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Lumbar primary dorsal branch L5

Bogduk  &  Long  1979

MB

L5L5

Posterolateral

Lumbar primary dorsalramus L5(Bogduk & Long 1979)

Anatomy of the‘articular nerves’:

§ Primary dorsal ramus L5shows other topography

§ …medial branch tocaudal L5-S1 facet jointand multifidus muscleand…

2

Lumbar primary dorsal branch L5

Bogduk  &  Long  1979

Lumbar primary dorsalramus L5(Bogduk & Long 1979)

Anatomy of the‘articular nerves’:

§ Primary dorsal ramus L5shows other topography

§ …lateral branch to (amongst others) SI joint

MB

L5 LB

L5L5

Posterolateral

3

Lumbar primary dorsal branch L5

Bogduk  &  Long  1979

MB

MB

MB

L4 LB

L5 LB

S1 LB

L5

Posterolateral

Lumbar primary dorsalramus L5(Bogduk & Long 1979)

Anatomy of the‘articular nerves’:

§ Primary dorsal ramus L5shows other topography

§ Complete system:sacrococcygeal plexusposterior to sacrum &coccygis

4

Sacral lateral branches S1-S3 (S4)

McGrath  et  al  2009

McGrath et al 2009 © Elsevier Masson

Dorsal view

Sacral lateral branches:McGrath et al 2009

Describe same branching pattern in SI joint pain S1-S3 (S4)

Dorsal sacral rami ( ) give rise to medial and lateral branches

Lateral (& medial) branches form a ...

PSIS – posterior superior iliac spineLPSL – long posterior sacroiliac lig.

(part of sacrotuberal lig.)LT – lateral third sacral tubercleDSR – Dorsal sacral ramus

LPSL

DSR

LT

5

Sacral lateral branches S1-S3 (S4)

McGrath  et  al  2009

Dorsal view

McGrath et al 2009 © Elsevier Masson

DSR

LPSL

PSIS – posterior superior iliac spineLPSL – long posterior sacroiliac lig.

(part of sacrotuberal lig.)LT – lateral third sacral tubercleDSR – Dorsal sacral ramus

LT

Sacral lateral branches:McGrath et al 2009

Sacroiliac joint painS1-S3 (S4)

Dorsal sacral rami ( ) give rise to medial and lateral branches

…sacrococcygeal plexus,posterior to sacrum and coccygis

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Sacral lateral branches S1-S3 (S4)

McGrath  et  al  2009

PSIS – posterior superior iliac spineLPSL – long posterior sacroiliac lig.

(part of sacrotuberal lig.)LT – lateral third sacral tubercleDSR – Dorsal sacral ramus

Sacral lateral branches:McGrath et al 2009

Sacroiliac joint painS1-S3 (S4)

(& L5 dorsal branch itself)

§ SI pain provoking pointclose to this sacrococcygeal plexus

McGrath et al 2009 © Elsevier Masson

Dorsal view

LPSL

DSR

LT

7

Sacral lateral branches S1-S3 (S4)

McGrath  et  al  2009,  Collection  A/E  MUMC

McGrath et al 2009 © Elsevier MassonDorsal view

LPSL

DSR

LT

Sacral lateral branches:McGrath et al 2009

Sacroiliac joint painS1-S3 (S4)

(& L5 dorsal branch itself)

§ Plexus also close to posterior sacroiliac ligg. and multifidus -> complex substrate!

SI joint innervation - Histology

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Forst et  al  2006,  Vanelderen et  al  2010,  http://www.bartleby.com/

SI joint well innervated:Forst et al 2006, Vanelderenet al 2010

Histology shows nerve fibersin SI joint capsula and SI ligg. from variously described sources

• Previously mentioned dorsal rami L5, S1-S2

• Almost exclusively from sacral dorsal rami

• Ventral rami L4-L5 • Superior gluteal nerve

L4

L5

Superior  gluteal  n.

9

Ventral nociception? - Histology

Collection  A/E  MUMC

Ventral sacroiliac ligg.:Fortin et al. 1999

Histological study: sensory nerves in ventral capsular ligament

SI joint cartilage:Szadek et al 2010

Immunohistochemical study:possible nociceptive structures in SI joint cartilage

-> complex substrate!

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Lumbar medial branch L1-L4

www.jurewitz.com,  www.neuros.nl.gif

Lumbar medial branch:

Several approaches:

§ Posteromedial (PM)

§ Posterolateral (PL)

PM

PL

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Lumbar medial branch L1-L4

www.treatingpain.com,  www.backpainreliefsecrets.com

Lumbar medial branch:

Several approaches:

§ Posteromedial (PM)

§ Posterolateral (PL)

§ Posteroanterior (PA)

PA

PA

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Lumbar primary dorsal branch L5L5 primary dorsal branch:

Special approach:

§ Posteroanterior (PA)at alar groove:junction of sacral ala and superior articular processof sacrum

MB

MB

MB

L4 LB

L5 LB

S1 LB

L5

Posterolateral  view

Cranial  view