Sinuvertebral Nerve

Goal of the Study?

In this clinical anatomical study and literature review article from the European Spine Journal 1 the authors’ goals were twofold: (a)  identify the anatomical mechanism of the Sinuvertebral Nerve in its relationship to lumbar discogenic pain and (b) clarify the different morphological aspects of the Sinuvertebral Nerve they found to those in similar clinical anatomical literature.

 

Why are they doing this study?

The Sinuvertebral Nerve (SVN) is a recurrent nerve that originates from the ventral ramus and enters the intervertebral canal supplying the bone, disc, ligament, dura mater and veins. Its complex anatomy and relationship to discogenic pain have warranted great interest among clinical anatomists owing to its sympathetic contribution to the lumbar spine.  In healthy individuals, the intervertebral disc is only weakly supplied by primary and sympathetic postganglionic fibres via the SVN.  In degenerative disc disease, the increased load leads to an inflammatory reaction and the release of growth factors resulting in increased sprouting of the nerve fibres in the deeper layers of the disc.  Previous experimental studies have established a correlation between hyperinnervation of the annulus fibrosus by additional sprouting of the SVN and increased discogenic pain, but the anatomical mechanism is not clearly understood and was inconsistent when reviewing existing literature.  

 

What was done?

Six spine blocks were dissected and thoroughly examined from six embalmed human body donors, three males and three females aged between 59 and 94.  Forty-eight levels were dissected and 43 SVN’s in 39 levels were observed (89.6%).  Major factors limiting the dissection of all SVN’s were caused by the disruption of the surrounding structures.  The author’s dissection and anatomical results were compared to similar literature that used a combination of human body donors, fetuses, embryos, rats and other animals.

 

What did they find?

The origin of the Sinuvertebral Nerve was always formed by two roots; a somatic root arising from the spinal nerve and sympathetic branch from the rami communicantes. In all the 43 SVN’s segments studied the nerve was close to the interior notch of the vertebral pedicle.  The authors conclude that this location could be an effective anatomical landmark for SVN blocking.

 

Why do these findings matter?

According to some studies, the lumbar intervertebral disk accounts for 39% of chronic low back pain. One possible cause of lumbar discogenic diffuse pain is the lumbar SVP. Reports of significant improvements in low back pain with low complication rates involve blocking the SVN.  This treatment is most effective when combined with a clear indication using imaging techniques to identify the best anatomical landmark.   A thorough understanding of the anatomy of the SVN might lead to significant benefits in therapy of discogenic low back pain.  This study confirms blocking the SVN at the level of the inferior vertebral notch of two adjacent segments may be the most effective landmark.

 

At Dynamic Disc Designs, we craft realistic models to help clinicians of spine educate patients about the sources (and solutions) of lower back pain.

sedentary behaviour

Goal of the Study?

In this qualitative systematic review and meta-analysis article from the Journal of Health Promotion Perspectives 1 the authors investigated existing studies to determine if consistent correlations exist between various types of sedentary behaviour and low back pain in both children and adults.

 

Why are they doing this study about sedentary behaviour?

Low Back Pain (LBP) is a universal public health concern contributing to self-perceived disability and a high economic burden worldwide.  It is estimated that about 80% of the population has experienced an episode of LBP in their lives.  Sedentary behaviours are a substantial risk for many chronic diseases, including LBP, but the relationship between sitting time and LBP in current literature is inconsistent. This is due to the differences in study design, measurement methods and occupational groups.  

 

 

What was done?

A systematic search using PubMed, Embase, Web of Science and Scopus databases were searched and 3,406 articles were initially found.  After removing duplicates, non-full text, non-english and inappropriate studies, 27 articles were fully analyzed using a variety of meta-analysis tools, looking for correlations between sedentary behaviours and LBP.  Factors included in the meta-analysis were correlation between body mass, age groups (adults and children/adolescents), coffee consumption, smoking and hours spent in sedentary behaviour (screen,  driving and sitting time). Various meta-analysis statistical tools such as Odds Ratio, Cochran’s Q and inconsistency index, STROBE scores and Forest Plots were applied to the 27 articles.

 

What did they find?

Using the pooled effect sizes obtained from the meta-analysis studies of children/adolescents, the authors determined that LBP was significantly correlated with body mass and two sedentary behaviours; prolonged TV watching and screen playing time. Among the adult population, obesity, sitting time and driving time were significantly correlated with LBP, whereas correlations with smoking and coffee consumption were inconsistent, and only moderately associated with LBP.  It appears that body mass and smoking interact with sitting and LBP.  It was suspected that sedentary behaviour decreases the level of water supply to the vertebral disc, which in turn leads to degenerative changes and disk herniation. Smoking seems to have both a direct and indirect effect on LBP.  Smoking is a risk factor for osteoporosis and also alters the blood supply of vertebral disks by impairing vasoconstriction and atherosclerosis. Excessive coffee consumption tends to flush magnesium from the body, resulting in increasing painful contractions of the paraspinal muscles.

 

Why do these findings matter?

There are many inconsistencies in the definition and measurement of LBP and sedentary behaviour in current research articles.  Very few studies used any type of objective measurements to determine LBP or sitting time.  LBP is a complex disorder with many interacting risk factors.  Given the increasing trend of sedentary behaviour worldwide, especially in this era of the COVID pandemic, increased health education is necessary to avoid sedentariness in early childhood to prevent future musculoskeletal consequences such as LBP.

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YouTube Video Shorts – Patient Education for Spine

 

 

 

 

 

 

 

 

 

 

 

 

 

IVDD

Goal of the Study?

In this qualitative primary research study from the Oxidative Medicine and Cellular Longevity Journal 1 the authors’ goal was to determine the potential role of the Integrin Alpha 6 receptor in the inner nucleus pulposus in response to high oxygen tension in intervertebral disc degeneration.

 

Why are they doing this study?

Intervertebral Disc Degeneration (IVDD) is the most common musculoskeletal disorder and a major cause of disability.  The development of IVDD is directly associated with several factors including ageing, genetic susceptibility, body weight, heavy workload and smoking.  The Intervertebral Disc (IVD) mainly consists of three tissue compartments; the outer Annulus Fibrosus (AF), the inner Nucleus Pulposus (NP) and the cephalic and caudal cartilage endplates.  The AF and NP tissues work together to provide two major anatomical functions of the IVD; spinal flexibility and load distribution.  Increasing evidence suggests that integrins such as Alpha 6 (⍺6) are involved in the pathogenesis of IVDD, however, the exact method by which the low oxygen environment initiates IVDD is not fully understood.

 

What was done?

Twenty-five MRI scans of surgical patients were categorized using the Pfirrmann classification system.  Degenerated specimens were obtained from 21 patients who underwent spinal fusion surgery with low back pain.  Normal disc specimens were taken from four young patients with burst lumbar fracture without IVDD.  Eighteen research rats were euthanized and the Co4-5 caudal discs were collected and analyzed.  Both human and rat specimens were analyzed by a series of histology stainings.  The NP cells were isolated and cultured.  A complex sequence of procedures and analyses were performed.  These were designed to explore the relationship between the ⍺6 integrins and the oxygen content of the NP tissue.

 

What did they find?

The study demonstrated for the first time that the expression of the integrin ⍺6 increased significantly in the IVDD at an early degeneration stage.  The increase of oxygen content of the NP tissue was a critical factor for the upregulation of this ⍺6 integrin.  Furthermore silencing this integrin in vivo appears to accelerate puncture-induced IVDD.   As such this study concludes that the increase of the ⍺6 integrin is a critical protective factor in IVD degeneration as well as acting to restore the NP cell function.

 

Why do these findings matter?

Low back pain due to IVDD affects many individuals, especially in the elderly population and identifying the mechanisms of IVDD and finding new therapeutic targets is critical.  This study confirmed that the expression of integrin ⍺6 was increased during the early stages of disc degeneration.  It also confirmed that the destruction of the hypoxia environment in the NP tissue is a leading cause of the increased ⍺6  integrin.  It is hoped that this study provides a foundation for new insights into the development of pharmacological and physical therapies that can modify the course of IVDD.

 

Dynamic Disc Designs create realistically crafted disc models to help in the education of back pain and degenerative disc disease. This important paper revealed how oxygen infiltration into the nucleus pulposus upregulates integrin ⍺6 as protective against IVDD.

Sacroiliac Joint Dysfunction

Goal of the Study?

In this comprehensive literature review from the European Spine Journal 1 the authors’ goal was to examine the literature concerning the pathophysical, risk factors, clinical presentation, diagnostic modalities and treatment options for Sacroiliac Joint Dysfunction.

 

Why are they doing this study?

The Sacroiliac Joint (SIJ) connects the hip bones (iliac crests) to the sacrum, the triangular bone between the lumbar spine and the tailbone (coccyx). The primary function of the SIJ is to absorb shock between the upper body and the pelvis and legs. Age-related changes in the SIJ begin in puberty and continue throughout life.  In early adulthood, the joint surfaces are smooth and allow for multi-directional gliding motion but by the third decade, morphological changes restrict motion and begin to resemble osteoarthritic degeneration and include surface irregularities, fissures, chondrocyte clustering and fibrillation.

 

LumboPelvic Model

 

What did they do?

Over 6,104 articles were initially identified but after removing duplicates and screening for eligible content only 33 articles were included.

 

What did they find?

Pathophysiology:

  • SIJ dysfunction can result from various clinical conditions, including trauma, degenerative arthritis, inflammatory arthropathy, infections and moderate impact exercise.  The dysfunction can occur during abnormal lifting, bending forward or lordotic posturing when the line of gravity is displaced relative to the centre of the acetabula.  Pain localized to the SIJ region can be broad and include pain from the lumbar spine, SIJ and hip joint as well as visceral pain.  

Prevalence and Risk Factors:

  • It has been found that 15-30% of all primary Lower Back Pain (LBP) may be the result of SIJ dysfunction.  Both genders and all races seemed to be affected equally.  SIJ dysfunction is a common cause of LBP in athletes, especially in sports with repetitive or asymmetric loading.  Other risk factors include pregnancy, obesity, and a sedentary lifestyle. leg length discrepancy, hypermobility, degenerative joint disease and previous spinal fixation.

Clinical Presentation:

  • Compared with discogenic LBP, individuals with SIJ dysfunction often present with unilateral pain below L5 and this pain can extend down the posterior thigh to the S1 dermatome.  The most common SIJ injury results are from sudden rotational and axial strain.  Most athletes will not present acutely following injury but rather experience gradually progressive symptoms following repetitive microtraumas.  

Diagnosis:

  • No single provocation test has accurately identified SIJ dysfunction.  However, using a combination of three provocation tests such as FABER (Flexion, Abduction, and External Rotation) and Graenslen’s distraction, high thrust and compression tests have shown diagnostic validity.  Laboratory tests provide no diagnostic benefit. Definitive evaluation of the SIJ pathology is both diagnostic and therapeutic and involves ultrasound-guided injections of steroid and anesthetic solutions into the joint.  Image guidance is crucial due to the complex anatomy of the SIJ and the high likelihood of needle misplacement.

 

Why do these findings matter?

With the ageing nature of the population, SIJ dysfunction has emerged as an extremely prevalent issue.  A better understanding of the pathophysiology, risk factors and associated clinical conditions will help guide diagnostic procedures and improve therapeutic outcomes.

 

At Dynamic Disc Designs, we have crafted realistic models to help in the greater understanding of the motion and the associated dysfunction that may contribute to problems.

OA

Goal of the Study?

In this research review article from the Annals of Medicine and Surgery 1 the authors’ purpose was to focus on the update of clinical prospects and management of osteoarthritis as well as future treatment possibilities.

 

Why are they doing this study? 

Osteoarthritis is a general term that incorporates several different joint diseases.  OA’s main effects include cartilage degradation, acute and chronic synovial inflammation, subchondral bone alteration, the presence of osteophytes and changes in synovial fluid.  The first studies on OA were conducted about 130 years ago and OA is now recognized as a multifactorial complex disorder.  OA was once believed to be a degenerative condition, but it is now known to have an infectious cause as well as a metabolic etiology.  The exact pathophysiology of OA remains unclear and both the pharmacological and non-pharmacological management of OA is continually evolving.

 

 

What was done?

The review began with an overview of OA’s inflammatory pathology focusing on the various cytokines, a group of secreted polypeptides that appears essential for the initiation of inflammation. Some cytokines are released in response to acute chronic inflammation and have anti-inflammatory properties and responses.   The majority of the review covered the pharmacological and non-pharmacological management of OA.  The more effective treatments include:

  • Exercise which is the recommended first-line treatment of OA.
  • Heat and Cold Therapy.  Heating decreases discomfort and increases the expression of Heat Shock Protein 70 which has both a relaxing effect and is involved in cartilage defence, reducing inflammation and preventing chondrocyte apoptosis.  The only reported benefit of cold therapy seems to be pain reduction.
  • Transcutaneous Electrical Nerve Stimulation (TENS), Low-level Laser Therapy, Massage, Acupuncture and Assistive Devices (canes, braces and insoles) can also improve mobility but seem to be more effective if used in conjunction with exercise.

The effectiveness of various pharmacological management tools were also discussed.  These included NSAIDs and other analgesics, topical agents, intra-articular therapy, Hyaluronic Acid, Anti-cytokine Therapy, Omega 3 fatty acids and Herbs and Ayurvedic formulations.  It appears that some ancient herbal Ayurvedic formulations, such as Triphala, Triphaghula, Balaraja and Dashamoola extracts, are re-emerging as an effective treatment option without the side effects of potentially risky medications.  Arthroscopic and replacement surgery are also discussed and use cases are provided. 

 

What did they find?

The researchers found a few gaps in the current pathogenesis of OA.  They also discussed some promising recent developments, especially ones that target the articular cartilage molecular process.  OA seems to present itself with overlapping endotypes and as such a single-targeted approach is not likely to be as successful as an integrated personalized approach.

 

Why do these findings matter?

Osteoarthritis (OA) severely restricts the everyday activities of senior citizens.  As the population ages, the frequency and prevalence of OA is expected to double over the next decade.  By age of 65, most people have radiographic proof of OA and by age 75 this increases to about 80% of the population.  OA is currently the most prevalent articular disease worldwide. Even though the exact pathophysiology of OA is unclear, there appear to be some effective non-pharmacological interventions.

 

At Dynamic Disc Designs, we work to help professionals explain the anatomy (in a dynamic and postural way) to help patients understand the positive things they can do for themselves to help reduce their pain.

Stature Change

Goal of the Study?

In this case-control study from researchers in Thailand and Australia, published in the journal; Trends in Sciences 1 the authors’ goal was to investigate the effect of time of day (morning versus afternoon) on the variability of the change in stature of participants with Chronic Lower Back Pain (CLBP) on two consecutive days.

 

Why are they doing this study?

Prolonged sitting places load on the lumbar discs.  The resulting stress from both body mass and gravity reduces disc height, causing what is termed “Stature Loss”.  This loss in stature normally varies over the course of a day but there is some confusion over the magnitude of this diurnal compression and its recovery.  Previous research has shown that the rate of change in stature occurs in two phases; fast and slow.  Stature loss has been reported to be significantly greater when an individual rises in the morning and gradually slows during the day.  This research study is an attempt to understand the variability in the stature change response and determine if this change is a result of time of day effects or measurement variations.

 

 

What was done?

Forty-four participants (50:50 male: female) with Chronic Lower Back Pain (CLBP) were recruited for a same-participant test-retest design study.  The authors defined CLBP as pain between the T12 and L5, which was not referred to beyond the knees and had been present for at least three months. Using seated stadiometer variations in stature change were recorded at a similar time for two consecutive days.  One half of the group was assigned to the morning and the other half the afternoon.  The next week the groups were reversed.  Stadiometer readings were taken every 15 seconds over a series of two-minute intervals.  An average of 75 data points were averaged to reduce uncontrollable movement and breathing patterns that may influence the recorded stature loss.

 

What did they find?

There were slight differences in the amount of stature loss between the morning and afternoon sessions.  0.995mm in the morning and 1.149mm in the afternoon.  But due to the large variations in stadiometer readings, these results were not statistically significantly different.

 

Why do these findings matter?

When applying a medical treatment one must determine if the medical intervention caused stature changes or if the changes were due to natural variation. Even though this study did not prove statistically that there is a difference between morning and afternoon, it did show that there appear to be smaller changes in the morning when compared to the afternoon.

 

At Dynamic Disc Designs, we understand that spinal symptoms can correlate to the natural diurnal rhythms of disc height. We have thought carefully about this and provide dynamic disc models to help professionals make sense of a patient’s symptoms.

 


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