Comprehensive anatomical and immunohistochemical review of the innervation of the human spine and joints with application to an improved understanding of back pain

Preferences and Avoidance of Sleeping Positions Among Patients With Chronic Low Back Pain: A Cross-Sectional Study

Background Chronic low back pain (CLBP) is a common issue among the working-age population. Sleeping position may affect CLBP, with the prone position commonly suggested to be avoided. This study aims to examine the relationship between preferred and avoided sleeping positions and to explore the frequency of increased pain in various sleeping positions among patients with nonspecific CLBP and pain and disability levels. Methods This cross-sectional study included all adult patients referred for specialist consultation for CLBP at the outpatient clinic of the Central Hospital of Central Finland's spine department. Pain intensity was measured using a visual analog scale (VAS), and disability was assessed with the Oswestry Disability Index (ODI). Patients completed a questionnaire detailing the main sleeping positions and positions avoided due to low back pain (LBP). Results The study enrolled 375 consecutive patients, with a mean age of 51 ± 17 years; 64% (n=240) were female. The mean VAS score was 63 ± 24, and the mean Oswestry Index was 38 ± 18%. The majority of patients (87%, n=327) reported sleeping in a side-lying position, followed by supine (47%, n=176) and prone (22%, n=82) positions. A negative correlation was found between age and the preference for sleeping in the prone position. No significant gender differences in sleep positions were observed (p=0.69). Sleep was disturbed in 77% of patients (n=289) due to LBP, and 87% (n=327) reported difficulties due to LBP when getting up. Overall, 92% of participants (n=345) experienced difficulties sleeping or getting up in the morning due to LBP. Many patients avoided certain positions due to pain: 42% (n=157) avoided the prone position, 35% (n=131) the back, 15% (n=56) the left side, and 13% (n=49) the right side. Although the prone position was most commonly linked with pain, especially among women, our findings suggest that any sleeping position could potentially exacerbate pain in individuals with CLBP. Conclusions This study highlights the variability in how sleeping positions affect pain in patients with nonspecific CLBP. While the prone position is most frequently associated with increased pain, individual preferences and responses vary significantly, and often sidelying and supine positions provoke pain. The diversity in sleeping positions that exacerbate pain highlights the need for tailored advice in the management of patients with CLBP.

Current Evidence for Diagnosis of Common Conditions Causing Low Back Pain: Systematic Review and Standardized Terminology Recommendations

OBJECTIVE

The purpose of this systematic review is to evaluate and summarize current evidence for diagnosis of common conditions causing low back pain and to propose standardized terminology use.

METHODS

A systematic review of the scientific literature was conducted from inception through December 2018. Electronic databases searched included PubMed, MEDLINE, CINAHL, Cochrane, and Index to Chiropractic Literature. Methodological quality was assessed with the Scottish Intercollegiate Guidelines Network checklists.

RESULTS

Of the 3995 articles screened, 36 (8 systematic reviews and 28 individual studies) met final eligibility criteria. Diagnostic criteria for identifying likely discogenic, sacroiliac joint, and zygapophyseal (facet) joint pain are supported by clinical studies using injection-confirmed tissue provocation or anesthetic procedures. Diagnostic criteria for myofascial pain, sensitization (central and peripheral), and radicular pain are supported by expert consensus-level evidence. Criteria for radiculopathy and neurogenic claudication are supported by studies using combined expert-level consensus and imaging findings.

CONCLUSION

The absence of high-quality, objective, gold-standard diagnostic methods limits the accuracy of current evidence-based criteria and results in few high-quality studies with a low risk of bias in patient selection and reference standard diagnosis. These limitations suggest practitioners should use evidence-based criteria to inform working diagnoses rather than definitive diagnoses for low back pain. To avoid the unnecessary complexity and confusion created by multiple overlapping and nonspecific terms, adopting International Association for the Study of Pain terminology and definitions is recommended.

On the importance of the innervation of the human cervical longitudinal ligaments at vertebral level

PURPOSE

In our aging society, the prevalence of degenerative spinal diseases rose drastically within the last years. However, up till now, the origin of cervical pain is incompletely understood. While animal and small cadaver studies indicate that a complex system of sensory and nociceptive nerve fibers in the anterior (ALL) and posterior longitudinal ligament (PLL) at the level of the intervertebral disc might be involved, there is a lack of data exploring whether such a network exists and is equally distributed within the cervical vertebrae (VB). We, therefore, aimed to investigate the spatial distribution of the mentioned nerve networks in human tissue.

METHODS

We performed macroscopic (Sihler staining, Spalteholz technique, and Plastination) and microscopic (immunohistochemistry for PGP 9.5 and CGRP) studies to characterize spatial differences in sensory and nociceptive innervation patterns. Therefore, 23 human body donors were dissected from level C3-C6.

RESULTS

We could show that there is a focal increase in sensory and nociceptive nerve fibers at the level of C4 and C5 for both ALL and PLL, while we observed less nerve fiber density at the level of C3 and C6. An anatomical vicinity between nerve and vessels was observed.

CONCLUSION

To our knowledge, these findings for the first time report spatial differences in sensory and nociceptive nerve fibers in the human cervical spine at VB level. The interconnection between nerves and vessels supports the importance of the perivascular plexus. These findings might be of special interest for clinical practice as many patients suffer from pain after cervical spine surgery.

[Lumbar facet joint disease : Classification, clinical diagnostics, and minimally invasive treatment]

BACKGROUND

The degeneration of the lumbar facet joint is a multi-factorial process that is closely linked to degeneration of the intervertebral discs and has been implicated as one of the causes of low-back pain of elderly patients in about 15 up to 40% of cases. Moreover, emerging data suggest that increased inflammatory features play an important role in the progression of lumbar facet joint disease and may serve as a link to the afferent pain nerve fibers.

OPERATIVE TECHNIQUES

Since the first description in 1975 of minimally invasive treatment of lumbar facet joint disease, different techniques have been developed and used with varying results. Today, the major techniques are thermorhizotomy, cryorhizotomy, and endoscopic or percutaneous facet debridement with different anatomical targets, such as the medial branch of the dorsal ramus or facet joint capsule.

[Imaging of the lumbosacral plexus : Diagnostics and treatment planning with high-resolution procedures]

BACKGROUND

Technical advances in magnetic resonance (MR) and ultrasound-based neurography nowadays facilitate the radiological assessment of the lumbosacral plexus.

OBJECTIVE

Anatomy and imaging of the lumbosacral plexus and diagnostics of the most common pathologies.

MATERIAL AND METHODS

Description of the clinically feasible combination of magnetic resonance imaging (MRI) and ultrasound diagnostics, case-based illustration of imaging techniques and individual advantages of MRI and ultrasound-based diagnostics for various pathologies of the lumbosacral plexus and its peripheral nerves.

RESULTS

High-resolution ultrasound-based neurography (HRUS) is particularly valuable for the assessment of superficial structures of the lumbosacral plexus. Depending on the examiner's experience, anatomical variations of the sciatic nerve (e. g. relevant in piriformis syndrome) as well as more subtle variations, for example as seen in neuritis, can be sonographically depicted and assessed. The use of MRI enables the diagnostic evaluation of more deeply located nerve structures, such as the pudendal and the femoral nerves. Modern MRI techniques, such as peripheral nerve tractography allow three-dimensional depiction of the spatial relationship between nerves and local tumors or traumatic alterations. This can be beneficial for further therapy planning.

CONCLUSION

The anatomy and pathology of the lumbosacral plexus can be reliably imaged by the meaningful combination of MRI and ultrasound-based high resolution neurography.