2-24
Terms
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copy deck
- Descending abdominal aorta bifurcates at about __A__ into __B__. __B__ will in turn bifurcate into __C__.
-
A. L4
B. Right and Left Common Iliac Arteries
C. Internal and External Iliac Arteries - Two major sources of nerves into the Posterior Abdominal Wall. Rest of the nerves are from __A__.
-
Autonomic
1) Sympathetic Vagus Nerve
2) Part of Craniosacral outflow of parasympathetic (S2,3,4)
A. Lumbar Plexus - Largest vein of the body bifurcates at what level?
- L5
-
Quadratus Lumborum
1) Cephalad attachment
2) Caudal attachment
3) Action of both
4) Action with just one side
5) Innervation -
1) 12th rib
2) Iliac crests
3) Extension of back
4) Lateral deviation
5) Ventral rami T12,L1-L3 -
Psoas Major
1) Type of meat
2) Action
3) Innervation
4) Origin
5) Insertion -
1) Tenderloin
2) Strongest flexor (possible lateral rotator-weak)
3) L1-L3
4) Transverse processes of L1-5
5) Lesser Trochanter - Combine the __A__ and the __B__, and they form compound muscle __C__, which attaches directly to the __D__ for the action of __E__. It helps form the __F__ structure of lower extremity.
-
A. Psoas major
B. Iliacus
C. Iliopsoas
D. Femur
E. Hip Flexion
F. Femoral Triangle - Iliopsoas forms the ____ of the femoral triangle.
- lateral 1/2 of the floor
- ____ is only found in about half of the bodies due to ethnic differences.
- Psoas minor
-
Psoas minor
1) Innervation
2) Origin
3) Insertion
4) Location in relation to psoas major -
1) L1
2) Bodies of T12 and L1 and intervening intervertebral disc
3) Iliopubic eminence
4) superficial -
Iliacus Muscle
1) Origin
2) Insertion
3) Innervation -
1) Iliac fossa within abdomen
2) Lower Trochanter
3) Femoral Nerve (which is formed from ventral rami of the lumbar plexus) - specifically genitofemoral nerve - __A__ pierces through the __B__ of the diaphragm.
-
A. Inferior Vena Cava
B. Central tendon - Significance of IVC piercing the central tendon. Significance of other organs going through diaphragm.
-
Central tendon opens up and holds taught the IVC acting as a siphon to bring venous return.
Compresses structures running within it. Good for esophagus and can be bad for IVC if compressed. - What is thought to be the corresponding muscle to the infraspinatous in the lower extremity?
- Iliacus
- The esophageal hiatus is contributed to by what crura of the diaphragm? What runs through it?
-
-Right Crus
-Esophagus, Anterior and posterior vagal trunks and esophageal branch of left gastric artery - What travels through the aortic hiatus?
- Aorta, Thoracic duct, Azygos vein
-
1) What are the crura?
2) Where are they located?
3) What pierces the left crus?
4) What is the right crus attached to? -
1. Legs of the diaphragm
2. Midline anterior of the vertebral bodies in the lumbar region
3. Hemiazygous
4. Attached to the ligament of Treitz that runs to duodenojejunal junction -
What is an arcuate ligament?
What are they named? -
-Thickenings of the fascia near the posterior inferior attachment of the diaphragm
-Median, medial, lateral arcuate ligaments - Where is the sternocostal hiatus? What passes through it? What is a potential problem at this point?
-
-anteriorly, just lateral to the xiphoid process
-Lymphatics and superior epigastric
-Morgagni herniation (but not as common as Bochdalek herniation, through vertebrocostal trigone) - IVC hiatus pierces what vertebra level of diaphragm? Esophageal hiatus? Aortic hiatus?
-
-T8
-T10
-T12 - Which crura is longer and thicker?
- Right
- What passes with the IVC through the hiatus in the central tendon? What is the hiatus called? What type of innervation do the phrenic nerves supply?
-
-Right Phrenic nerve
-Caval Foramen
-Motor fibers to entire muscle on inferior surface and central portion with sensory fibers (arborize) - What is usually the first branch off of the descending abdominal aorta but are occasionally branches of the celiac trunk? What does it supply?
-
-Inferior phrenic arteries
-Underside of diaphragm - Where are the medial and lateral arcuate ligaments located? Are they paired?
-
Medial-thickened fascia between diaphragm and psoas major (medial side)
Lateral - lateral side
-Yes are paired - Where is the median arcuate ligament located? What is the clinical significance of this ligament?
-
-It's the thickening of fascia between the right and left crus.
-Can compress the aorta causing Dunbar's syndrome (inadequate distribution of bloodflow, especially to celiac trunk) - Does the aorta pierce the diaphragm?
- No, it runs posterior
- Major branches off the abdominal aorta
-
1) Unpaired - Celiac Trunk then Superior Mesentary Artery
2) Paired visceral - Renal Arteries then Gonadal Arteries (testicular/ovarian)
3) Paired somatic - 4 lumbar arteries supplying regional muscles and connective tissue
3) Unpaired - Inferior Mesentary Artery - What artery is on the left side in the upper lumbar region and is very important in supplying the distal spinal cord?
- Artery of Adamkiewicz
- What should you get the patient to do after a surgery fixing an aortic abdominal aneurism (AAA)?
- Postoperatively, you should make sure patient can move their lower extremities because you can ding the small vessels and compromise bloodflow to distal spinal cord
- What does the ascending lumbar vein (ALV) connect? What will it form on the right and the left side and what does it communicate with perpendicularly to make these connections?
-
-Common iliac veins to the lumbar veins and has connections to the left renal vein.
-Communicates with subcostal vein perpendicularly
Right - azygos vein
Left - hemiazygous vein - What is the cisterna chyli (CC)? Where can it be located?
-
-The dilated proximal portion of the thoracic duct as it ascends through the aortic hiatus.
-Just deep to the right crus of the diaphragm - The lumbar plexus is a collection of __A__ formed within the __B__ from __C__ to __D__.
-
A. Ventral Rami
B. Psoas Major
C. L1
D. L4 - What are the main regions that lumbar plexus will extend to? What is the largest branch of this plexus and what does it supply?
-
-Two of the three muscular compartments of the thigh
-Femoral nerve supplies anterior thigh - Nerves of the Lumbar Plexus, (superior to inferior) and their ventral rami supply: SEE EXTRA SHEET FOR ENTIRETY
-
1) subcostal nerve - T12
2) Iliohypogastric - L1
3) Ilioinguinal - L1
4) Genitofemoral Nerve - L1/L2
5) Lateral Femoral Cutaneous Nerve - L2,L3
6) Femoral Nerve - L2-L4
7) Obturator Nerve - L2-L4
8) Lumbosacral trunk - L4/L5 - What is commonly seen in new army and military recruits? What nerve has been entrapped and what are the symptoms?
- Entrapment of Lateral femoral cutaneous known as neuralgia parasthetica (numbness and pain on lateral part of thigh)
- Innervation/location of subcostal nerve
- muscles of anterior abdominal wall/T10 Dermatome & skin of anterolateral wall via mdial/lateral cutaneous branch; runs over anterior surface of quadratus lumborum
- Innervation/location of Iliohypogastric nerve:
- muscles of lower abdominal wall & skin over pubic bone (innervates pyramidalis); runs over surface of quadratus lumborum
- Innervation/location of Ilioinguinal nerve:
- muscles of lower abdominal wall; patch of skin on anterior thigh; skin of anterior scrotum/labium majorus; runs over surface of quadratus lumborum (travels w/ spermatic cord superficially)
- Innervation/location of Lateral Femoral Cutaneous nerve:
- patch of skin down lateral thigh; travels over iliacus/exits medial to ASIS
- Innervation/location of Femoral Nerve:
- most muscles of anterior thigh and skin of anterior thigh via cutaneous branches; lateral to psoas major and escapes via pelvis
- Innervation/location of Obturator nerve:
- muscles/skin of medial thigh; medial to psoas major and escapes via obturator foramen
- Location of lumbosacral trunk:
- medial to obturator
- As the ilioinguinal nerve comes into the anterior scrotum or anterior labia, it changes names to __A__. It supplies __B__ (amount) of cutaneous skin in these areas.
-
A. Anterior scrotal or anterior labial nerves
B. 1/3 - Which of the following have lateral cutaneous branches: iliohypogastric, subcostal, and ilioinguinal
- iliohypogastric and subcostal, not ilioinguinal
- Genitofemoral nerve pierces __A__ and splits into genital branch and femoral branch. Give course/innervation of these branches.
-
A. pasoas major
Genital Branch - enters ilioinguinal canal through deep ring and leaves through superficial ring and runs out to supply the cremaster muscle and skin of scrotum/labia
Femoral - runs out to skin over femoral triangle - What is the cremaster reflex and what nerve is involved with it? Where is the sensory area of this nerve? What does this reflex test during a physical?
-
-causes testicles to ascend
-through genital branch of genitofemoral nerve
-anterior medial thigh conveyed by ilioinguinal nerve
-integrity of L1 spinal nerve - The rich plexus of the anterior aorta is called the __A__. It is reinforced by __B__ as it descends into the lumbar region.
-
A. Preaortic plexus
B. Sympathetic trunk - What are splanchnic nerves? What is their course? What type of neurons do they carry?
-
-Presynaptic fibers extending off the thoracic sympathetic trunk
-pierce the diaphragm and run out and synapse in ganglia associated with major vessels of proximal aorta like celiac trunk, SMA, and junction of aorta/renal artery
-autonomic and sensory - What is the course of the postganglionic fibers of the splanchnic nerves as they continue down the anterior aorta?
- Some pass out to various structures like ureter. As streamlined preaortic plexus descends, it is reinforced by other presynaptic fibers from lumbar sympathetic trunk, the lumbar splanchnic nerves
- What happens to the splanchnic nerves/plexus as one passes the bifurcation of the aorta (at L4)?
- Changes names to superior hyogastric plexus, which is a sympathetic plexus that carries motor/sensory fibers. Can occasionally see hypogastric nerves come off of superior hyogastric plexus as it descends (left and right bundles).
- As the lumbar splanchnics descend into the pelvis they mingle with the craniosacral outflow. What type of nervous system comes from here, and what regions is it from? When they disseminate to viscera of pelvis they change their name to what?
-
-Parasympathetic & S2-S4
-sympathetic is merging with parasympathetic
-inferior hypogastric plexus - What is a lumbar sympathectomy? Why is it done?
- Cutting of the lumbar sympathetic trunk. It can be done to control hypertension or because of lower extremity disease.
- How does a lumbar sympathectomy help control hypertension?
- Creates more of a reservoir for the blood of the body. When cutting trunk, you no longer have vascular tone of vessels in abdominal region and lower extremities because dilated. Blood pressure drops b/c diameter of vessels increases. Not used much anymore b/c of new drugs.
- What is the problem with doing a lumbar sympathectomy done for lower extremity disease?
- Interferes with ejaculation
- What do the parasympathetics of the abdominopelvic region come from?
- Anterior and posterior vagal trunks to the splenic flexure where the descending colon/transverse colon merge.
- After the ____ inferioly, parasympathetic fibers are brought by the S2-S4.
- splenic flexure
- What is the primary contributor (parasympathetic) to the celiac plexus? What comes in and synapses with these ganglia?
- Posterior vagal trunk; Splanchnic nerves
- What is a convenient thing to do with intractable pain coming from a pelvic organ? What is the bad part about this procedure?
-
-Cut its inflow into the spinal cord (presacral neurectomy-cut superior hypogastric plexus near promontory of sacram)
-not all viscera of pelvis have pain fibers that travel in sympathetic system - What surrounds the very outside of the kidney?
- Fibrous capsule
- What do vertebra do the kidneys lie between?
- T12 & L3
- What is the outer/inner portion of the kidney called?
- Cortex/Medulla
- What is the renal pelvis?
- The proximal part of the ureter which will drain into the urinary bladder
- How many major and minor calices are there?
-
major-1 to 3
minor-7 to 14 - With each beat of the heart, how much urine will enter the minor calices?
- one drop
- Which kidney is more inferiorly placed and why? What ribs are associated with the left/right kidney?
-
-Right kidney because of the liver
-Left: 11th/12th ribs
-Right: 12th rib - The __A__ muscle travels down the most lateral part of the kidney. The __B__ muscle travels down the middle part of the kidney. The __C__ muscle travels down the most medial part of the kidney.
-
A. Transversus abdominus
B. Quadratus lumborum
C. Psoas major - Before MRI & CT what would they use to visualize the kidneys?
- Would inject the abdomen retroperitoneally with air. Air would ascend and fill the renal fascia and they could look for tumors in and around the kidney on radiographs.
- What is the anterior/posterior fascia around the kidney called? The entire name for the fascia is ____.
-
Anterior-Toldt
Posterior-Zuckerkandyt
-Gerota's fascia - What veins do the left/right renal vein receive?
-
Left - adrenal vein, iferior phrenic vein, left gonadal vein, ascending lumbar vein, lumbar vein
Right - just adrenal vein - What is the relationship of the SMA to left renal vein? What is the clinical significance?
-
-SMA is anterior to left renal vein
-SMA can compress left renal vein and 3rd part of duodenum. Can cause obstruction of vessels draining into that vein. Patient could present this with a huge left swollen testicle. - What are the branches of the renal arteries? What would happen if you were to clip one of these terminal branches and why?
-
-Apical, inferior, posterior, anterior superior, anterior inferior
-That part of kidney would necrose because they do not anastomose with each other - What is the watershed area of the kidney between and what is its name? When would you need to utilize this line?
-
-Between the anterior superior and posterior called Brodel's White Line
-to remove a kidney stone can utilize this line when slicing into the kidney - How long are the ureters? What is its course? What is the the blood supply? What is it innervated by?
-
-about 25 cm
-goes along tips of lumbar transverse processes
-mainly from renal artery
-innervated by lesser/least splanchnics - Course of ureter:
- crossed by gonadal vessels; crosses over very beginning of external iliac and descends into pelvis to enter urinary bladder
- If someone has a proximal/distal kidney stone, where will the pain be? What dermatomes is the referred pain in?
-
proximal (subcostal) - flank pain
distal (inguinal) - pain in scrotal region or in labia as it nears the bladder
T11-L2 - What is the shape of the left/right adrenal gland? Innervation? Blood supply?
-
Left - Semilunar
Right - Pyramid
-Greater Splanchnic-primarily celiac ganglion
-Inferior adrenal artery from renal artery, middle from aorta, and superior off of inferior phrenic artery - What is the significance of the preganglionic fibers that go to adrenal gland medulla?
- They do not end on ganglia. There are modified cells in medulla that are catecholamine secreting and they act as postganglionic fiber.
- Why could someone have unexplained hypertension?
- May have ectopic adrenal medulla tissue found in organs of Zuckerkandl (paraaortically) that can cause elevated catecholamine levels that increases blood pressure.