M. Yamagata

The afferent pathways of discogenic low-back pain. Evaluation of L2 spinal nerve infiltration.

The afferent pathways of discogenic low-back pain have not been fully investigated. We hypothesised that this pain was transmitted mainly by sympathetic afferent fibres in the L2 nerve root, and in 33 patients we used selective local anaesthesia of this nerve. Low-back pain disappeared or significantly decreased in all patients after the injection. Needle insertion provoked pain which radiated to the low back in 23 patients and the area of skin hypoalgesia produced included the area of pre-existing pain in all but one. None of the nine patients with related sciatica had relief of that component of their symptoms. Our findings show that the main afferent pathways of pain from the lower intervertebral discs are through the L2 spinal nerve root, presumably via sympathetic afferents from the sinuvertebral nerves. Discogenic low-back pain should be regarded as a visceral pain in respect of its neural pathways. Infiltration of the L2 nerve is a useful diagnostic test and also has some therapeutic value.

Sensory innervation of the cervical facet joints in rats.

Study Design. With a retrograde neurotracing method with Fluoro-Gold (FG; Fluorochrome, Denver, CO), the level of dorsal root ganglions (DRGs) innervating the C1–C2, C3–C4, and C5–C6 facet joints and their pathways were investigated in rats. Objectives. To clarify the levels of DRGs and parasympathetic nodose ganglions innervating the cervical facet joints and to determine the pathways from the facet joint to DRGs. Summary of Background Data. Patients with cervical facet lesions and whiplash sometimes experience diffuse neck pain, headache, arm, and shoulder pain, but the pattern of sensory innervation of the facet joint is still unclear. Methods. Sixty male Sprague–Dawley rats were used. Fluoro-gold crystals (FG) were applied into the C1–C2 (C1–C2 group), C3–C4 (C3–C4 group) and C5–C6 (C5–C6 group) facet joints, and numbers of the labeled neurons in DRGs from C1 to T5 and nodose ganglions were determined. To determine the sensory pathway, bilateral sympathectomy was performed. Results. Neurons labeled with FG were present in the DRGs from C1 through C8 in the C1–C2 group, from C1 to T2 in the C3–C4 group, and from C3 to T3 in the C5–C6 group without sympathectomy. In the nodose ganglions, 17 FG-labeled neurons were present. The number of the labeled neurons after sympathectomy was not significantly different in the C1, C2, and C3 DRGs in the C1–C2 group, in the C3 and C4 DRGs in the C3–C4 group, and in the C5 and C6 DRGs in the C5–C6 group from that in the groups without sympathectomy. In contrast, the number of labeled neurons in the DRGs was significantly less at the other levels than that in the groups without sympathectomy (P < 0.01). Conclusion. Sensory nerve fibers of the cervical facet joint were derived from the C1–T3 DRGs. Some sensory nerves from the cervical facet joint entered the paravertebral sympathetic trunks and reached the DRGs at multisegmental levels. The present findings regarding the multisegmental innervation to the facet joint may be of importance in the treatment of facet joint syndrome.

Sensory nerve fibres from lumbar intervertebral discs pass through rami communicantes: A POSSIBLE PATHWAY FOR DISCOGENIC LOW BACK PAIN

It has been thought that lumbar intervertebral discs were innervated segmentally. We have previously shown that the L5-L6 intervertebral disc in the rat is innervated bilaterally from the L1 and L2 dorsal root ganglia through the paravertebral sympathetic trunks, but the pathways between the disc and the paravertebral sympathetic trunks were unknown. We have now studied the spines of 17 rats to elucidate the exact pathways. We examined serial sections of the lumbar spine using immunohistochemistry for calcitonin gene-related peptide, a sensory nerve marker. We showed that these nerve fibres from the intervertebral disc ran through the sinuvertebral nerve into the rami communicantes, not into the corresponding segmental spinal nerve. In the rat, sensory information from the lumbar intervertebral discs is conducted through rami communicantes. If this innervation pattern applies to man, simple decompression of the corresponding nerve root will not relieve discogenic pain. Anterior interbody fusion, with the denervation of rami communicantes, may be effective for such low back pain.

Fracture-dislocation of the fifth lumbar vertebra

We have studied fracture-dislocation of the fifth lumbar vertebra in seven patients and reviewed 50 previously reported cases. Based on this information, we have classified the injury into five types: type 1, unilateral lumbosacral facet-dislocation with or without facet fracture; type 2, bilateral lumbosacral facet-dislocation with or without facet fracture; type 3, unilateral lumbosacral facet-dislocation and contralateral lumbosacral facet fracture; type 4, dislocation of the body of L5 with bilateral fracture of the pars interarticularis; and type 5, dislocation of the body of L5 with fracture of the body and/or pedicle, with or without injury of the lamina and/or facet. Conservative treatment of fracture-dislocation of L5 is generally not effective because the lesion is fundamentally unstable. Planning of the operation should be made on the basis of the various types of injury.

Brain-derived neurotrophic factor and vanilloid receptor subtype 1 immunoreactive sensory DRG neurons innervating the lumbar facet joints in rats.

The rat L5/6 facet joint is innervated from L1 to L6 by the dorsal root ganglia (DRG). The presence of substance P- and calcitonin gene-related peptide-immunoreactive (ir) DRG neurons innervating the L5/6 facet joint has been demonstrated. However, the presence of brain-derived neurotrophic factor (BDNF)-ir and the vanilloid receptor subtype 1 (VR1)-ir DRG neurons, which relate to inflammatory and burning pain innervating the L5/6 facet joint, has not. Fluoro-gold (FG)-labeled neurons innervating the L5/6 facet joint were distributed throughout the DRGs from T13 to L6 levels. Of the FG-labeled neurons, the proportions of BDNF-ir in L1, L2, L3, L4 and L5 DRG neurons were 9%, 15%, 21%, 17% and 20% and the proportions of VR1-ir L1, L2, L3, L4 and L5 DRG neurons were 8%, 9%, 15%, 16% and 15%, respectively.

Spatial and temporal collagen gene expression in lumbar intertransverse fusion in the rabbit

We have examined the process of fusion of the intertransverse processes and bone graft in the rabbit by in situ hybridisation and evaluated the spatial and temporal expression of genes encoding pro-alpha1 (I) collagen (COL1A1), pro-alpha1 (II) collagen (COL2A1) and pro-alphal (X) collagen (COL10A1). Beginning at two weeks after operation, osteogenesis and chondrogenesis occurred around the transverse process and the grafted bone at the central portion of the area of the fusion mass. Osteoblasts and osteocytes at the newly-formed woven bone expressed COL1A1. At the cartilage, most chondrocytes expressed COL2A1 and some hypertrophic chondrocytes COL10A1. In some regions, co-expression of COL1A1 and COL2A1 was observed. At four weeks, such expressions for COLlA1, COL2A1 and COL10A1 became prominent at the area of the fusion mass. From four to six weeks, bone remodelling progressed from the area of the transverse processes towards the central zone. Osteoblasts lining the trabeculae expressed a strong signal for COL1A1. At the central portion of the area of the fusion mass, endochondral ossification progressed and chondrocytes expressed COL2A1 and COL10A1. Our findings show that the fusion process begins with the synthesis of collagens around the transverse processes and around the grafted bone independently. Various spatial and temporal osteogenic and chondrogenic responses, including intramembranous, endochondral and transchondroid bone formation, progress after bone grafting at the intertransverse processes. Bone formation through cartilage may play an important role in posterolateral spinal fusion.

The influence of early ambulation and other factors on headache after lumbar myelography

In order to determine the influence of early ambulation and other factors on headaches occurring after lumbar myelography we randomised 207 patients (127 men and 80 women) into two groups. Following the investigation, we allowed the 101 patients (65 men and 36 women) in group A to sit or stand freely, while we confined the 106 patients (62 men and 44 women) in group B to bed for 20 hours. The nine patients in group B who could not maintain bed rest were excluded. There was no significant difference between the two groups as regards the prevalence of spinal headache (8.9% in group A v 14.4% in group B). Patients who reported headaches, however, were significantly more likely to be women (18.7%) than men (73%), be younger (mean age 45 years v 56 years), have a higher cerebrospinal pressure before removal of fluid (mean values 172 v 137 mm H2O) and a lower systolic (mean values 120 v 134 mmHg) and diastolic blood pressure. We conclude that, although other factors may be associated with headaches, late ambulation is not effective in preventing spinal headaches after lumbar myelography.