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Lumbar primary dorsal branch L5
Bogduk & Long 1979
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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…
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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
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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
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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
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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
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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.
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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