The nerve supply of the lumbar intervertebral disc - 논문 정리

[문형철]

허리디스크로 인한 통증의 기전을 명확하게 하기 위해서..

논문을 읽어서 정리해야겠다.

돌이켜보니 15년전 허리디스크로 인한 증상에 대해서 고민해보고 그 이후로는 증상에 대한 고민보다는

솔루션에 초점을 맞추어 생각을 몰입했다.

증상에 대한 기전이 불명확하니 솔루션도 조금 미흡할 수 있었겠다는 생각이 들어서 논문을 뒤지기로 결정..ㅋㅋ

The neuroanatomical basis of discogenic pain can be summarised as follows: 

1. The intervertebral disc receives an extensive innervation, especially the annulus fibrosus. 

2. Nerve extension was found into the nucleus pulposus of the degenerated disc. 

3. The sinuvertebral nerve plexuses facilitate a polysegmental signal and pain spreading. 

4. The innervation of the intervertebral disc is very high connected with the paravertebral muscles. 

5. A local denervation of the paravertebral muscles was found in post-discotomy syndrome.

1. 추간판은 광범위한 신경지배를 받음. 특히 섬유륜에

2. 신경확장은 퇴행성 디스크의 수핵에서 발견됨. 

3. 동추골신경총은 다분절 신호와 통증 확장을 촉진함.

4. 추간판의 신경지배는 척추옆 근육과 매우 밀접하게 연결됨.

5. 척추옆 근육의 국소적 탈신경은 디스크 수술후 증후군에서 흔히 발견됨. 

panic bird..

The discogenic pain.pdf

26-the-nerve-supply-of-the-lumbar-intervertebral-disc.raw.pdf

Eur Spine J. 2008 Dec;17 Suppl 4:428-31. Epub 2008 Nov 13.

Resolving discogenic pain.

Takahashi K, Aoki Y, Ohtori S.

Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuoku, Chiba, Chiba, 260-8677, Japan. 19501114@faculty.chiba-u.jp

Abstract

Recent basic science studies on discogenic low back pain have provided new knowledge about this condition. This paper reviews some of these results and presents an overview of the following findings. The rat lumbar intervertebral disk may be innervated non-segmentally through the paravertebral sympathetic nerve and segmentally through the sinuvertebral nerves, and also by dichotomizing sensory fibers. The exposure of the nucleus pulposus (NP) to the outer annulus fibrosus (AF) may induce nerve injury and ingrowth into the disk. Nerve growth factor (NGF)-sensitive neurons are predominant in the rat intervertebral disk, which indicates that hyperalgesic responses can be induced by inflammation. NGF in the NP may promote axonal growth. Lumbar fusion may inhibit nerve ingrowth into the degenerated disk and reduce the percentage of calcitonin gene related peptide (CGRP)-positive neurons.

- 디스크 기원성 아래허리 통증에 대한 최신의 논문은 새로운 지식을 제공함. 

- 이 논문은 이러한 연구결과에 대해서 리뷰함. 

- 쥐 허리디스크는 non-segmentally 척추옆 교감신경을 통해 지배되고, segemntally 동추골신경을 통해 지배됨. 또한 두개로 나누어진 감각신경에 의해서 지배받음. 

- 수핵에서 바깥쪽 섬유륜의 노출은 신경손상을 유도하고, 디스크에 신경 ingrowth가 발생함. 

- nerve growth factor  민감성 뉴런은 추간판에 우세하고, 그것은 염증에 의해서 유도되는 통각과민 반응을 야기함. 

- 수핵에서 NGF는  axonal growth를 촉진할 수 있음. ...

Z Orthop Ihre Grenzgeb. 2004 Nov-Dec;142(6):706-8.

[Neuroanatomic basis for discogenic pain]

[Article in German]

Faustmann PM.

Abteilung fur Neuroanatomie und Molekulare Hirnforschung, Ruhr-Universitat Bochum. pedro.faustmann@rub.de

Abstract

AIMS: The aim of this study is to give a short overview about the innervation of the intervertebral disc and the nerve connections between the somatosensible and autonomous nervous systems in the paravertebral region. 

METHODS: A short review of the clinical and experimental literature including gross-anatomical, histochemical and immunohistochemical studies as well as functional studies after application of tracer substances has been made. We also present our own experimental immunohistochemical and molecular biological investigations on paravertebral muscle biopsies of a patient with post-discotomy syndrome. 

RESULTS: The annulus fibrosus of the intervertebral disc is innervated by myelinated nerve fibres. Neuronal markers for pain-leading fibres were found to be positive in the dorsal region of the annulus, and especially in the posterior longitudinal ligament. Nerve ingrowth into the diseased intervertebral disc was found in chronic back pain. The main innervation of the intervertebral disc is formed by the sinuvertebral nerves. The sinuvertebral nerves are recurrent branches of the ventral rami that re-enter the intervertebral foramina to be distributed within the vertebral canal. They are mixed polysegmental nerves and nerve plexuses, each being formed by a somatic root from a ventral ramus and an autonomic root from a grey ramus communicans. The number of nerve bundles was reduced by resection of sympathetic trunks. The expression‎ of neuronal markers in the sarcolemma of the paravertebral muscles is reduced after discotomy. 

CONCLUSIONS: The neuroanatomical basis of discogenic pain can be summarised as follows: 

1. The intervertebral disc receives an extensive innervation, especially the annulus fibrosus. 

2. Nerve extension was found into the nucleus pulposus of the degenerated disc. 

3. The sinuvertebral nerve plexuses facilitate a polysegmental signal and pain spreading. 

4. The innervation of the intervertebral disc is very high connected with the paravertebral muscles. 

5. A local denervation of the paravertebral muscles was found in post-discotomy syndrome.

1. 추간판은 광범위한 신경지배를 받음. 특히 섬유륜에

2. 신경확장은 퇴행성 디스크의 수핵에서 발견됨. 

3. 동추골신경총은 다분절 신호와 통증 확장을 촉진함.

4. 추간판의 신경지배는 척추옆 근육과 매우 밀접하게 연결됨.

5. 척추옆 근육의 국소적 탈신경은 디스크 수술후 증후군에서 흔히 발견됨. 

J Bone Joint Surg Br. 2007 Sep;89(9):1135-9.

The nerve supply of the lumbar intervertebral disc.

Edgar MA.

Surgery UCL, UCLH, Emmanuel Kaye House, 37a Devonshire Street, London W1G 6QA, UK. hornbeams@googlemail.com

Erratum in:

• J Bone Joint Surg Br. 2008 Apr;90(4):543.

Abstract

The anatomical studies, basic to our understanding of lumbar spine innervation through the sinu-vertebral nerves, are reviewed. Research in the 1980s suggested that pain sensation was conducted in part via the sympathetic system. These sensory pathways have now been clarified using sophisticated experimental and histochemical techniques confirm‎ing a dual pattern. One route enters the adjacent dorsal root segmentally, whereas the other supply is non-segmental ascending through the paravertebral sympathetic chain with re-entry through the thoracolumbar white rami communicantes. 

- 1980년 제안된 동추골 신경지배에 대한 리뷰논문

- 감각전달로는 정교한 실험과 조직학적 기술로 확인됨. 

- 하나의 길은 인접 dorsal root segmentally이고, 다른 하나는 non-segmental ascending 경로임. 이는 paravertebral sympathetic chain을 통함. 

Sensory nerve endings in the degenerative lumbar disc penetrate deep into the disrupted nucleus pulposus, insensitive in the normal lumbar spine. Complex as well as free nerve endings would appear to contribute to pain transmission. The nature and mechanism of discogenic pain is still speculative but there is growing evidence to support a 'visceral pain' hypothesis, unique in the muscloskeletal system. This mechanism is open to 'peripheral sensitisation' and possibly 'central sensitisation' as a potential cause of chronic back pain.

- 퇴행성 디스크에서 감각신경 종말은 파열된 수핵으로 깊이 들어감. 

- 디스크 기원성 통증의 기전은 여전히 명확하지 않지만 visceral pain 통증 가설을 지지하는 방향으로 증거가 모이고 있음. 

- 이 기전은 말초 감작과 중추감작이 만성요통의 가능성있는 원인으로 제기됨.

Systematic review of diagnostic utility and therapeutic effectiveness of cervical facet joint interventions.

Falco FJ, Erhart S, Wargo BW, Bryce DA, Atluri S, Datta S, Hayek SM.

Mid Atlantic Spine & Pain Specialists, Newark, DE 19713, USA. cssm01@aol.com

Abstract

BACKGROUND: Chronic, recurrent neck pain is common and is associated with high pain intensity and disability, which is seen in 14% of the adult general population. Controlled studies have supported the existence of cervical facet or zygapophysial joint pain in 36% to 67% of these patients. However, these studies also have shown false-positive results in 27% to 63% of the patients with a single diagnostic block. There is also a paucity of literature investigating therapeutic interventions of cervical facet joint pain. 

STUDY DESIGN: A systematic review of cervical facet joint interventions. 

OBJECTIVE: To eval‎uate the accuracy of diagnostic facet joint nerve blocks and the effectiveness of cervical facet joint interventions. 

METHODS: Medical databases and journals were searched to locate all relevant literature from 1966 through December 2008 in the English language. A review of the literature of the utility of facet joint interventions in diagnosing and managing facet joint pain was performed according to the Agency for Healthcare Research and Quality (AHRQ) criteria for diagnostic studies and observational studies and the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials. 

LEVEL OF EVIDENCE: The level of evidence was defined as Level I, II, or III based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). 

OUTCOME MEASURES: For diagnostic interventions, studies must have been performed utilizing controlled local anesthetic blocks which achieve at minimum 80% relief of pain and the ability to perform previously painful movements. For therapeutic interventions, the primary outcome measure was pain relief (short-term relief up to 6 months and long-term relief greater than 6 months) with secondary outcome measures of improvement in functional status, psychological status, return to work, and reduction in opioid intake. 

RESULTS: Based on the utilization of controlled comparative local anesthetic blocks, the evidence for the diagnosis of cervical facet joint pain is Level I or II-1. The indicated evidence for therapeutic cervical medial branch blocks is Level II-1. The indicated evidence for radiofrequency neurotomy in the cervical spine is Level II-1 or II-2, whereas the evidence is lacking for intraarticular injections. 

LIMITATIONS: A systematic review of cervical facet joint interventions is hindered by the paucity of published literature and lack of literature for intraarticular cervical facet joint injections. 

CONCLUSIONS: The evidence for diagnosis of cervical facet joint pain with controlled comparative local anesthetic blocks is Level I or II-1. The indicated evidence for therapeutic facet joint interventions is Level II-1 for medial branch blocks, and Level II-1 or II-2 for radiofrequency neurotomy.

Eval‎uation of sacroiliac joint interventions: a systematic appraisal of the literature.

Rupert MP, Lee M, Manchikanti L, Datta S, Cohen SP.

Vanderbilt Interventional Pain Center, Cool Springs, Cool Springs Surgery Center, Franklin, TN 37067, USA. mattrupert@comcast.net

Abstract

BACKGROUND: The sacroiliac joint has been implicated as a source of low back and lower extremity pain. There are no definite historical, physical, or radiological features that can definitively establish a diagnosis of sacroiliac joint pain. Based on the present knowledge, an accurate diagnosis is made only by controlled sacroiliac joint diagnostic blocks. The sacroiliac joint has been shown to be a source of pain in 10% to 27% of suspected patients with chronic low back pain utilizing controlled comparative local anesthetic blocks.

 STUDY DESIGN: A systematic review of diagnostic and therapeutic sacroiliac joint interventions. 

OBJECTIVE: To eval‎uate the accuracy of diagnostic sacroiliac joint interventions and the utility of therapeutic sacroiliac joint interventions. 

METHODS: The literature search was carried out by searching the databases of PubMed, EMBASE, and Cochrane reviews. Methodologic quality assessment of included studies was performed using the Agency for Healthcare Research and Quality (AHRQ) methodologic quality criteria for diagnostic accuracy and observational studies, whereas randomized trials were eval‎uated utilizing the Cochrane review criteria. Only studies with scores of 50 or higher were included for assessment. Level of evidence was based on the U.S. Preventive Services Task Force (USPSTF) criteria. 

OUTCOME MEASURES: For diagnostic interventions, the outcome criteria included at least 50% pain relief coupled with a patient's ability to perform previously painful maneuvers with sustained relief using placebo-controlled or comparative local anesthetic blocks. For therapeutic purposes, outcomes included significant pain relief and improvement in function and other parameters. Short-term relief for therapeutic interventions was defined as 6 months or less, whereas long-term effectiveness was defined as greater than 6 months. 

RESULTS: The indicated level of evidence is II-2 for the diagnosis of sacroiliac joint pain utilizing comparative, controlled local anesthetic blocks. The preval‎ence of sacroiliac joint pain is estimated to range between 10% and 38% using a double block paradigm in the study population. The false-positive rate of single, uncontrolled, sacroiliac joint injections is 20% to 54%. The evidence for provocative testing to diagnose sacroiliac joint pain is Level II-3 or limited. For radiofrequency neurotomy the indicated evidence is limited (Level II-3) for short- and long-term relief. 

LIMITATIONS: The limitations of this systematic review include the paucity of literature eval‎uating the role of both diagnostic and therapeutic interventions and widespread methodological flaws. 

CONCLUSIONS: The indicated evidence for the validity of diagnostic sacroiliac joint injections is Level II-2. The evidence for the accuracy of provocative maneuvers in the diagnosing of sacroiliac joint pain is limited (Level II-3). The evidence for radiofrequency neurotomy is also limited (Level II-3).

PMID: 19305487 [PubMed - indexed for MEDLINE]Free Article

[문형철]

“Normal nucleus pulposus and inner annular zones are devoid of nerves.” The three outer lamellae of the disc are innervated with nociceptive afferents. However, nerves can extend to the inner third in 50% of painful degenerative discs. These nerves arise from granulation tissue growing into the degenerative disc, “neo-innervation.”

정상적인 수핵과 섬유륜의 안쪽에서는 신경의 분포가 없다.디스크의 바깥 3개정도의 lamellae 정도만이 감각신경 섬유가 분포되어 있다.그러나 통증을 유발하는 퇴행성 디스크에서는 50%정도에서 그보다 더 안쪽으로 신경이 분포되어 있는데 이러한 현상을 neo-innervation이라고