Sciatic Nerve

Atlas of Nerve Conduction Studies and

Electromyography (2 ed.)
A. Arturo Leis and Michael P. Schenk

Publisher: Oxford University Press Print Publication Date: Nov 2012

Print ISBN-13: 9780199754632 Published online: Sep 2013
DOI: 10.1093/med/
9780199754632.001.0001

Sciatic Nerve  

Chapter: Sciatic Nerve

Author(s): A. Arturo Leis and Michael P. Schenk

DOI: 10.1093/med/9780199754632.003.0018

THE SCIATIC NERVE is a continuation of the upper, larger cord of the

sacral plexus, and is formed by the lumbosacral trunk (L4, L5) and the
first, second, and part of the third sacral ventral rami (Gray's Anatomy,
1995). It is the broadest nerve of the human body (2 cm at its origin) and
is composed of independent tibial and common peroneal divisions that are
usually united as far as the lower part of the thigh, although simple
dissection reveals the double structure. In about 10% of cases, the two
divisions remain distinct from the outset. The sciatic nerve leaves the
pelvis via the greater sciatic foramen below the lower margin of the
piriformis muscle and descends between the greater trochanter of the
femur and ischial tuberosity along the back of the thigh. Just above the
popliteal fossa it separates into its two terminal divisions.

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Sciatic Nerve

Figure 18-1
Diagram of the sciatic nerve (posterior view) and its branches. Note: The
white oval signifies that a muscle receives part of its innervation from
another peripheral nerve.

In the gluteal region (after emerging below the piriformis), the nerve is
deep to the gluteus maximus. On leaving the gluteal region, the nerve
continues down the midline of the thigh closely related to the shaft of the
femur. Muscular branches are given to the biceps femoris (the short head
is supplied by peroneal division and the long head by tibial division),
semitendinosus, semimembranosus, and the ischiocondylar part of the
adductor magnus. Articular branches supply the hip joint.

Although the sciatic nerve, or its branches, may be involved by

penetrating injuries at any level, there are regions where the nerve is
prone to certain types of injury. Anatomical features of particular clinical
significance are found in the pelvis (see Chapter 17), the gluteal region,
and the thigh (Sunderland, 1968). On leaving the pelvis, the nerve may
rarely be entrapped by the piriformis muscle (piriformis syndrome). In the
gluteal region, the sciatic nerve is at risk because the buttock is a
common site for therapeutic injections. The nerve is also intimately
related to the hip joint and may be involved with injuries to that joint.
Damage may also occur during operations on the hip joint or femur. In the
thigh, the nerve may be injured during fractures of the femur or when
compressed against the firm edge of a seat.

Sciatic Nerve Lesion

Etiology

Tumors and metastatic lesions can cause a sciatic nerve lesion.

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Sciatic Nerve

Trauma, including hip fracture or dislocation, or more distal fractures of

the femur can cause a sciatic nerve lesion.

A traction injury can occur during orthopedic or other surgical

manipulation (common during hip joint replacement).

Radiation therapy (usually related to radiation plexopathy) is causative.

Compression injury can occur in the gluteal region. As the nerve appears
from beneath the gluteus maximus, it is relatively superficial and may be
compressed when seated on a firm surface. Common peroneal fibers are
maximally or exclusively affected (Sunderland, 1968).

Entrapment by the piriformis muscle (piriformis syndrome) is an

uncommon cause of sciatic pain or “sciatica” that involves the buttock
and leg. However, this syndrome is controversial and there is some doubt
as to whether such an entrapment exists (Halpin and Ganju, 2009; Tiel,
2008).

Intramuscular injections can cause a sciatic nerve lesion. The nerve may
be damaged by the needle, by sclerosing or toxic agents, or later by
scarring that follows the tissue reaction (Sunderland, 1968).

General Comments

Malignant infiltration usually involves the nerve roots contributing to the

formation of the sciatic nerve in the pelvis. It gives rise to painful and
slowly progressive paralysis unilaterally (Kimura, 1989).

Radiation injury causes very slowly progressive painless leg weakness.

There is a greater vulnerability of the common peroneal fibers to most

injuries of the sciatic nerve. This may be related to various factors,
including the more exposed position of the peroneal division in the thigh,
and to the poorer blood supply (less nutrient arteries). In addition, the
size, number, and disposition of the funiculi may predispose the peroneal
division to injury because it is composed of fewer and larger bundles with
less connective tissue than the tibial division. Peroneal fibers are also
securely fixed at both the sciatic notch and the neck of the fibula, and
therefore subjected to greater stretch (Sunderland, 1968).

Clinical Features

Weakness or wasting involves the hamstring muscles as well as the

muscles supplied by the common peroneal and tibial nerves.

Numbness occurs over the lateral half of the leg and the entire foot.

The Achilles stretch reflex is absent or reduced.

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Electrodiagnostic Strategy

Use nerve conduction studies to confirm a lesion involving the tibial and
common peroneal fibers (absent or low amplitude sensory responses from
sural and superficial peroneal nerves, absent or low amplitude motor
responses from tibial and peroneal nerves, absent or delayed H-reflex
response).

Demonstrate neurogenic EMG needle examination (i.e., spontaneous

activity, abnormal motor unit potentials, abnormal recruitment) in
muscles supplied by the sciatic nerve (hamstrings) and muscles supplied
by the common peroneal and tibial nerves.

Use needle EMG to exclude lumbosacral radiculopathies. Radiculopathies

produce neurogenic findings in paraspinal muscles as well as in limb
muscles; peripheral nerve injury never does so because the peripheral
nerve is formed by the ventral rami, whereas the paraspinal muscles are
innervated by the posterior rami (Wilbourn, 1985).

References
Gray's Anatomy. 38th Edition. Churchill Livingstone, New York, 1995, pp.
1282–1288.

Halpin RJ, Ganju A. Piriformis syndrome: a real pain in the buttock?

Neurosurgery 2009;65(4 Suppl):A197–202.

Kimura J. Electrodiagnosis in Diseases of Nerve and Muscle. 2nd Edition.

FA Davis, Philadelphia, 1989, pp 456–457.

Sunderland S. Nerves and Nerve Injuries. Williams & Wilkins, Baltimore,

1968, pp. 1069–1095.

Tiel RL. Piriformis and related entrapment syndromes: myth & fallacy.
Neurosurg Clin N Am 2008;19:623–627.

Wilbourn AJ. Electrodiagnosis of plexopathies. Neurol Clin 1985;3:511–

529.

Wilbourn AJ. AAEE case report #12: Common peroneal mononeuropathy

at the fibular head. Muscle Nerve 1986;9:825–836.

Needle Electromyography

Semitendinosus

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Sciatic Nerve

Innervation

Innervation is via the sciatic nerve (tibial division), sacral plexus, and
roots L5, S1,S2.

Origin

The semitendinosus originates at the ischial tuberosity.

Insertion

Insertion is at the upper part of the medial surface of the shaft of the
tibia.

Activation Maneuver

Flexion of the knee activates the muscle. Note: The “hamstrings” cross
both hip and knee joints, integrating extension at the hip with flexion of
the knee. In addition, the semitendinosus can act as a medial rotator of
the leg.

EMG Needle Insertion

Insert the needle one-third to midway along a line connecting the

semitendinosus tendon (easily palpable as it forms the proximal medial
margin of the popliteal fossa) with the ischial tuberosity.

Pitfalls

There are no pitfalls. If the needle is inserted too laterally, it may be in

the biceps femoris long head, which is also supplied by the tibial division
of sciatic nerve and roots L5, S1, and S2. If the needle is inserted too
medially, it may be in the semimembranosus (also the tibial division of the
sciatic nerve and roots L5, S1, S2).

Clinical Comments

Neurogenic changes on needle examination may be seen with lesions of

the tibial division of the sciatic nerve, sacral plexus, and roots L5, S1 or
S2.

Semimembranosus

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Innervation

Innervation is via the sciatic nerve (tibial division), sacral plexus, and
roots L5, S1,S2.

Origin

The semimembranosus originates at the ischial tuberosity.

Insertion

Insertion is at the medial condyle of the tibia (major insertion); it also

inserts on the medial shaft of the tibia and the fascia over the popliteus
and contributes to an expansion that inserts on the lateral femoral
condyle.

Activation Maneuver

Flexion of the knee activates the muscle. Note: The “hamstrings” cross
both hip and knee joints, integrating extension at the hip with flexion of
the knee. In addition, the semimembranosus can act as a medial rotator
of the leg.

EMG Needle Insertion

Palpate the semitendinosus tendon in the proximal popliteal fossa. Insert

the needle on either side of the semitendinosus tendon.

Pitfalls

If the needle is inserted too laterally, it may be in the biceps femoris short
head, which is supplied by the peroneal division of the sciatic nerve and
roots L5, S1, S2.

If the needle is inserted too medially and proximally, it may be in the

adductor magnus or gracilis. The adductor magnus is supplied by the
obturator nerve (L2-L4 roots) and the tibial division of the sciatic nerve (L4
root), while the gracilis receives innervation from the obturator nerve
(L2-L4 roots).

Clinical Comments

Neurogenic changes on needle examination may be seen with lesions of

the tibial division of the sciatic nerve, sacral plexus, and roots L5, S1 or
S2.

Biceps Femoris (Long Head)

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Innervation

Innervation is via the sciatic nerve (tibial division), sacral plexus, and
roots L5, S1,S2.

Origin

The long head of the biceps femoris originates at the ischial tuberosity.

Insertion

Insertion is at the head of the fibula.

Activation Maneuver

Flexion of the knee activates the muscle. Note: The “hamstrings” cross
both hip and knee joints, integrating extension at the hip with flexion of
the knee. In addition, the biceps femoris can act as a lateral rotator of the
leg.

EMG Needle Insertion

Insert the needle one-third to midway along a line connecting the fibular
head with the ischial tuberosity.

Pitfalls

If the needle is inserted too distally, it may be in the short head of the
biceps femoris, which is supplied by the peroneal division of the sciatic
nerve and roots L5, S1, S2 (at the mid-thigh, the fibers of the short head
are narrow and deep).

If the needle is inserted too laterally, it may be in the vastus lateralis,

which is supplied by the femoral nerve (L2-L4 roots).

If the needle is inserted too medially, it may be in the semitendinosus,

which is also supplied by the tibial division of the sciatic nerve (L5-S2
roots).

Clinical Comments

Neurogenic changes on needle examination may be seen with lesions of

the tibial division of the sciatic nerve, sacral plexus, and roots L5, S1 or
S2.

Biceps Femoris (Short Head)

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Sciatic Nerve

Innervation

Innervation is via the sciatic nerve (peroneal division), sacral plexus, and
roots L5, S1, S2.

Origin

The short head of the biceps femoris originates at the lateral lip of the
linea aspera on the posterolateral surface of the shaft of the femur, and
from the lateral intermuscular septum.

Insertion

Insertion is at the head of the fibula.

Activation Maneuver

Flexion of the knee activates the muscle. The short head of the biceps
femoris does not cross the hip joint; it cannot contribute to hip extension,
but it can act as a lateral rotator of the leg.

EMG Needle Insertion

Palpate the tendon of the long head of the biceps femoris in the popliteal
fossa.

Insert the needle just medial to the tendon.

Pitfalls

If the needle is inserted too laterally it may penetrate the long head of the
biceps femoris, which is supplied by the tibial division of the sciatic nerve
(roots L5, S1, S2).

If the needle is inserted too medially, it may be in the semimembranosus,

which is supplied by the tibial division of the sciatic nerve (roots L5, S1,
S2).

Clinical Comments

Neurogenic changes on needle examination may be seen with lesions of

the peroneal division of the sciatic nerve, sacral plexus, and L5, S1, or S2
roots.

This is the only muscle in the thigh innervated by the peroneal division of
the sciatic nerve.

This muscle is of great importance in the electrodiagnostic evaluation of

peroneal nerve lesions because it is crucial in defining the proximal
extent of the lesion. If neurogenic EMG changes are present in this
muscle, the lesion must be at or proximal to the mid-thigh (Wilbourn,
1986).

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