Osteopathic Journals and Research by Darren Chandler

 

entrapment neuropathies causing low back and pelvic pain

Posted on

0 Comments

Introduction

A common clinical presentation in patients with low back pain is pain around the region of the posterior superior iliac spine (PSIS) and buttocks. Amongst other conditions various local entrapment neuropathies in the soft tissue can account for these symptoms. Some of these entrapment neuropathies have been well documented and others due to observations on dissection could be a potential site of a double crush syndrome.

The proposed sites of entrapment of the L5 and sacral rami giving PSIS and buttock pain are (from above down):

  • External transforaminal ligaments of the lumbosacral spine.
  • Psoas Major.
  • Osteofibrous tunnel (formed by the thoracolumbar fascia and iliac crest).
  • Lumbosacral ligament.
  • L5 to sacral multifidus muscle.
  • Long dorsal sacroiliac ligament.
  • Between the thoracolumbar composite and sacrotuberous ligament.
  • Potentially the sacroiliac joint.

Firstly the individual unique peculiarities of the anatomy of the muscles, ligaments, fascia and nerves are covered. Then these peculiarities in relation to the anatomy of various nerves in the Lumbar and Sacral rami are discussed regarding osteopathic practise.

Essentially most of the anatomical courses and relation of various structures are illustrated in the diagrams. The real value of the text is to illustrate how these structures are adhered to each other to get a better appreciation of their potential implications.

For instance when palpating the sacrum it’s easy to forget you’re palpating soft tissue as it’s so dense and tightly attached to the bone. When dissecting the multifidus over the sacrum, carefully moving one layer at a time, the sacral rami are so tightly adhered to the muscle bits of the nerve come off in the substance of the mutifidus (Cox & Fortin 2014). This level of detail which is important when reviewing the possible causes of an entrapment neuropathy of these sacral rami in causing sacroiliac joint pain can’t be illustrated in a diagram.

Muscular anatomy

Psoas Major

  • Psoas Major fibers run from the transverse processes and interverterbral discs of the lumbar spine (except the L5-S1 disc) to the lesser trochanter.
  • Lumbosacral plexus lies in the substance of the Psoas Major between the transverse process and vertebral body.
  • Lumbosacral plexus exits along the medial edge of the Psoas Major distally.
  • Superior Cluneal nerve passes through the Psoas Major.

The Psoas Major stabilises the lumbar lordosis by pulling L1-2 and L2-3 into extension, L3-4 and L4-5 downwards into compression and L5-S1 into flexion (Penning 2000). This creates a shear force at L5-S1.

Benglis et al (2009) found the lumbosacral plexus to lie in the substance of the Psoas Major between the transverse process and vertebral body exiting it distally along the medial edge of this muscle.

Tubbs et al (2010) found the Superior Cluneal nerve to pass through the Psoas Major and paraspinal muscles running posterior to the Quadratus Lumborum.

Erector Spinae

  • Iliocostalis and spinalis sections of the erector spinae fuse in the lower lumbar spine to form the transversospinalis.
  • The aponeurosis of the erector spinae muscle receives strong attachments from the multifidus.

The general rule of thumb with the erector spinae (as well as its investing fascia) is the lower down it goes the more densely fused it becomes.

Willard et al (2012) describes the two most lateral muscles of the erector spinae group often fused in the lower lumbar and sacral levels to be termed the ‘sacrospinalis muscle’.

These paraspinal muscles are completely covered by the dense erector spinae aponeurosis. Willard et al (2012) describes this aponeurotic band as extending laterally to approximately the inferior border of L3 while medially it extends further into the thoracic region. Williams & Warwick (1980) describes the aponeurosis as attached medially to the sacral crest and the spinous process from L5 to T11 (and the supraspinous ligament), medial part of the iliac crest and the lateral sacral crest where it blends with the dorsal sacroiliac ligament, sacrotuberous ligament and with some fibers running continuous with the Gluteus Maximus.

McGrath and Nicholson (2009) attributed the erector spinae aponeurosis, and not the 'thin' sacral thoracolumbar fascia, as providing a functional link between the upper and lower extremities.

Creze et al (2018) found the erector spinae to be formed of regular longitudinal orientated connective tissue fibers.

Being named the erector spinae aponeurosis would suggest when the erector spinae contracts the aponeurosis contracts. However the multifidus strongly attaches to the inner surface of this aponeurosis giving it the potential to exert a direct line of pull (Willard et al 2012). Creze et al (2018) found the superficial fibers of the multifidus to be attached to the erector spinae aponeurosis at the midline in the lumbar spine and at the sacral levels. It would therefore be more apt to name this aponeurosis ‘the erector spinae-multifidus aponeurosis’.

Multifidus

  • Multifidus attaches on to the PSIS and dorsal sacroiliac ligament.
  • Medial branches of the sacral dorsal rami attach to the Multifidus.

The Multifidus arises from the spinous process of L5 to as low as the fourth sacral foramen, PSIS and dorsal sacroiliac ligament. The longest fibers of the Multifidus run from the spinous processes of L1 and L2 to the dorsal segment of the iliac crest.

Along with being tightly adhered to the erector spinae aponeurosis at the lumbar (close to the midline) and sacral levels (Creze et al 2018) the sacral attachment of the multifidus is also tightly adhered to the medial branches of the sacral dorsal rami. To illustrate how tight this adherence is when the multifidus was removed piecemeal many of these nerves were removed along side with it (Cox & Fortin 2014).

Johnson and Zang (2002) found the multifidus, longissimus thoracis and thoracolumbar fascia as contributers to the supraspinous and interspinous ligaments. 

Piriformis

  • Piriformis attaches from S2-4 and the fascial origin at the anterior sacroiliac joint to the greater trochanter and hip joint capsule.
  • Piriformis is in contact with S1-3 nerve roots and S1 nerve.
  • Piriformis can cause an entrapment neuropathy of the superior gluteal nerve causing low back pain at it innervates the sacroiliac joint. It is also associated with sciatic symptoms.

The Piriformis muscle arises from S2-4. There is also a fascial origin arising from the capsule of the sacroiliac joint whose fibres pass inferiorly rather than laterally. This brings the Piriformis in contact with the anterior ligament of the sacroiliac joint and the S1-3 nerve roots (Han et al 2017). The first sacral nerve is located just behind the layer of parietal fascia covering the piriformis (Florian-Rodriguez et al 2017).

Spanning the pelvis the Piriformis attaches to the summit and medial aspect of the greater trochanter as well as having variable attachments to the fibrous capsule of the hip joint (Roche et al 2013). 

The Piriformis forms a canal with the gemellus superior through which the sciatic nerve passes (Lewis et al 2016). It is enclsoed by a common sheath and is supported by the Piriformis just behind where the sacrospinous ligament attaches to the ischial spine (Hernando et al 2015).

Simonova (1979) claimed the suprapiriform canal should be considered a fascial osseous canal. It is formed by the upper margin of the greater sciatic notch being covered with a thin fascia, fascia of the gluteal and Piriformis muscles and the parietal layer of the pelvic fascia. The proper fascial vaginae(*) of the upper gluteal vessels and nerves are adhered to the fascial walls of the canal.

*: this presumably relates to the fascia of the blood vessels as vaginae can be defined as a sheath-like structure, especially a sheath formed around a stem.

Containing the superior gluteal nerve Diop et al (2002) found hypertrophy of the Piriformis can narrow this tight fascial suprapirifom canal and cause superior gluteal nerve entrapment.

With the relations of the S1-3 nerve roots (Han et al 2017) and S1 nerve (Florian-Rodriguez et al 2017) to the Piriformis could there be a potential for an entrapment neuropathies of these nerves in causing low back pain?

Fascia anatomy

Only the relevant anatomy of the fascia is discussed here in relation to entrapment neuropathies.

Paraspinal Reticular Sheath (PRS) and Thoracolumbar Composite (TLC)

  • PRS (or vertebral aponeurosis) is the deep layer of the posterior thoracolumbar fascia enclosing the paraspinal muscles.
  • The TLC is the lower part of the PRS in the pelvis.
  • The TLC is a fusion of the thoracolumbar fascia, aponeurosis of the erector spinae and mutlifidus.
  • The TLC is the “soft tissue” you’re palpating when palpating the sacrum and PSIS.

PRS

The thoracolumbar fascia is typically described as consisting of three layers in the lumbar region.

  • Anterior layer: attaches to the lumbar transverse processes. Covers the quadratus lumborum.
  • Middle layer: attaches to the tips of the lumbar transverse processes. Gives rise to the transverse abdominis and internal oblique aponeurosis.
  • Posterior layer: attaches to the spinous processes and median sacral crest. Covers the deep back muscles. The posterior layer ascends from the pelvis and sacrotuberous ligament, covering the erector spinae, ascending to the inferior boarder of the serratus posterior inferior. Here it splits into the superficial and deep lamina encircling the aponeurosis of the serratus posterior inferior (Schuenke et al 2012). The superficial lamina provides attachments for the latissimus dorsi and serratus posterior inferior. The superficial part of the thoracolumbar fascia is the part that gives rise to the latissimus dorsi and serratus posterior inferior. The PRS is the deep part of the posterior lumbar fascia that encircles the paraspinal muscles up the spine. The vertebral aponeurosis is the posterior wall of the PRS in the thoracic region starting from where the PRS splits deep to the serratus posterior inferior (Willard et al 2012). 

Superficial layer of the posterior thoracolumbar fascia

The origin of the superficial lamina is the gluteus maximus fascia. It attaches to the spinous processes and the median sacral crest. It fuses with the aponeurosis of the latissimus dorsi and serratus posterior inferior. Fibers of the superficial lamina can, in cases, ascend to be continuous with the aponeurosis of the trapezius muscle (Loukas et al 2008).

Deep layer of the posterior thoracolumbar fascia (aka the PRS) and vertebral aponeurosis

The PRS is attached medially to the spinous processes of the lumbar and thoracic vertebrae and the median sacral crest; laterally to the angles of the ribs; anteriorly it runs continuous with the aponeurosis of the transverse abdominis and internal oblique (via middle layer of the thoracolumbar fascia and lateral raphe), blends with the iliolumbar ligaments and ventral sacroiliac joint capsule; superiorly it run deep to the serratus posterior superior to cover the splenius capitis and blend with the deep fascia of the neck.

Bogduk & Macintosh (1984) found the PRS to form a series of accessory posterior ligaments that runs from the L2 to L5 spinous processes to the ilium. These accessory ligaments resist flexion. This all enables the muscles to tense the PRS and stabilize the Lumbar spine and pelvis. 

The vertebral aponeurosis is the posterior wall of the PRS in the thoracic region (Willard et al 2012). Therefore anatomically it's the same structure. It is not an aponeurosis in the true sense of the term as it has no muscular component (Loukas et al 2008).

Being the posterior wall of the PRS Loukas et al (2008) identified the vertebral aponeurosis deep to the latissimus dorsi and blending with the superficial lamina of the thoracolumbar fascia at the serratus posterior inferior. The authors also identified the thoracic attachments of the PRS/vertebral aponeurosis as the thoracic spinous processes and rib angles.

Being part of the the PRS Loukas et al (2008) found the vertebral aponeurosis to blend cephalad deep to the serratus posterior superior and splenius capitis with the deep cervical fascia; caudad to run over the erector spinae to blend with the sacrotuberous ligament.

Loukas et al (2008) hypothesized the PRS/vertebral aponeurosis, due to its association with the serratus posterior inferior, may also play a role in proprioception as this muscle has been implicated in this function.

TLC

Below L5 the PRS changes its name to the ‘thoracolumbar composite’ (TLC). Anatomically it is the same structure although it becomes far more dense and tightly adhered to its surrounding structures.

Willard et al (2012) gives an anatomical description of this TLC. He describes it as being a fusion at or below the level of L5 of:

  • the thoracolumbar fascia.
  • aponeurosis of the erector spinae and multifidus muscles.

McGrath and Nicholson (2009) disputed the fusion of the thoracolumbar fascia to the erector spinae aponeurosis. They found this layer of thoracolumbar fascia forms a thin fascial structure that also does not attach to the LDSL. Willard et al (2012) however claimed the sacral thoracolumbar fascia and erector spinae aponeurosis was fused and this fusion forms a thick composite. This composite attaches to the PSIS spreading caudolaterally to join the gluteus maximus and terminating by covering the sacrotuberous ligament. Distally the TLC receives attachments from the biceps femoris, semimembranosus and semitendinosus muscles.

Vleeming et al (2012) states about the TLC “while palpating the upper part of the sacrum lateral of the spinous processes, this composite of structures can give the impression of feeling hard bone. This could mistakenly suggest that it is the sacrum itself that can be directly felt, instead of the tight fascial and tendinous composite enclosing the multifidus and sacrospinalis muscles”.

Ligamentous anatomy

Iliolumbar ligaments

  • Blends with the PRS.
  • The PRS and iliolumbar ligaments blends with the ventral sacroiliac joint capsule.

The iliolumbar ligament runs from L5 (sometimes L4) to the sacrum and ilium. Because of variations in its anatomical attachments to the L5 transverse process sometimes the lumbosacral ligament is termed an iliolumbar ligament. The iliolumbar ligament blends with the ventral sacroiliac ligaments and anterior portions of the PRS.

These ligaments are subject to fatty degeneration after the first decade of life and potentially ossification.

Lumbosacral ligament

  • Extends anteriorly from L5 vertebral body (or transverse process) to the sacrum.
  • Hypertrophies in response to instability.
  • 'Squashes' the L5 nerve root between the ligament anteriorly and sacrum posteriorly (Lumbosacral tunnel syndrome).
  • The sympathetic ramus communicans to the L5 nerve root pierces and can become tethered in the lumbosacral ligament.
  • The perineurium of the L5 nerve root has adhesions to the periosteum of the sacrum potentially causing a double crush syndrome with Lumbosacral tunnel syndrome.
  • Tarsal tunnel syndrome can be associated with Lumbosacral tunnel syndrome and can act as a double crush syndrome.

Variations in the anatomy of the lumbosacral ligaments

The anatomical attachments of the lumbosacral ligament to L5 and the sacrum can vary.

L5 attachments can be:

  • Antero-inferior aspect of the L5 transverse process (costal process) (Hanson & Sorensen 2000).
  • L5 vertebral body and transverse process of L5 (Protas et al 2017).
  • L5 vertebral body (Protas et al 2017).
  • L5 pedicle (Hanson & Sorenson 2000). 

Sacrum attachments can be:

  • Ala of the sacrum (Hanson & Sorenson 2000).
  • Sacral promontory (Hanson & Sorenson 2000).

The lumbosacral ligament can, in some cases, be attached by a thin fascia to the iliolumbar ligament, ventral sacroiliac ligament and/or L5 nerve root (Hanson & Sorenson 2000).

Hanson & Soreen (2000) determined from the position of the ligament its primary mechanical function is to restrict contralateral lateral flexion and probably also extension.

Lumbosacral tunnel syndrome

The lumbosacral ligament forms, with its attachments to L5 and the sacrum, an osteofibrotic tunnel as an extension of the intervertebral foramen (Nathan et al 1982). Although this tunnel is not a constant finding (Hanson & Sorenson 2000).

The 5th lumbar nerve root passes through the L5-S1 intervertebral foramen and through this tunnel formed by the ala of the sacrum posteriorly and the lumbosacral ligament anteriorly (lumbosacral tunnel).

A branch of the 4th lumbar nerve root passes in front of the lumbosacral ligament to join the 5th below the ligament to form the lumbo-sacral trunk.

The sympathetic ramus communicans to the L5 root always penetrates the lumbosacral ligament at its superior border and reaches the nerve inside the lumbosacral tunnel. Protas et al (2017) found the piercing of the rami communicants through the lumbosacral ligament forms a tethering point between the L5 ventral ramus and adjacent sympathetic trunk.

Protas et al (2017) defined lumbosacral tunnel syndrome (LSTS) as a narrowing of the lumbosacral tunnel leading to compression of the L5 nerve root against the ala of the sacrum, causing radiculopathy.

To complicate the mechanical predisposition of the L5 nerve root to injury Kelihues et al (2001) found the perineurium of the L5 nerve root to have adhesions to the periosteum of the sacrum. This made the nerve root manually undetachable. These adhesions were found to be located at the level between the ilium attachments of the iliolumbar ligament and the sacral attachment of the lumbosacral ligament.

Clinically LSTS can be associated with Tarsal Tunnel Syndrome (Protas et al 2017) potentially forming a double crush syndrome.

Symptoms of LSTS are L5 radiculopathy with normal strength and no signs of muscle atrophy.

Long Dorsal Sacroiliac Ligament

  • Blends with the TLC, erector spinae (& Multifidus) aponeurosis and sacrotuberous ligament.
  • Sacral rami can either run through tunnels in the LDSL, over the LDSL or under the LDSL.

The long dorsal sacroiliac ligament (LDSL) runs from the sacrum to the PSIS and the inner lip of the dorsal part of the iliac crest. This ligament can either be penetrated by the sacral rami (McGrath & Zhang 2008) or have the nerves run underneath or over it (Konno et al 2017). There is a wide-ranging variation among fibers of the LDSL, being connected to (Vleeming et al 2012):

  • The deep lamina of the posterior lumbar fascia.
  • Aponeurosis of the erector spinae muscle and multifidus muscle.
  • Blending distally into the sacrotuberous ligament.

Traditionally lip service has been paid to these attachments of the LDSL but on dissection it must be remembered that these attachments are through the tough dense connective tissue sheaths of the TLC (Willard et al 2012).

Sacrotuberous Ligament

  • Acts as a caudal attachment for the TLC.
  • This attachment forms tunnels the nerves to the sacral rami run through.

Anatomically the sacrotuberous ligament (STL) runs from the sacrum to the ischial tuberoisity. For the purposes here it is merely a terminal anchorage for the TLC so functionally it is a continuation of this structure.

The attachment of the TLC to the sacrotuberous ligament creates another tunnel that nerves from the sacral rami run through (Willard et al 1998).

External transforaminal ligaments lumbosacral spine

Several external transforminal ligaments exist in the lumbosacral spine but of particular importance is the corpotransvere ligament (Amonoo-Kuofi et al 1988). This ligament passes obliquely downwards, forwards and medially from the inferior aspect of the accessory process of the fifth lumbar vertebra to the lateral surface of the intervertebral disc and the adjacent parts of the bodies of the L5 and S1.

It has been proposed that changes in this ligament could be responsible for compression of the L5 nerve root (Kuofi et al 1988 & Maric et al 2015). This was confirmed by Qian et al (2011) who proposed entrapment of the nerve roots by transforaminal ligaments secondary to loss of intervertebral disc height whereby the ligament lowers down or pathological changes to the ligament itself.

Superficially, the ligament is related to another flat band - the lumbosacral hood (Kuofi et al 2015). Together these ligaments separate and provide openings for the sympathetic ramus, the ventral ramus and blood vessels related to the intervertebral foramen.

L4 & L5 nerve root

The L5 nerve root can course through the lumbosacral tunnel (between the sacrum posteriorly and lumbosacral ligament anteriorly). The L4 nerve root passes in front of the lumbosacral ligament. The L4 and L5 nerve root unite below the level of the Lumbosacral ligament to form the lumbosacral trunk. Ebraheim et al (1997) found the L5 nerve root and lumbosacral trunk coursed across the sacroiliac joint and was relatively fixed to the sacral ala with fibrous connective tissue. 

Anatomy of dorsal lumbar rami

  • Dorsal lumbar rami divides into medial and lateral branches within the intertransverse ligaments (an extension of the middle lamina of the TLF).
  • Medial branch of the dorsal rami innervates the facet joints and Multifidus.
  • Lateral branch of L5 dorsal ramus joins the S1 dorsal ramus ?contributes to S1 dorsal ramus pain.

Dorsal rami

Spinal cord --> dorsal root (sensory) & ventral root (motor) --> spinal nerve (mixed sensory & motor) --> ventral rami (motor > sensory) & dorsal rami (sensory > motor). Dorsal rami --> medial branch of dorsal rami & lateral branch of dorsal rami.

Bogduk and Long (1979) and Masini et al (2005) found the L1-L4 dorsal rami to divide into the medial and lateral branches within the intertransverse ligament (an extension of the middle laminae of the TLF).

Dorsal rami: medial branch

The medial branch of the dorsal rami passes through a groove formed between the root of the transverse process and root of the superior articular process. At this point Bogduk et al (1982) found the medial branch bound to the periosteum by connective tissue extending between the superior articular process and transverse process.

The medial branch of the dorsal rami then passes through a fibroosseous canal formed by the junction of the transverse process and the lateral aspect of the superior articular process. The roof of the canal is formed by the mammilloaccessory ligament. 

The medial branch of the dorsal rami then penetrates the deep fascia near the median line to enter the subcutaneous tissue.

The medial branch of the dorsal rami innervates:

  • Facet joints: innervates the two to three adjacent facet joints e.g. the L4 facet joint is innervated by the L3 and L4 medial branches. To innervate the facet joint the proximal nerve runs between the intertransversarii and the most lateral fibres of multifidus; the distal nerve runs deep to the multifidus (Bogduk et al 1982).
  • Multifidus: Shuang et al (2015) found this innervation to be highly specific. They found each medial branch ran on the deep aspect of the multifidus and was solely innervated by this one branch without any communicating branches. This finding was disputed by Wu et al (1997) who found the multifidus to be polysegmentally innervated.
  • Interspinous ligament and muscle: the nerve weaves medially between the fascicles of the multifidus to reach the interspinous space (Bogduk et al 1982).
  • Supraspinous ligament.

Dorsal rami: lateral branch

The lateral branch of the lumbar dorsal rami innervates the tissues lateral to the zygapophysial joint line i.e. erector spinae and cutaneous innervation of the back and pelvis.

The lateral branch of the L5 dorsal ramus descends and merges into the S1 dorsal ramus (Zhou et al 2012). Bogduk et al (1982) described the L5 dorsal rami as lacking a lateral branch dividing into medial and intermediate branches. This was due to the absence of an attachment of the iliocostalis to L5 that was replaced by the iliolumbar ligament.

However both these authors also described the intermediate branch (Bogduk et al 1984) and lateral branch (Zhou et al 2012) of the L5 dorsal ramus as innervating the Longissimus Thoracics as it attaches to the medial aspect of the dorsal segment of the iliac crest.

Dorsal rami: intermediate branch

The intermediate branch of the dorsal rami is commonly viewed as the muscular branch of the lateral dorsal rami.

The L3 and L4 dorsal rami (and sometimes L1 and L2) give off intermediate branches which supply the lumbar fibers of the longissimus thoracis (Zhou et al 2012).

Anatomy of the dorsal sacral rami

  • Middle cluneal nerve comprises of afferent nerves of the dorsal rami of the S1&2 > - S4 foramina supplying the skin of the posteromedial area of the buttock.
  • Responsible for gluteal and sacroiliac joint pain.
  • Covered and adhered to the multifidus and TLC.
  • Nerves run through the LDSL and between the STL and TLC.

S1-4 not S5 arises from the dorsal sacral foramina. The S1-4 dorsal rami, that form the middle cluneal nerve, are covered by the multifidus and a dense fascial composite (TLC). From here they divide into medial and lateral branches.

The medial branches end in the multifidus and the dense fascia (TLC). The lateral branches join with each other along with branches from the L5 and S4 rami.

The nerves run from the PSIS to the coccyx either through (McGrath & Zhang 2008), beneath or over (Konno et al 2017) the long dorsal sacroiliac ligament (along with minute blood vessels potentially creating ischaemic zones Willard et al 1998) and Gluteus Maximus (Williams & Warwick, 1980). Kikuta et al (2020) found they pierced the gluteus maximus by two different pathways and supplied the gluteal skin or the gluteus maximus muscle. They then run through a tunnel created by the sacrotuberous ligament internally and an outer sheath of TLC (Willard et al 1998).

The levels at which the lateral branches of the dorsal sacral rami typically penetrate the LPSL are:

 

S1

4%

S2

96%

S3

100%

S4

59%

(McGrath & Zhang 2005)

Clinically entrapment of these nerves can cause sacroiliac joint pain. Interestingly when Murakami et al (2007) compared the effects of blocking injections into the sacroiliac joint and around the LPSL in patients with sacroiliac joint pain 100% got relief by blocking the LPSL and only 9 out of the 25 patients got relief from the intraarticular injection.

Anatomy of the superior cluneal nerve & osteofibrous tunnel

The superior cluneal nerve is a cutaneous branch of the T12 to L5 nerve roots. A high percentage of the dorsal rami of L1-L3 contribute to the superior cluneal nerve. Iwanaga et al (2019) found it to be at L1: 75% of the dorsal rami; L2: 90% of the dorsal rami; L3: 95% of the dorsal rami; L4: 45% of the dorsal rami; L5: 10% of the dorsal rami.

The nerve penetrates the psoas major and paraspinal muscles. It traverses through the superficial layer of thoracolumbar fascia before crossing the posterior iliac crest or through the gluteal fascia. After crossing the iliac crest it supplies the skin overlying the upper half of the gluteus muscles (Konno et al 2017). 

When the medial branch of the superior cluneal nerve penetrates the gluteal fascia, the nerve passes through a space surrounded by the iliac crest and the fascia attached to the iliac crest, the so called “osteofibrous tunnel.” Predominantly it’s the L4 and L5 lateral branches that run through the osteofibrous tunnel (Konno et al 2017).

Lu et al (1998) found the medial branch of the superior cluneal nerve is confined within the osteofibrous tunnel but the intermediate and lateral branches of the superior cluneal nerve either pierces the thoracolumbar fascia or passes through an orifice or fissure in the thoracolumbar fascia.

The mean distance from the PSIS to the osteofibrous tunnel was 40.8mm (Konno et al 2017).

Sacroiliac joint and potential neuropathies

  • Anteriorly and posteriorly the sacroiliac joint is closely related to lumbosacral trunk, obturator nerve and sacral rami.
  • The sacroiliac joint allows a "leakage" of fluid anteriorly and posteriorly through defects in the joint capusle.
  • Could this "leakage" of fluid include inflammation causing a neuropathy through irritation of the nerves or tightening of connective tissue? Could this account for the variety of sacroiliac joint referred pain patterns?

The ventral sacroiliac joint capusle relates closely to the nerve fibers of the lumbosacral trunk (L4 and L5 nerve roots) and the nerve bundles of the obturator nerve (Vleeming et al 2012). The ventral sacroiliac joint capsule being relatively thin allows substances in the joint space to leak out and potentially irritate the lumbosacral trunk (Vleeming et al 2012).

The dorsal sacroiliac joint capsule is discontinuous (Fortin et al 1999) and is closely related to the nerves exiting the sacral foramen. This discontinous capsule allows once again for extravastation of joint fluid to potentially irritate the neighbouring nerves.

Fortin et al (1999) found three pathways between the sacroiliac joint and neural structures. These were:

(1) Posterior extravastation into the dorsal sacral foramen.

(2) Superior recess extravastation at the sacral alar level to the L5 epiradicular sheath.

(3) Ventral extravastation to the lumbosacral plexus.

Due to the discontinuous nature of the dorsal sacroiliac joint capsule the most common pattern of extravastation was posteriorly. Whilst it is not known if this 'inflammatory leakage' is a pathological mechanism for neuropathies its potential effects not only directly on the nerves but indirectly by its effects on the connective tissue could be a potential mechanism for neuropathies.

Osteopathic practice

Osteopathic practice encompasses many different treatment techniques the efficiency of which is not covered here. All of these treatment techniques aim to normalise soft tissue and articular dysfunction.

With a better appreciation of not only the anatomical location of the different soft tissue and neurological structures but an appreciation for their dense consistency and attachments a better appreciation can be obtained as to their relative importance in different low back and pelvic pain presentations.

Several authors for instance have noticed pain and tension in the LDSL and have attributed this to mechanics of the pelvis (Vleeming et al 1996) and entrapment of dorsal sacral rami in this ligament has been associated with producing pain around the posterior superior iliac spine (McGrath et al 2009).

Broadening this concept further the dense adherence of the various muscular, fascial and ligamentous structures having either a direct or indirect effect on neural tension can be responsible for many different pain presentations.

The dual innervation of the facet joint and the multifidus could explain why in facet joint pain there can be pain on segmental palpation associated with mutlfidus spasm (Stephen et al 2007) or central sensitization (Crosby et al 2014) and atrophy of the multifidus in cases of chronic back pain (Woodham et al 2014).

The influence of abnormalities in multifidus tone with its attachments to the sacral rami, LDSL, erector spinae aponeurosis and PRS/TLC has the potential to cause an array of different pain presentations be it via an entrapment neuropathy or other causes of MSK pain.

References

The sacroiliac joint: an overview of its anatomy, function and potential clinical implications (2012). A Vleeming et al

The thoracolumbar fascia: anatomy, function and clinical considerations. (2012). Willard FH et al

The anatomy of the lateral branches of the sacral dorsal rami: implications for radiofrequency ablation (2014). Cox R, Fortin  J.

The long posterior interosseous ligament and the sacrococcygeal plexus Willard F, Carreiro J, Manko W (1998). Third Interdisciplinary world congress on low back and pelvic pain

Ligaments associated with lumbar intervertebral foramina.  The fifth lumbar level. Harold S. et al (1988)

Lateral branches of dorsal sacral nerve plexus and the long posterior sacroiliac ligament. (2005). McGrath MCZhang M.

The function of the long dorsal sacroiliac ligament: its implication for understanding low back pain. (1996). Vleeming A et al 

The long posterior sacroiliac ligament: a histological study of morphological relations in the posterior sacroiliac region (2009). McGrath et al

Gray’s Anatomy 36th edition (1980). Pg 544 & 1090. Williams P & Warwick R

An anatomical study of the lumbar external foraminal ligaments: appearance at MR imaging (2015) Marić DL 

Pathogenesis, Diagnosis, and Treatment of Lumbar Zygapophysial (Facet) Joint Pain (2007). Steven P. et al

Long-Term Lumbar Multifidus Muscle Atrophy Changes Documented With Magnetic Resonance Imaging: A Case Series (2014). WoodhamM et al

Early Afferent Activity from the Facet Joint after Painful Trauma to its Capsule Potentiates Neuronal Excitability and Glutamate Signaling in the Spinal Cord (2014). Crosby N et al

Anatomical etiology of “pseudo-sciatica” from superior cluneal nerve entrapment: a laboratory investigation (2017). Tomoyuki Konno, Yoichi Aota, Hiroshi Kuniya, Tomoyuki Saito, Ning Qu, Shogo Hayashi, Shinichi Kawata, Masahiro Itoh

Anatomic considerations of superior cluneal nerve at posterior iliac crest region (1998). Lu J, Ebraheim NA, Huntoon M, Heck BE, Yeasting RA.

The applied anatomy of the thoracolumbar fascia (1984). Bogduk N and Macintosh JE.

Three pathways between the sacroiliac joint and neural structures (1999). Fortin JD, Washington WJ Falco FJ.

Relationship of the lumbosacral plexus to the sacrum and sacroiliac joint (1997). Ebraheim NA, Lu J, Biyani A, Huntoon M, Yeasting RA

Anatomical entrapment from middle cluneal entrapment (2017).  Tomoyuki Konno, Yoichi Aota, Tomoyuki Saito, Ning Qu, Shogo Hayashi, Shinichi Kawata, and Masahiro Itoh

Effect of periarticular and intraarticular lidocaine injections for sacroiliac joint pain: prospective comparative study (2007). Murakami E, Tanaka Y, Aizawa T, Ishizuka M, Kokubun S

Transforaminal ligament may play a role in lumbar nerve root compression of foraminal stenosis (2011). Yu Qian, An Qi, Ming Zheng

Variations in the lumbosacral ligament and associated changes in the lumbosacral region resulting in compression of the fifth dorsal root ganglion and spinal nerve (1995). Briggs and Chandraraj (1995)

The Lumbosacral Ligament An Autopsy Study of Young Black and White People (2000). Patrick Hanson Henrik Sørensen

The lumbosacral ligament (LSL), with special emphasis on the "lumbosacral tunnel" and the entrapment of the 5th lumbar nerve (1982). Nathan HWeizenbluth MHalperin N.

The Lumbosacral Tunnel: Cadaveric Study and Review of the Literature (2017). Matthew Protas, Bryan Edwards, Marios Loukas, R. Shane Tubbs

Psoas muscle and lumbar spine stability: a concept uniting existing controversies Critical review and hypothesis (2000). L Penning

An anatomical study of the lumbosacral plexus as related to the minimally invasive transpsoas approach to the lumbar spine (2009). Benglis DMVanni SLevi AD.

Anatomy and landmarks for the superior and middle cluneal  nerves: application to posterior iliac crest harvest and entrapment syndrome (2010). Tubbs RS, Levin MR, Loukas M, Potts EA, Cohen-Gadol AA.

Organization of the fascia and aponeurosis in the lumbar paraspinal compartment (2018). Creze M, Soubeyrand MNyangoh Timoh KGagey O.

Anatomy and biomechanics of the vertebral aponeurosis part of the posterior layer of the thoracolumbar fascia (2008). Loukas MShoja MMThurston TJones VLLinganna STubbs RS.

A description of the lumbar interfascial triangle and its relation with the lateral raphe: anatomical constituents of load transfer through the lateral margin of the thoracolumbar fascia (2012). M D Schuenke, A Vleeming, T Van Hoof, and F H Willard.

Regional differences within the human supraspinous and interspinous ligaments: a sheet plastination study (2002). Gillian M Johnson and Ming Zhang

Anatomic Study of Superior Cluneal Nerves: Revisiting the Contribution of Lumbar Spinal Nerves. (2019). Iwanaga JSimonds ESchumacher MOskouian RJTubbs RS.

Revisiting the Middle Cluneal Nerves: An Anatomic Study with Application to Pain Syndromes and Invasive Procedures Around the Sacrum (2019). Kikuta SIwanaga JWatanabe KTubbs RS.

The surgical anatomy of the Piriformis tendon, with particular reference to total hip replacement A cadaver study (2013). J. J. W. Roche, C. D. S. Jones, R. J. K. Khan, P. J. Yates

Surgical Treatment of Piriformis Syndrome (2017). Suk Ku Han, Yong Sik Kim, Tae Hyeon Kim, Soo Hwan Kang

Anatomical variations of the sciatic nerve, in relation to the Piriformis muscle (2016). Samara Lewis, Jade Jurak, Christina Lee, Rusty Lewis, Thomas Gest

Deep Gluteal Syndrome: anatomy, imaging and management of the sciatic nerve entrapments in the subgluteal space (2015). M. Fernández Hernando, L. Cerezal , L. Pérez Carro, R. Dominguez Oronoz, A. Saiz Ayala, F. Abascal, Santander ES, Barcelona/ES

Fascia canals of the greater sciatic foramen and their practical importance (1979). Simonova LB.

Anatomical bases of superior gluteal nerve entrapment syndrome in the supraPiriformis foramen (2002). Diop M, Parratte B, Tatu L, Vuillier F, Faure A, Monnier G.

The sacral thoracolumbar fascia (2009). Maurice Christopher McGrath & Helen Nicholson

First sacral nerve and anterior longitudinal ligament anatomy: clinical applications during sacrocolpopexy. Maria E. Florian-Rodriguez, Jennifer J. Hamner, Marlene M. Corton

The Anatomy of Dorsal Ramus Nerves and Its Implications in Lower Back Pain (2012) Linqiu Zhou, Carson D. Schneck, Zhenhai Shao

The anatomy of the so-called “articular nerves” and their relationship to facet denervation in the treatment of low-back pain (1979). Nikolai Bogduk and Don M. Long

Anatomical description of the facet joint innervation and its implication in the treatment of recurrent back pain (2005). M Masini, W S Paiva, A S Araújo Jr

Clinical Anatomy and Measurement of the Medial Branch of the Spinal Dorsal Ramus (2015). Feng Shuang, Shu-Xun Hou, Jia-Liang Zhu, Yan Liu, Ying Zhou, Chun-Li Zhang, Jia-Guang Tang.

An electrophysiological demonstration of polysegmental innervation in the lumbar medial paraspinal muscles (1997). P B WuW S KingeryM L FrazierE S Date

Add a comment:

Leave a comment:

Comments

Add a comment