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Fascicular Anatomy of Human Femoral Nerve: Implications for Neural Prostheses Using Nerve Cuff Electrodes

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Fascicular Anatomy of Human Femoral Nerve: Implications for Neural Prostheses Using Nerve Cuff Electrodes Volume 46, Number 7, 2009 JRRDJRRD Pages 973–984 Journal of Rehabilitation Research & Development Fascicular anatomy of human femoral nerve: Implications for neural prostheses using nerve cuff electrodes Kenneth J. Gustafson, PhD;1–2* Gilles C. J. Pinault, MD;2–3 Jennifer J. Neville, MD;4 Ishaq Syed, MD;4 John A. Davis Jr, MD;5 Jesse Jean-Claude, MD;2–3 Ronald J. Triolo, PhD1–2,5 1Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH; 2Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH; 3Department of Surgery, 4School of Medicine, and 5Department of Orthopedics, Case Western Reserve University, Cleveland, OH Abstract—Clinical interventions to restore standing or stepping ing or walking after paralysis resulting from upper motor by using nerve cuff stimulation require a detailed knowledge of neuron damage secondary to spinal cord injury (SCI), or femoral nerve neuroanatomy. We harvested eight femoral nerves peripheral nerve damage due to trauma, require a detailed with all distal branches and characterized the branching patterns knowledge of the morphology and fascicular anatomy of the and diameters. The fascicular representation of each distal nerve femoral nerve. However, the fascicular anatomy and spe- was identified and traced proximally to create fascicle maps of the cific dimensions of the human femoral nerve have not been compound femoral nerve in four cadaver specimens. Distal nerves fully described and must be quantitatively documented. were consistently represented as individual fascicles or distinct groups of fascicles in the compound femoral nerve. Branch-free The femoral nerve originates from the second, third, length of the compound femoral nerve was 1.50 +/– 0.47 cm and fourth lumbar spinal nerves and innervates the anterior (mean +/– standard deviation). Compound femoral nerve cross thigh muscles, hip and knee joints, and skin on the antero- sections were noncircular with major and minor diameters of medial thigh [1]. We define the compound femoral nerve 10.50 +/– 1.52 mm and 2.30 +/– 0.63 mm, respectively. In vivo as the femoral nerve section between the inguinal ligament intraoperative measurements in six subjects were consistent with and the first branching point in the thigh. The three vasti cadaver results. Selective stimulation of individual muscles inner- muscles are important for standing function; they extend vated by the femoral nerve may therefore be possible with a single the leg at the knee joint without flexing the thigh, which neural prosthesis able to selectively stimulate individual groups of would be detrimental to a stable upright posture. Vastus lat- fascicles. eralis and vastus intermedius are the strongest of the three muscles; therefore, they are commonly targeted by neural Key words: fascical map, femoral nerve, functional electrical prostheses that employ functional electrical stimulation stimulation, nerve cuff electrode, nerve morphology, neuro- anatomy, rehabilitation, spinal cord injury, standing, surgical anatomy. Abbreviations: ASIS = anterior superior iliac spine, FES = functional electrical stimulation, SCI = spinal cord injury, SD = standard deviation. INTRODUCTION *Address all correspondence to Kenneth J. Gustafson, PhD; Department of Biomedical Engineering, Neural Engi- Muscles innervated by the femoral nerve are prime neering Center, Wickenden Building, Rm 114, Case West- movers for leg extension at the knee joint and thigh flexion ern Reserve University, Cleveland, OH 44106-7207; 216- and critical for standing and stepping function. Therefore, 368-8626; fax: 216-368-4872. Email: [email protected] effective clinical interventions to restore or improve stand- DOI:10.1682/JRRD.2008.08.0097 973 974 JRRD, Volume 46, Number 7, 2009 (FES) for standing after SCI [2–4]. The vastus medialis Therefore, if distinct fascicles or groups of fascicles rep- muscle is important for locking the knee in terminal exten- resent the distal nerves of the compound femoral nerve, sion and preventing the patellar drift and lateral subluxation we may possibly control distal muscles at a proximal site that could possibly be caused by the pull of the vastus later- using a single multicontact nerve cuff electrode. A single alis. Although the biarticulate rectus femoris and sartorius nerve cuff electrode able to selectively recruit multiple muscles are critically important during the sit-to-stand heads of the vasti muscles simultaneously would improve transition and during stepping and walking [5–6], they neuroprosthesis performance by extending standing time have undesirable actions for standing [4,7], such as thigh and eliminating the need for multiple implants. flexion. The sartorius also flexes the leg at the knee joint Our objectives for this project were to determine (1) the and medially rotates the leg. The pectineus muscle gener- branching patterns, branch-free lengths, and nerve diame- ates low forces easily counteracted by other thigh muscles, ters of the branches of the human femoral nerve; and (2) the and the saphenous and medial cutaneous sensory nerves fascicular representation of distal nerve branches at the are unessential to standing. level of the compound femoral nerve. We require accurate Currently available neural prostheses for standing and nerve anatomy representations to develop accurate com- stepping after SCI use muscle-based, rather than nerve- puter models to evaluate and optimize potential stimulating based, electrodes. Surgically implanted FES systems nerve cuff electrode designs for standing and stepping after employing epimysial electrodes sutured to the muscle at SCI [20]. Nerve morphology (diameters and branch free- the nerve entry point [8–9] and/or intramuscular electrodes lengths) provides important design parameters for con- inserted into the muscle belly near its innervating neural structing nerve cuff electrodes to avoid mechanical trauma structure [10] have been successful in restoring hand grasp and maximize stimulation efficiency [21–22]. Furthermore, to individuals with midcervical tetraplegia [11–12]; exer- this knowledge is critical for defining surgical approaches cise, standing, and transfer ability to individuals with tho- to the nerve, identifying the most practical and desirable racic or low cervical-level lesions [2,13–15]; and short- locations for nerve cuff electrodes, and developing imple- distance stepping for individuals with thoracic paraplegia mentation strategies for advanced implanted neural prosthe- [5–6]. In spite of these successes, placement of a nerve ses. Finally, we require the fascicular structure of the cuff electrode on the compound femoral nerve or its distal compound femoral nerve and the relationship of individual branches would address several significant limitations of fascicles to distal nerve branches and terminal muscles to currently available muscle-based stimulation technologies. determine the electrode specifications and initial feasibility Epimysial and intramuscular electrodes rarely recruit all of selectively activating individual fascicles within the com- the motor units in a paralyzed muscle, especially in large pound nerve with a single proximally located nerve cuff lower-limb muscles with complex innervation patterns, electrode. Computer models using the data from this study leading to limited standing durations or insufficient stimu- have demonstrated that selective stimulation of the human lated joint moments to support taller and heavier implant femoral nerve is feasible using nerve cuff electrodes [23]. recipients. For complete recruitment using muscle-based electrodes, multiple electrodes must be placed within the muscle belly, which is surgically time consuming and can METHODS be difficult to implement [16]. Nerve cuff electrodes can completely activate the motor neurons they encompass and Anatomy and Morphology produce contractions closer to the maximal capacity than We harvested and dissected eight femoral nerves and muscle-based designs. all distal branches from each leg of four female formalin- Distal nerves may be represented as distinct fascicles fixed cadavers, ranging in age from 87 to 99 years (mean = or groups of fascicles in proximal compound peripheral 91). We measured the distance from the anterior superior nerves. A fascicle map of a compound nerve relates each iliac spine (ASIS) to the pubic symphysis bilaterally on fascicle to the distal nerve branch with which it exits and, each cadaver as an anatomical landmark. We located the therefore, to the distal muscles or organs innervated by femoral nerve through transverse incisions from the ASIS that distal nerve branch (Figure 1). Available techniques to the pubic symphysis and incisions originating from the allow us to selectively electrically stimulate individual midpoint between the ASIS and the pubic symphysis fascicles or areas within a compound nerve [17–19]. extending longitudinally to the patella. We chose the 975 GUSTAFSON et al. Fascicular anatomy of human femoral nerve Figure 1. (a) Harvested nerve and (b) complete fascicle map of femoral nerve (cadaver specimen 4 [left side]). We traced distal nerve branches of femoral nerve proximally to compound femoral nerve. Nerve cross sections are shown ventral side up. A = nerve just proximal to branching, B = nerve branch to sartorius muscle, C = nerve just distal to sartorius nerve branching and just proximal to pectineus nerve branching, D = nerve branch to pectineus muscle, E = nerve just distal to pectineus nerve branching and
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