examined in detail in this study. The first dorsal interosseus was innervated by a branch from the deep peroneal nerve as well as a branch of the lateral plantar nerve in 92.1%, the second dorsal interosseus in 10. 5% and the third dorsal interosseus in 2.6%. In three specimens, branches from the deep peroneal nerve innervated the oblique head of the adductor hallucis or the lateral head the flexor hallucis brevis. In addition, branches from the medial and lateral plantar nerves and the deep peroneal nerve formed communication loops in three specimens. The first dorsal interosseus, the oblique head of the adductor hallucis and the lateral head of the flexor hallucis and their innervating nerve branches are closely related within the first intermetatarsal space. Since the tibial part of the first interosseus muscle primordium is occupied in the space during development, the variations of innervation patterns and formation of the communicating nerve loops may be explained by various combinations of the part and the other muscle primordia.     

The bilateral anatomical variation of the sural nerve and a review of relevant literature

The sural nerve is a sensory nerve, usually formed in the distal part of the leg by the union of the lateral sural cutaneous nerve or the communicating fibular branch with the medial sural cutaneous nerve. The aim of this paper is to present a case of a variant formation of the sural nerve and a review of the literature related to this case. During the dissection of an adult male cadaver, the medial sural cutaneous nerve and communicating fibular branch, after respectively deriving from the tibial and common fibular nerve, were noticed to continue their course without any formation of a unique nerve trunk on the posterior side of both lower limbs. A transverse communicating branch, connecting these two nerves, was present in both legs. As the sural nerve is of significant diagnostic and therapeutic importance, detailed knowledge of the sural nerve’s anatomy and its contributing nerves is also of great importance.     

Lateromedial and dorsoplantar borders among supplying areas of the nerves innervating the intrinsic muscles of the foot

The branching patterns of nerves supplying the intrinsic muscles of the foot were analyzed as a basis to confirm the muscle layer structure. Thirty‐eight feet of 20 Japanese cadavers were examined in detail in this study. The first dorsal interosseus was innervated by a branch from the deep peroneal nerve as well as a branch of the lateral plantar nerve in 92.1%, the second dorsal interosseus in 10.5% and the third dorsal interosseus in 2.6%. In three specimens, branches from the deep peroneal nerve innervated the oblique head of the adductor hallucis or the lateral head the flexor hallucis brevis. In addition, branches from the medial and lateral plantar nerves and the deep peroneal nerve formed communication loops in three specimens. The first dorsal interosseus, the oblique head of the adductor hallucis and the lateral head of the flexor hallucis and their innervating nerve branches are closely related within the first intermetatarsal space. Since the tibial part of the first interosseus muscle primordium is occupied in the space during development, the variations of innervation patterns and formation of the communicating nerve loops may be explained by various combinations of the part and the other muscle primordia. Anat Rec 255:465–470, 1999. © 1999 Wiley‐Liss, Inc.     

Formation and location of the sural nerve in the newborn

In this study, the location and formation of the sural nerve were examined in 40 legs of new-born cadavers. The sural nerve was formed by the peroneal communicating branch from the common peroneal nerve joining the medial sural cutaneous nerve in 27 of 40 legs (67.5%). It was formed by the peroneal communicating branch from the lateral sural cutaneous nerve joining the medial sural cutaneous nerve in 4 (10%). It was formed by the peroneal communicating branch from the common peroneal nerve and fibers from the posterior femoral cutaneous nerve joining the medial sural cutaneous nerve in 2 (5%). In 5 of 40 legs (12.5%), the medial sural cutaneous nerve was in the place of the sural nerve without joining any other nerve. In one case (5%), the sural nerve was not formed bilaterally.     

Anatomical study of the communicating branches between the medial and lateral plantar nerves

The plantar areas of the foot have specific biomechanical characteristics and play a distinct role in balance and standing. For the forefoot surgeon, knowledge of the variations in the anatomy of communicating branches is important for plantar reconstruction, local injection therapy and an excision of interdigital neuroma. The anatomy of the communicating branches of the plantar nerves between the fourth and third common plantar digital nerves in the foot were studied in 50 adult men cadaveric feet. A communicating branch was present between the third and fourth intermetatarsal spaces nerves in all eight left feet and in six right feet (overall, 28%), and absent in 36 (72%). A communicating branch was found in 14 ft. Ten of the 14 communications were from the lateral to the medial plantar nerve. The length of the communicating branch ranged from 8 to 56 mm (average 16.4 mm) and its diameter was 0.2–0.6 times of the fourth common plantar digital nerve. The angle of the communicating branch with the common plantar digital nerve from which it originated was less than 30° in 11 ft, 30–59° in 27 ft, 60–80° in 8 ft, and more than 80° in 4 ft. Classification of the branch is based on the branching pattern of the communicating branch and explains variations in plantar sensory innervations. We think that the perpendicular coursing communicating branch is at higher risk to be severed during surgery.     

Intramuscular nerve distribution pattern of the oblique and transverse heads of the adductor hallucis muscles in the human foot

To understand which layer of the intrinsic muscles of the foot the adductor hallucis muscle belongs to, it is essential to investigate the innervation patterns of this muscle. In the present study, we examined the innervation patterns of the adductor hallucis muscles in 17 feet of 15 Japanese cadavers. We investigated the intramuscular nerve supplies of the adductor hallucis muscles in six feet and performed nerve fiber analysis in three feet. The results indicate that: (i) the oblique head of the adductor hallucis muscle is divided into three compartments (i.e. lateral, dorsal and medial parts) or two compartments (i.e. dorsal and medial parts) based on its intramuscular nerve supplies, but we could not classify the transverse head into any parts; (ii) the communicating twig between the lateral and medial plantar nerves penetrated the oblique head of the adductor hallucis muscle in 13 of 17 feet (76.5%); (iii) the penetrating twig entered between the lateral and dorsal parts of the oblique head, passed between the lateral and medial parts of this muscle and then connected with the medial plantar nerve; and (iv) the majority of the nerve fibers of the penetrating twig derived from the lateral plantar nerve. The present study demonstrated that only the lateral part of the oblique head of the adductor hallucis muscle had a unique innervating pattern different from other parts of this muscle, suggesting that the lateral part of the oblique head has a different origin from other parts of this muscle.     

Analysis of motor fibers in the communicating branch between the cervical nerves and the spinal accessory nerve to innervate trapezius in the rat

The communicating branch between the ventral rami of cervical nerves and the spinal accessory nerve (SAN) has been reported to also send motor fibers to supply the trapezius. However, the motor fiber type of the communicating branch and its peripheral distribution are still unclear. To determine the fiber elements within the branch and its peripheral distribution of the motor fibers in the trapezius, the anterograde tracing method was used in this study. The results show that a few a motor end plates from the communicating branch were observed on the extrafusal fibers, while in the muscle spindle the motor elements from the communicating branch were distributed to the polar portions of the intrafusal fibers. These results indicated that the motor fibers passing through the communicating branch to supply the trapezius are mainly y motor fibers, with some a motor fibers. Moreover, the a and y motor fibers from the communicating branch were observed in the clavotrapezius, acromiotrapezius and the rostral part of spinotrapezius. These findings also correlate with the clinical observation indicating that even when the spinal accessory nerve is injured, the trapezius is still capable of slight movement.     

The communicating branch of the lateral plantar nerve: A descriptive anatomic study

Since the communicating branch of the lateral plantar nerve has been implicated as a factor in the etiology of Morton's neuroma, a painful perineurofibrosis of a common plantar digital nerve, this project was designed to investigate the anatomy of this communicating branch. Both feet of 40 embalmed human cadavers were dissected to show the frequency of occurrence and anatomical variation of the communicating branch. The communicating branch was present in 66.2% of the feet we studied with no large gender-based differences. Branches occurred bilaterally in 52.5% of cadavers, while 27.5% had branches unilaterally. The occurrence of this branch does not correlate well with the likelihood of development of Morton's neuroma. Differences in diameter of the communicating branch ranged from less than 0.5 mm to as large as the common plantar digital nerves themselves, about 2 mm. The presence or absence of the communicating branch made no qualitative difference in the diameters of the common plantar digital nerves. There were 60.4% of the communicating branches in this study that had a typically-described orientation, arising more proximally in the foot from the fourth common plantar digital nerve, while 39.6% of the branches had a reversed orientation, arising more proximally from the third common plantar digital nerve. These reversed branches had a more oblique orientation when compared to the classic branches. Other anatomical variations were noted, including accessory branches that attached to deeper structures in the foot. These data form a basis for further research into the etiology of Morton's neuroma and improved surgical techniques for correcting this condition. © 1996 Wiley-Liss, Inc.     

Motor unit numbers,motor unit sizes and innervation of single muscle fibres in hyperinnervated adult mouse soleus muscle

The sural and the lateral plantar nerves were implanted simultaneously into the denervated soleus muscle of adult mice. Each of these nerves contained approximately the normal number of soleus motor axons. This procedure therefore allowed a study of how an initial excessive number of motor axons provided by two different, foreign nerves and terminating into the soleus muscle affected the final pattern of muscle innervation. In muscles examined two months or more after the implantation of the foreign nerves all muscle fibres were innervated. The fraction of the muscle innervated by either nerve varied widely from one preparation to another. However, all the motor axons which were implanted into the muscle appeared to make permanent synapses. Moreover, the distribution of motor unit sizes of each foreign nerve relative to the total number of muscle fibres innervated by that nerve was similar to the distribution of motor unit sizes in muscles cross-innervated by that nerve alone, although the absolute motor unit sizes were reduced. Estimated by intracellular recording, 20–30% of the muscle fibres were polyneuronally innervated. A similar fraction of teased muscle fibres stained for acetylcholinesterase had more than one endplate.     

Some aspects of the communicating branch between the musculocutaneous and median nerves in man

Fascicular arrangement of the human brachial plexus is examined on 2 common cases and 3 peculiar cases in which a communicating branch was observed between the median and the musculocutaneous nerve. The musculocutaneous nerve consitss of spinal nerves from C.5, 6 and 7. The branch to the coracobrachialis receives its fibers from C.7 before it leaves the musculocutaneous nerve in 3 cases and after it leaves the musculocutaneous nerve in one case. In one case, C.7 does not send a branch to the coracobrachialis. The median nerve arises by two roots, one from the lateral cord, and the other from the medial cord of the brachial plexus. In a case in which a communicating branch was observed from the median nerve to the musculocutaneous, the fibers from C.7 join to the median nerve via the medial cord. Thus the median nerve involved all elements of the spinal nerve from C.5 to T.1. The elements of the median and the musculocutaneous nerves, therefore, are not affected by appearance of the communicating branch. The communicating branch between the median and the musculocutaneous nerves, consists of the fibers arose from C.5 and C.6, in all examined cases.     

Fiber composition of the rat sciatic nerve

The rat sciatic nerve originates from the spinal segments L4-L6. It is unifascicular at the trochanter; 5-7 mm distally, the nerve splits into two and then into four fascicles. The tibial portion gives rise to the tibial and the sural nerves, and the peroneal portion gives rise to the peroneal nerve and a cutaneous branch that perforates the lateral hamstring muscles to innervate the proximolateral face of the calf. The number and type of the axons in these branches were determined in light and electron micrographs of normal nerves, and after de-efferentation or sympathectomy. Deafferentation was technically not feasible because spinal ganglia and ventral roots were supplied by the same vascular plexus. The tibial nerve contained 1,000 motor and 3,500 myelinated afferent axons, 3,700 sympathetic axons, and 5,400 unmyelinated afferent axons. The peroneal nerve contained 600 motor and 1,300 myelinated afferent axons, 1,100 sympathetic axons and 3,000 unmyelinated afferent axons. The sural nerve contained 1,100 myelinated and 2,800 unmyelinated afferent axons; in addition, there were 1,500 unmyelinated sympathetic axons. The cutaneous branch consisted of 400 myelinated and 1,800 unmyelinated afferent axons. Thus, the entire sciatic nerve at midthigh is composed of about 27,000 axons; 6% are myelinated motor axons, 23% and 48% are myelinated and unmyelinated sensory axons, respectively, and 23% are unmyelinated sympathetic axons. The techniques used did not demonstrate sympathetic axons in the cutaneous branch and did not reveal the few motor axons contained in the sural nerve.     

Application of the modified Sihler's stain technique to cadaveric peripheral nerves after medical students' dissection course

The exact ramification and distribution pattern of the peripheral nerves is one of the most important information for anatomists and clinicians. However, it is very difficult to pursue perfectly all of the fine twigs of nerve branches even if we use a stereoscopic microscope. Recently, Liu et al. (Anat. Rec., 247: 137, 1997) applied a modified Sihler's stain technique to study the distribution of intramuscular nerve branches in mammalian skeletal muscles. Then, we attempted to apply this technique to plantar nerves of human foot removed from cadavers which were used for ordinary dissection practices at the School of Medicine. Intrinsic muscles of the foot with motor and sensory nerve branches were removed en bloc from bones of the foot. They were macerated and depigmented in 3% aqueous potassium hydroxide, decalcified in Sihler's solution 1. Then, after staining in Sihler's solution II, they were destained in Sihler's solution I, neutralized in 0.05% lithium carbonate, and cleared in increasing concentrations of glycerin. As a result, each nerve fascicle, which are bundles of nerve fibers invested by the perineurium, was very clearly visualized, since only nerve fibers were stained deep blue-purple, while muscles, the epineurium and the perineurium were made transparent in glycerin. We found an anastomosis between a deep branch of the lateral plantar nerve and the medial plantar nerve, composed of several nerve fascicles. Therefore, the modified Sihler's stain technique can be applied to cadaveric peripheral nerves after medical students' dissection course.     

Morphine-sensitive late components of the flexion reflex in the neonatal rat

The 8-15-day-old rat spinal cord was isolated together with peripheral nerves innervating a hindlimb. Multiunit neural discharges in response to electrical stimulation of a cutaneous nerve (sural, plantar of superficial peroneal nerve) were recorded from a flexor nerve (deep peroneal nerve or nerve innervating the hamstring muscles). Attempts were made to find relations between the magnitude of the flexion reflex discharges and the sizes of the volleys in the myelinated or unmyelinated afferent fibers. The neonatal flexion reflex discharges due to myelinated fiber volleys were exaggerated when compared with those in the adult rats. Higher stimulus strengths recruited later components of the flexion reflex discharges. The observed increment of the flexion reflex discharges was precisely associated with the recruitment of unmyelinated afferent fibers in the nerve. These late flexion reflex discharges were shown to be depressed by the opiate analgesic morphine in a naloxone-reversible manner.     

Scalenus muscles in macaque monkeys

The attachment and innervation of the scalenus muscles in both sides of two Japanese monkeys and a rhesus monkey were observed to discuss their morphological significance while comparing their findings in humans. The scalenus ventralis muscle in macaques had almost the same attachments as the scalenus anterior muscle in humans and was innervated by the cervical nerve branches, which were lower in spinal segment than in humans and had a close relationship with the branches to the intertransversus ventralis muscles. Furthermore, the scalenus ventralis muscle was penetrated by the phrenic nerve in all cases observed. The posterior part of the scalenus muscle in macaques (the scalenus dorsalis muscle) was divided into short (the scalenus dorsalis brevis) and long (the scalenus dorsalis longus) parts according to their attachments. The former was attached to the transverse processes of the lowest two cervical vertebrae and the first rib, whereas the latter was attached to the 3rd-5th ribs. It is notable that the scalenus dorsalis muscles in macaques were innervated by branches from the long thoracic nerve in addition to direct branches from the cervical nerve roots. In addition, the scalenus dorsalis longus was supplied by twigs from the lateral cutaneous branches of the 2nd and 3rd intercostal nerves. This indicates that the scalenus dorsalis muscles contain a muscular component derived from the upper limb girdle musculature, unlike the human scalenus muscles, which have been considered to belong to the cervical trunk muscles.     

Ramification pattern of the deep branch of the lateral plantar nerve in the human foot

To understand how the oblique and transverse heads of the adductor hallucis muscle of the human foot are phylogenitically and ontogenetically developed, it is essential to know nerve supplies of these two heads of the muscle. In the present study, we dissected seven feet of five Japanese cadavers in detail to clarify the ramification patterns of the deep branch of the lateral plantar nerve by peeling off its epineurium (the nerve fascicle analysis method). We found that the muscular branch to the oblique head of the adductor hallucis muscle directly separated from nerve fascicles constituting the deep branch of the lateral plantar nerve, whereas the muscular branch to the transverse head arose in common with branches which innervated other intrinsic muscles of the foot, i.e., the 2nd and 3rd lumbrical muscles and the 1st and 2nd dorsal interossei muscles. The present study revealed that two heads of the adductor hallucis muscle, the oblique and transverse, had different innervating patterns, suggesting that two heads of the human adductor hallucis muscle develop from different primordia, and not from common ancestors.