International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - Vol 05 Issue 14, July, 2013

Pages: 106-110

Date of Publication: 29-Jul-2013


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ANATOMICAL AND CLINICAL INSIGHT OF VARIANT MORPHOLOGIES OF PSOAS MINOR MUSCLE: A CASE REPORT

Author: S. Gandhi, N. Gupta, A. Thakur, A. Anshu, V. Mehta, R.K. Suri , G. Rath

Category: Healthcare

Abstract:Psoas minor is long, slender and functionally weak muscles that assist psoas major in flexing the trunk and spinal column. Psoas minor at its origin lies just in front of the psoas major muscle has small belly and long tendon like plantaris and palmaris longus muscle. Psoas minor receives its nerve supply from the ventral rami of L1 spinal nerves, which after piercing through the psoas major muscle enter into the muscular belly. In the present case, psoas minor muscle was found bilaterally in a 60 years old male formalin fixed cadaver. Bilaterally, the muscle depicted absence of fusion with adjacent psoas major and was found to exist independently. The distal insertion of the muscle was variable when compare to the contralateral peer. Moreover, in contrast to the muscular portion, the tendinous portion was remarkably lengthier. As the muscle is closely related to important neurovascular structures of retroperitoneum, it may compress them during its involvement in psoas minor syndrome and psoas abscess; yielding myriads of clinical signs and symptoms. The incidence and morphometric parameters of this inconsistent muscle are highly variable and had been frequently correlated with ethnic and racial characteristics. The current report reveals a case of bilateral existence of psoas minor and disparity in its morphometric attributes on either side. Against this background, analysis of deviation in structural architecture and its distribution in population has been attempted. To consolidate the scattered pieces of information about variability in different parameters of this muscle and reemphasize its significant role in radiographic and surgical procedures, a review of literature is constructed to appraise the medical persons working in related fields.

Keywords: Psoas major, Psoas minor, Psoas minor syndrome, variations

Full Text:

INTRODUCTION
The Psoas minor muscle is a constituent of the posterior abdominal wall and lies ventral to the psoas major muscle. When present, it usually originates from the lateral sides of the body of the twelfth thoracic vertebra (T12), first lumbar vertebra (L1), and the intervening intervertebral disc. The short muscular part is continuous with a thin tendon, which is inserted into the iliopubic eminence, pectineal line of the pubis and laterally in the iliac fascia1,2. The psoas minor muscle have been found to flex the lumbar spine and tilts it sideways when contracting unilaterally3 , apart from providing stabilization to the hip joint 4 . It is classified as an inconsistent muscle 5 and is often absent 3 . It is considered the muscle with highest percentage of unilateral or bilateral agenesis, considered ranging from 40% to 66% in different populations2,5. In case of its existence, the thin tendon of this muscle can rarely arise from an expansion of the medial border of the psoas major muscle5 . Morphometric and morphological descriptions on the psoas minor muscle are scarce, discrete and unorganized in the literature and do not provide any conclusive anatomical information about the muscle. The aim of the present study is to reveal the anatomy of the psoas minor muscle, ascertain their origin and insertion points, analyze the possible dependent relationship between the fibers of the psoas minor and major muscles, neurovascular relations and determine the proportional relationship between the tendinous and muscular parts of the psoas minor. We also aim at providing an insight into the clinicosurgical importance of this variant muscle.

CASE REPORT
During the course of routine cadaveric dissection for undergraduate students of a 60 year old male cadaver, the posterior abdominal wall revealed the bilateral existence of well formed psoas minor muscle taking origin from the lateral surfaces of the body of T12 and LI vertebra and from intervening tendinous arch (fig. 1a and 1b). Bilaterally the psoas minor muscles were getting inserted onto the iliopubic eminence, the insertion being tendinous on the left side (fig1b) and tendinoaponeurotic that fuses with the iliac fascia on the right side. On further exploration, the length of left sided psoas minor measured as 10.5 cm and 12 cm for the muscular and tendinous part respectively (fig 1b). The maximum width of the muscle at muscular and tendinous part was 2.50 cm and 0.90 cm in that order (1b). On the right side, length of muscular belly and the variant tendinoaponeurotic part when compared to the left measured as 11 cm and 10.50 cm (fig1a). The maximum widths of muscular, tendinous and aponeurotic parts of the right sided psoas minor were 2.50 cm, 0.50 cm and 4.50 cm respectively (fig1a). The genitofemoral nerve, which pierced the psoas major muscle, oriented itself along the medial border of psoas minor muscle bilaterally. On both sides, the tendons of muscle were found positioned lateral to the external iliac artery. Bilaterally, they received the nerve supply from anterior division of L1 spinal nerve. No contracture, lump, tumor fixation or signs of injury were seen in the muscles. The cause of death of the case was apparently unrelated to previously mentioned variant findings.

DISCUSSION
The psoas minor muscle varies considerably in its morphology and morphometry. The possible variations in the morphology of psoas minor muscle can be broadly discussed and reviewed by taking into account the following parameters. Incidence of psoas minor- In majority, psoas minor muscle is deficient similar to commonly absent muscles like pyramidalis, psoas parvus, peroneus tertius, palmaris longus, and plantaris6 . In major studies, the incidence of existence of psoas minor was found to exhibit a range of findings such as 30% 6-9 . The relative discrepancy in frequencies is presumed to be correlated with the racial and ethnic differences in the population 6,10. They are illustrated in table1 Gender bias- The higher occurrence of this muscle in females compared to males6 had been contradicted in other study, where the gender bias was found to be insignificant7 . No scientific dictums regarding its probable correlation of its incidence with any particular gender was later established6 . Variations in origin and insertion- Usually it finds its attachment on the first two lumbar vertebras and the intervening intervertebral disc similar to present case. Infrequently it might originate through two heads, which may segregate partially or completely prior to its distal insertion on iliopubic eminence. Alternatively, its insertion may be erratically located at iliac fascia, inguinal ligament, neck of the femur or lesser trochanter in unison with psoas major. The tendinous insertion can bifurcate, leading to the attachment of additional aberrant band on the synchondrosis between the fifth lumbar vertebra and the sacrum, apart from its usual insertion at iliopectineal line 6 . The muscle may merge with the pelvic or iliac fascia, through which it possibly gets attached to crural arch 6,11 which simulates the findings observed in right sided psoas minor in the current case. The duplication of psoas minor has also been seen in the past, where the first belly overlapped the other from before backwards6 . Infrequently, the ramifications of muscular fibers of psoas major yielding psoas minor have been mentioned as source of unusual origin6 . Proportional extent of muscular and tendinous parts- Remarkably long tendons of psoas minor muscle have been accounted in the precedent history 5,12. Absolute tendinous replacement of this muscle is also reported in different studies 6,13 . However, the literature provides inconclusive data on the proportional relationship between the extent of muscular and tendinous parts of the psoas minor. Side difference- although the relative absence of this muscle on the right side compared with the left is mentioned6 . The preferential presence on either side remains statistically unresolved. Probable functions of the muscle- Psoas minor, if present, exerts minimal contribution in the flexion of lumbar spine14,15, yet it reinforces psoas major in maintaining lordotic lumbar curvature through the sustained tone inherent in itself 15 . Comparative anatomy- psoas minor has been found to be well developed in hopping animals like marsupials, macrocelides, jerboa etc 6 .

CLINICAL IMPLICATIONS
The psoas minor syndrome is attributed to unusual high tone in psoas minor muscle and tendon 15 where, the patient complaints of pain in the lower quadrant of the abdomen. In addition, the pain was aggravated by palpation of the taut tendon in lean individuals presenting with acute abdomen 15. In this syndrome, there is the limited extension, which impairs ambulation. Tenotomy is the only treatment of choice, which relieves the symptoms. This remarkable entity may simulate the pain of appendicitis or diverticulitis localized in iliac fossae 15. Psoas minor, functioning as an adjunct to psoas major, may be variably involved in psoas compartment syndrome 16. The psoas minor muscle being a retroperitoneal structure lies in close proximity to important neurovascular structures in the posterior abdominal wall. Infections, hematoma and neoplasm localized in the retroperitoneal planes have propensity to involve the adjacent psoas fascia and muscle 17 . Moreover, as the cranial portion of psoas minor is placed posterior to crural attachment of diaphragm, any pathological collection within the confinement of fascia overlaying the muscle may gain access to endothoracic cavity. The comprehension of these muscular variations allows insight into the pattern of localization and spread of infection and malignancy in the retroperitoneal region of the body18. The space occupying lesions situated in psoas muscles may impinge on the related nerves of lumbar plexus leading to motor or sensory neurological deficits of lower limb 18. Psoas compartment block has been inferred as useful alternative in alleviation of postoperative pain following hip and knee surgeries; hence, the comprehension of morphological variations of psoas minor is imperative for success of such techniques19. The variant muscle as observed in the current case should not be confused with the retroperitoneal lymphadenopathy. Since the originating head of psoas minor lies in posterior relation of renal pelvis and neurovascular pedicles, it may interfere with the operative field in percutaneous nephrolithostomy. In aberrant lower spinal curvature correction surgeries, the role of lengthening of predominantly tendinous configuration of psoas minor must be considered. To address the lack of information in the literature regarding psoas minor muscle’s morphology, morphometry and its clinical implications, this case endeavor to provide detailed information about the muscle in order to expand knowledge of its clinical anatomy.

CONCLUSION
The clinicians and academicians have often overlooked the role of psoas minor owing to its relative scarcity of anatomicosurgical comprehension. The review of psoas minor and its crucial disposition in the retroperitoneum would serve to appraise and guide the interventional procedures and differential diagnosis of relevant simulating clinical conditions.

References:

1. O’Rahilly R. Anatomia de Gardener. 5th ed. Mexico: Nuvea Editorial Americana; 1986.

2. Williams P, Warwick R. Anatomy the Grays. 37th ed. Edinburgh: Churchill Livingstone; 1992.

3. Gray H. Anatomia. 29th ed. Rio di Janeiro: Guanabara Kougan; 1977.

4. Moore K, Dally K. Anatomia orienteda para a clinica. 5th ed. Rio di Janeiro: Guanabara Kougan; 2007.

5. Tellez V, Acuna L. Consideraciones Anatomicas de los Musculos Inconstantes. Med Unab; 1998.

6. Kraychete DC, Rocha APC, Castro PACR de. Psoas muscle abscess after epidural analgesia: case report. Rev. Bras. Anestesiol. 2007 Apr;57(2):195–8.

7. Donovan PJ, Zerhouni EA, Siegelman SS. CT of the psoas compartment of the retroperitoneum. Semin. Roentgenol. 1981 Oct;16(4):241–50.

8. Snell R. membro inferior. In: Snell P, editor. Anat. Clin. Para Estud. Med. 5th ed. Rio de janeiro; 1999.

9. Bergman R, Afifi K, Miyauchi R. Illustrated Encyclopedia of Human Anatomic Variation, Virtual Hospital, University of Yowa, 2002, Yowa City, Yowa, USA, www.vh.org.

10. Mori M. Statistics on the musculature of Japanese. Folia Anat. Jap. 1964;195–300.

11. Gardener E, Gray D, O’Rahilly R. In: Gardener E, Gray D, O’Rahilly R, editors. Anat. Parede Abdom. Posterior. 4a ed. Rio di Janeiro: Guanabara Kougan; 1988. p. 356.

12. Lee J, Sagel S, Stanley R. Comput. Body Tomogr. Mri Correl. New York: Raven; 1989. p. 756–60.

13. Testut L, Latarjet A. Músculos del abdomen: región posterior o lumboiliaca. Tratado de anatomía humana. 9th ed. Barcelona: Salvat; 1976.

14. Pellegrino F, Tangelson C, Galiano L, Trevisan L, Sánchez G, Puricelli F. Criterios de homologación entre las cinturas escapular y pélvica y sus estructuras asociadas; Homologation criterion between the scapular and pelvic waists and their associated structures. Rev Chil Anat. 1998;16(1):75–82.

15. Travell J, Simons D. Myofascial Pain and Dysfunction: The Trigger Point Manual; Vol. 2., The Lower Extremities. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 1998.

16. Klammer A. [Fascia compartment syndrome of the iliac-psoas compartment]. Z. Für Orthop. Ihre Grenzgeb. 1983 Jun;121(3):298–304.

17. A Al-Zamil JTC. Psoas muscle hematoma-- an acute compartment syndrome. Report of a case. Vasa Z. Für Gefässkrankheiten J. Vasc. Dis. 1988;17(2):141–3.

18. Dyke JAV, Holley HC, Anderson SD. Review of Iliopsoas anatomy and pathology. Radiographics. 1987 Jan 1;7(1):53–84.

19. Touray ST, de Leeuw MA, Zuurmond WWA, Perez RSGM. Psoas compartment block for lower extremity surgery: a metaanalysis. Br. J. Anaesth. 2008 Dec;101(6):750–60.

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One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

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A Study by Amr Y. Zakaria et al. entitled "Single Nucleotide Polymorphisms of ATP-Binding Cassette Gene(ABCC3 rs4793665) affect High Dose Methotrexate-Induced Nephrotoxicity in Children with Osteosarcoma" is awarded Best Article for Vol 13 issue 19
A Study by Kholis Ernawati et al. entitled "The Utilization of Mobile-Based Information Technology in the Management of Dengue Fever in the Community Year 2019-2020: Systematic Review" is awarded Best Article for Vol 13 issue 18
A Study by Bhat Asifa et al. entitled "Efficacy of Modified Carbapenem Inactivation Method for Carbapenemase Detection and Comparative Evaluation with Polymerase Chain Reaction for the Identification of Carbapenemase Producing Klebsiella pneumonia Isolates" is awarded Best Article for Vol 13 issue 17
A Study by Gupta R. et al. entitled "A Clinical Study of Paediatric Tracheostomy: Our Experience in a Tertiary Care Hospital in North India" is awarded Best Article for Vol 13 issue 16
A Study by Chandran Anand et al. entitled "A Prospective Study on Assessment of Quality of Life of Patients Receiving Sorafenib for Hepatocellular Carcinoma" is awarded Best article for Vol 13 issue 15
A Study by Rosa PS et al. entitled "Emotional State Due to the Covid – 19 Pandemic in People Residing in a Vulnerable Area in North Lima" is awarded Best Article for Vol 13 issue 14
A Study by Suvarna Sunder J et al. entitled "Endodontic Revascularization of Necrotic Permanent Anterior Tooth with Platelet Rich Fibrin, Platelet Rich Plasma, and Blood Clot - A Comparative Study" is awarded Best Article for Vol 13 issue 13
A Study by Mona Isam Eldin Osman et al. entitled "Psychological Impact and Risk Factors of Sexual Abuse on Sudanese Children in Khartoum State" is awarded Best Article for Vol 13 issue 12
A Study by Khaw Ming Sheng & Sathiapriya Ramiah entitled "Web Based Suicide Prevention Application for Patients Suffering from Depression" is awarded Best Article for Vol 13 issue 11
A Study by Purushottam S. G. et al. entitled "Development of Fenofibrate Solid Dispersions for the Plausible Aqueous Solubility Augmentation of this BCS Class-II Drug" is awarded Best article for Vol 13 issue 10
A Study by Kumar S. et al. entitled "A Study on Clinical Spectrum, Laboratory Profile, Complications and Outcome of Pediatric Scrub Typhus Patients Admitted to an Intensive Care Unit from a Tertiary Care Hospital from Eastern India" is awarded Best Article for Vol 13 issue 09
A Study by Mardhiah Kamaruddin et al. entitled "The Pattern of Creatinine Clearance in Gestational and Chronic Hypertension Women from the Third Trimester to 12 Weeks Postpartum" is awarded Best Article for Vol 13 issue 08
A Study by Sarmila G. B. et al. entitled "Study to Compare the Efficacy of Orally Administered Melatonin and Clonidine for Attenuation of Hemodynamic Response During Laryngoscopy and Endotracheal Intubation in Gastrointestinal Surgeries" is awarded Best Article for Vol 13 issue 07
A Study by M. Muthu Uma Maheswari et al. entitled "A Study on C-reactive Protein and Liver Function Tests in Laboratory RT-PCR Positive Covid-19 Patients in a Tertiary Care Centre – A Retrospective Study" is awarded Best Article of Vol 13 issue 06 Special issue Modern approaches for diagnosis of COVID-19 and current status of awareness
A Study by Gainneos PD et al. entitled "A Comparative Evaluation of the Levels of Salivary IgA in HIV Affected Children and the Children of the General Population within the Age Group of 9 – 12 Years – A Cross-Sectional Study" is awarded Best Article of Vol 13 issue 05 Special issue on Recent Advances in Dentistry for better Oral Health
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A Study by Kumari PM et al. entitled "Study to Evaluate the Adverse Drug Reactions in a Tertiary Care Teaching Hospital in Tamilnadu - A Cross-Sectional Study" is awarded Best Article for Vol 13 issue 05
A Study by Anu et al. entitled "Effectiveness of Cytological Scoring Systems for Evaluation of Breast Lesion Cytology with its Histopathological Correlation" is awarded Best Article of Vol 13 issue 04
A Study by Sharipov R. Kh. et al. entitled "Interaction of Correction of Lipid Peroxidation Disorders with Oxibral" is awarded Best Article of Vol 13 issue 03
A Study by Tarek Elwakil et al. entitled "Led Light Photobiomodulation Effect on Wound Healing Combined with Phenytoin in Mice Model" is awarded Best Article of Vol 13 issue 02
A Study by Mohita Ray et al. entitled "Accuracy of Intra-Operative Frozen Section Consultation of Gastrointestinal Biopsy Samples in Correlation with the Final Histopathological Diagnosis" is awarded Best Article for Vol 13 issue 01
A Study by Badritdinova MN et al. entitled "Peculiarities of a Pain in Patients with Ischemic Heart Disease in the Presence of Individual Combines of the Metabolic Syndrome" is awarded Best Article for Vol 12 issue 24
A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
A Study by Habiba Suhail et al. entitled "Effect of Majoon Murmakki in Dysmenorrhoea (Usre Tams): A Standard Controlled Clinical Study" is awarded Best Article for Vol 12 issue 22
A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by Leow Jun Xian and Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
A Study by Avijit Singh et al. entitled "Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19
A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18
A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17
A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma COLAKOGLU entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by Arpita M. et al entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
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A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09
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List of Awardees

A Study by Ese Anibor et al. entitled "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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