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TOPIC:MYOTOMES *Definition:* Myotomes refer to specific groups of muscles that are innervated by the motor fibers of a single spinal nerve root. They play a crucial role in movement and are essential for assessing neurological function. Myotomes are associated with each spinal nerve root, which emerge from the spinal cord and exit the vertebral column through the intervertebral foramina. There are typically eight cervical nerves (C1-C8), twelve thoracic nerves (T1-T12), five lumbar nerves (L1-L5), five sacral nerves (S1-S5), and one coccygeal nerve (Co). Each spinal nerve root supplies specific muscles with motor innervation, corresponding to its level in the spinal cord. Here's a general overview of the myotomes and their associated nerve roots: - C1: No significant myotome, as it emerges above the first cervical vertebra. - C2: Supplies muscles that help with neck movement, such as the sternocleidomastoid and trapezius. - C3: Also involved in neck movements and contributes to shoulder elevation. - C4: Innervates muscles involved in shoulder movements, such as the deltoid and levator scapulae. - C5: Supplies muscles responsible for shoulder abduction (deltoid), elbow flexion (biceps), and wrist extension (extensor carpi radialis longus). - C6: Innervates muscles involved in elbow flexion (brachialis), wrist extension (extensor carpi radialis brevis), and finger flexion (flexor digitorum superficialis). - C7: Supplies muscles responsible for elbow extension (triceps), wrist flexion (flexor carpi radialis), and finger extension (extensor digitorum). - C8: Innervates muscles involved in finger flexion (flexor digitorum profundus) and thumb movement (flexor pollicis longus). - T1: Supplies muscles responsible for hand movements and finger abduction. - T2-T12: Innervate the intercostal muscles and some muscles of the abdomen and back. - L1-L5: Innervate muscles of the lower back, hips, and thighs, including the hip flexors, quadriceps, and some muscles of the foot. - S1-S5 and Co: Supply muscles involved in hip extension, knee flexion, ankle movement, and foot movement. Understanding the myotomes and their associated nerve roots is crucial for clinicians in diagnosing and treating neurological conditions affecting motor function. Myotome Distribution Most muscles in the limbs receive innervation from more than one spinal nerve root, and are hence comprised of multiple myotomes. Eg Biceps Brachii muscle flexes the elbow. It is innervated by the musculocutaneous nerve, which is innervated by C5, C6 and C7 nerve roots. All three of these spinal nerve roots can be said to be associated with elbow flexion. The list below details which movement(s) has the strongest association with each myotome: Upper Extremity: Nerve Root Upper Limb Movement C5 :Shoulder Abduction C6 :Elbow Flexion Wrist Extension C7 : Elbow Extension C8 : Thumb Extension Ulnar Deviation T1: Finger Abduction Lower Extremity: Nerve Root Lower Limb Movement L2 :Hip Flexion L3 :Knee Extension L4: Ankle Dorsiflexion L5 :Big Toe Extension S1: Ankle Plantarflexion S2: Knee Flexion Testing of myotomes, in the form of isometric resisted muscle testing, gives information about the level in the spine where a lesion may be present. During myotome testing, you are looking for muscle weakness of a particular group of muscles. Results may indicate lesion to the spinal cord nerve root, or intervertebral disc herniation pressing on the spinal nerve roots. The muscle strength grading scale, which assigns a rating to the degree of muscle weakness, is often used. Technique Begin by asking the client to perform a movement as per instructions and hold an isometric contraction against therapist resistance for a count of 5. C5- Shoulder abduction. Ask the patient to raise both their arms to the side of them simultaneously as strongly as then can while the examiner provides resistance to this movement. Compare the strength of each arm. C6- Elbow flexion & wrist extension. Test the strength of lower arm flexion by holding the patient's wrist from above and instructing them to "flex their hand up to their shoulder". Provide resistance at the wrist. Repeat and compare to the opposite arm. This tests the biceps muscle. Test the strength of wrist extension by asking the patient to extend their wrist while the examiner resists the movement. This tests the forearm extensors. Repeat with the other arm. C7- Elbow extension & wrist flexion. Ask the patient to extend their forearm against the examiner's resistance. Begin their extension from a fully flexed position because this part of the movement is most sensitive to a loss in strength. This tests the triceps. Note any asymmetry in the other arm. C8- Finger Flexion. Examine the patient's hands. Look for intrinsic hand, thenar and hypothenar muscle wasting. Test the patient's grip by having the patient hold the examiner's fingers in their fist tightly and instructing them not to let go while the examiner attempts to remove them. Normally the examiner cannot remove their fingers. This tests the forearm flexors and the intrinsic hand muscles. Compare the hands for strength asymmetry. Finger flexion is innervated by the C8 nerve root via the median nerve. C8- Finger abduction & adduction. Test the intrinsic hand muscles once again by having the patient abduct or "fan out" all of their fingers. Instruct the patient to not allow the examiner to compress them back in. Normally, one can resist the examiner from replacing the fingers. Finger abduction or "fanning" is innervated by the T1 nerve root via the ulnar nerve. C8 & T1- Thumb Opposition. To complete the motor examination of the upper extremities, test the strength of the thumb opposition by telling the patient to touch the tip of their thumb to the tip of their pinky finger. Apply resistance to the thumb with your index finger. Repeat with the other thumb and compare. Thumb opposition is innervated by the C8 and T1 nerve roots via the median nerve. L1 & L2 : Hip Flexion. Proceeding to the lower extremities, first test the flexion of the hip by asking the patient to lie down and raise each leg separately while the examiner resists. Repeat and compare with the other leg. This tests the iliopsoas muscles. L3: Knee Extension. Test extension at the knee by placing one hand under the knee and the other on top of the lower leg to provide resistance. Ask the patient to "kick out" or extend the lower leg at the knee. Repeat and compare to the other leg. This tests the quadriceps muscle. L4: Ankle Dorsiflexion. Test dorsiflexion of the ankle by holding the top of the ankle and have the patient pull their foot up towards their face as hard as possible. Repeat with the other foot. This tests the muscles in the anterior compartment of the lower leg. L5: Great toe extension. Ask the patient to move the large toe against the examiner's resistance "up towards the patient's face". This tests the extensor halucis longus muscle. S1: Ankle plantarflexion and eversion/knee flexion. Holding the bottom of the foot, ask the patient to press down as hard as possible. Or in standing rise up onto the ball of their foot. Repeat with the other foot and compare. This tests the gastrocnemius and soleus muscles in the posterior compartment of the lower leg. S2: Knee flexion.Test flexion at the knee by holding the knee from the side and applying resistance under the ankle and instructing the patient to pull the lower leg towards their buttock as hard as possible. Repeat with the other leg. This tests the hamstrings. Clinical relevance Myotomes are mainly useful for clinical evaluation of patients in understanding the pattern of neurological deficit after a complex nerve injury. Injury to each or a combination of spinal myotomes, lesions may be localized to the spinal nerve or trunk level.