Cadaveric and ultrasonographic validation of needling placement in the obliquus capitis inferior muscle.

BACKGROUND: Evidence suggests that suboccipital musculature plays an important role in headache. Proper therapeutic approaches targeting this muscle are needed. OBJECTIVE: Our aim was to determine with fresh cadavers and ultrasound imaging if a solid needle is able to properly penetrate the obliquus capitis inferior muscle during the application of dry needling. DESIGN: A cadaveric and human descriptive study. METHODS: Needling insertion and ultrasound imaging of the obliquus capitis inferior muscle was conducted on 10 pain-free healthy subjects and 5 fresh cadavers. Needling insertion was performed using a 40 mm needle inserted midway between the spinous process of C2 and transverse process of C1. The needle was advanced from a posterior to anterior direction into the obliquus capitis inferior muscle with an inferior-lateral angle to reach the lamina of C2. For the cadaveric study, the obliquus capitis inferior placement was verified by resecting the superficial upper trapezius, splenius capitis, and semispinalis capitis muscles. For ultrasographic study, a linear transducer was aligned with the long axis of the obliquus capitis inferior muscle after needle insertion. RESULTS: Both the cadaveric and ultrasonic studies showed that the needle penetrated the obliquus capitis inferior muscle during its insertion and that the tip of the needle rested against C2 laminae, thereby reaching the targeted muscle. CONCLUSION: This anatomical and ultrasound imaging study supports the assertion that needling insertion of the obliquus capitis inferior muscle can be properly conducted by an experienced clinician.

Cadaveric and Ultrasonographic Validation of Needling Placement in the Cervical Multifidus Muscle.

OBJECTIVE: The aim of this study was to determine if a needle is able to reach the cervical multifidus during the application of dry needling or acupuncture. METHODS: Dry needling and ultrasound imaging of cervical multifidi was conducted on 5 patients (age: 32 ± 5 years) with mechanical neck pain and on 2 fresh cadavers (age: 64 ± 1 years). Dry needling was done using a needle of 40 mm in length inserted perpendicular to the skin about 1 cm lateral to the spinous process at C3-C4. The needle was advanced from a posterior to anterior direction into the cervical multifidus with a slight inferior-medial angle (approximately 10°) to reach the vertebra lamina. For the cadaveric study, the multifidus was isolated by carefully resecting the superficial posterior cervical muscles: trapezius, splenius, and semispinalis. For the ultrasonographic study, a convex transducer was placed transversely over C3-C4 after the insertion of the needle into the muscle. RESULTS: The results of both the cadaveric and ultrasonic studies found that the needle does pierce the cervical multifidus muscle during insertion and that the tip of the needle rests properly against the vertebral laminae, thereby guarding the sensitive underlying spinal structures from damage. CONCLUSION: This anatomical and ultrasound imaging study supports that dry needling of the cervical multifidus could be conducted clinically.

[The effects of sacral nerve root electrostimulation on the colon function and its mechanisms in a rat model of spinal cord injury].

OBJECTIVE: To study the effects of sacral nerve root electrostimulation (SNS) on the colon function and its mechanisms in rats with spinal cord injury (SCI). METHODS: One hundred and four Wistar rats were divided into three groups: A, B and C. A group ( n = 24) was divided into three subgroups (n = 8) for studying the bioelectricity: Normal group (NG), SCI group (SCI) and SCI group with SNS(SNS); B group( n = 24) was divided into three subgroups( n = 8) for studying the colon motility: NG, SCI and SNS. C group( n = 56) were divided into three groups for studying the change of morphology and neurotransmitters(SP and VIP): NG (n = 8), SCI (n = 24), and SNS (n = 24) . In SCI and SNS, included of three subgroups: 24, 48, 72 h after spinal cord injury (n = 8). RESULTS: In SCI group, the activity of bioelectricity in proximal and distal colon was reduced; the colon motility was lessened, and colon mucosa appeared different degree of damage; cell-cell connections between intestinal epithelial cells were destroyed. The expressions of substance P(SP) and vasoactive intestinal peptide (VIP) in colon were decreased obviously. SNS was found to activate the bioelectricity, promote the colon motility, improve the intestinal mucosal, and increase the expressions of SP and VIP. Conclusion: SNS can activate the peristalsis, rehabilitate the motility of denervated colon, protection of the intestinal mechanical barrier between intestinal epithelial cells and tight junction, rebuild the colon function through activating the bioelectricity and increase the expressions of SP and VIP.

Anatomical relationship between BL23 and the posterior ramus of the L2 spinal nerve.

BACKGROUND: The acupuncture point BL23 is located in the region of the posterior ramus of the second lumbar spinal nerve (L2) and has historically been used to treat conditions such as lower back pain, pollakiuria, erectile dysfunction, dysmenorrhoea, tinnitus, and vertigo. Some of these treatment effects have been hypothesised to be mediated by the sympathetic nervous system. It was recently discovered that the posterior ramus of the spinal nerve (PRSN) at L2 forms not two but three branches. OBJECTIVE: To examine the relationship between the acupuncture point BL23 and the L2 PRSN in order to consider the pathways possibly affected by BL23 acupuncture. METHODS: Acupuncture needles were inserted through the skin at BL23 to a depth of 3 cm a total of 13 times in eight donor cadavers (seven right-sided, six left-sided). Leaving the needle in place, ventral dissection was performed to determine the PRSN anatomy between the L1 and L3 spinal segments. In four cadavers, the relationship between the L2 spinal nerve and sympathetic branches was additionally evaluated. Following dissection, three-dimensional (3D) data were acquired using a photo scanner and 3D structural images were created using 3D computer graphics software. One additional (female) cadaver was studied without insertion of an acupuncture needle (due to significant scoliosis). RESULTS: The L2 PRSN was divided into medial, intermediate and lateral branches. The needle inserted at BL23 came to lie in the region of the intermediate or lateral branches in all cases. Rami communicantes were found between the L2 spinal nerve and sympathetic trunk with fibres going on to supply the superior hypogastric plexus. CONCLUSIONS: Our findings suggest that acupuncture needles inserted at BL23 come into close proximity with the intermediate or lateral branch of the L2 PRSN, which could result in stimulation of both the somatic and sympathetic nervous systems.

Effects of sacral nerve stimulation on postpartum urinary retention-related changes in rat bladder.

OBJECTIVE: To examine the effect of sacral nerve stimulation (SNS) on the urodynamic function and molecular structure of bladders in rats following acute urinary retention (AUR) after parturition. MATERIAL AND METHODS: Thirty primiparous rats were divided into three groups: postpartum, postpartum+AUR, and postpartum+AUR+SNS. AUR was achieved by clamping the distal urethra of a rat for 60 minutes. The postpartum+AUR+SNS group received electrical stimulation 60 minutes daily for 3 days after AUR. In addition to cystometric studies and external urethral sphincter electromyography, the expression of caveolins and nerve growth factor (NGF) and caveolae number in bladder muscle were analyzed. RESULTS: The postpartum+AUR group has significantly greater residual volume than the postpartum group, but the residual volume decreased significantly after SNS treatment. The postpartum+AUR group had significantly lower peak voiding pressure, a longer bursting period and lower amplitude of electromyograms of external urethral sphincter activity than the postpartum and postpartum+AUR+SNS groups. The postpartum+AUR rats had higher NGF expression, lower caveolin-1 expression, and fewer caveolae in bladder muscle compared with the postpartum rats. Conversely, the caveolin-1 expression and caveolae number increased, and the NGF expression decreased after SNS treatment. CONCLUSION: Bladder dysfunction after parturition in a rat model caused by AUR may be restored to the non-AUR structural and functional level after SNS treatment.

Multi-Electrode Array for Transcutaneous Lumbar Posterior Root Stimulation.

Interest in transcutaneous electrical stimulation of the lumbosacral spinal cord is increasing in human electrophysiological and clinical studies. The stimulation effects on lower limb muscles depend on the depolarization of segmentally organized posterior root afferents and, thus, the rostro-caudal stimulation site. In previous studies, selective stimulation was achieved by varying the positions of single self-adhesive electrodes over the thoracolumbar spine. Here, we developed a multi-electrode surface array consisting of 3 × 8 electrode pads and tested its stimulation-site specificity. The array was placed longitudinally over the spine covering the T10-L2 vertebrae. Two different hydrogel layer configurations were utilized: a single layer adhered to all electrode pads of the array and a configuration comprised of eight separate strips attached to the three transverse electrode pads of each level. Voltage measurements demonstrated that an effectively focused field distribution along the longitudinal extent of the array was not accomplished when using the single continuous hydrogel layer, and segmental selective stimulation of the posterior root afferents was not possible. The separate strips produced a focused electric field distribution at the rostro-caudal level of the electrode pads selected for stimulation. This configuration allowed for the preferential elicitation of posterior root-muscle reflexes in either the L2-L4 innervated quadriceps or the L5-S2 innervated triceps surae muscle groups. Such multi-electrode array for transcutaneous spinal cord stimulation shall allow for improved control of stimulation conditions in electrophysiological studies and time-dependent and site-specific stimulation patterns for neuromodulation applications.

[THE APPLICATION OF ANTIHOMOTOXIC DRUG PREPARATIONS IN THE COMPLEX TREATMENT IN PATIENTS WITH NEUROLOGICAL MANIFESTATIONS OF LUMBAR OSTEOCHONDROSIS].

The expediency of application homeosyniatry by preparations of Traumel S and Placenta Compositum after the offered chart in relation to a complex with classic acupuncture and in relation to the group of the generally accepted treatment has been proved in complex treatment patients with reflex syndromes of lumbar osteochondrosis. A similar conclusion was done after the statistically reliable (P < 0.05) dynamics of parameters of endogenous intoxication, liperoxydation and antioxydant systems of the protection (by the level of katalase, superoxyddismutase, SH-groups, ceruloplasmine).

Recovery of sensory and supraspinal control of leg movement in people with chronic paraplegia: a case series.

OBJECTIVE: To report on unexpected findings in 4 patients with chronic paraplegia who underwent the laparoscopic implantation of neuroprosthesis procedure in the pelvic lumbosacral nerves. DESIGN: Observational case series. SETTING: Tertiary referral unit specialized in advanced gynecological surgery and neuropelveology. PARTICIPANTS: Three patients with incomplete American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade B (n=2) and AIS grade C (n=1) spinal cord injury (SCI) and 1 patient with flaccid complete chronic SCI (AIS grade A) (n=1). INTERVENTION: Functional electrical stimulation (FES)-assisted locomotor training and continuous low-frequency pelvic-lumbosacral neuromodulation. MAIN OUTCOME MEASURES: Change in ASIA Lower Extremity Motor Scores, ASIA sensory scores for light touch and pinprick sensation, and Walking Index for Spinal Cord Injury scores. RESULTS: All 4 patients developed progressive recovery of some sensory and voluntary motor functions below the lesions. Three are currently capable of voluntary weight-bearing standing and walking a few meters with a walker without FES. The first patient with the longest follow-up is even capable of electrically assisted standing/walking with 2 crutches without braces or assistance for a distance of about 900 meters, and of weight-bearing standing and walking for 30 meters with a walker without stimulation. CONCLUSIONS: We report unexpected sensory and locomotor recovery in 4 people with paraplegia with SCI. Our findings suggest that FES-assisted locomotor training with continuous low-frequency pelvic nerve stimulation in patients with SCI may induce changes that affect the central pattern generator and allow supra- and infraspinal inputs to engage residual spinal pathways.

[Correlation study on effects of electroacupuncture on the muscle condition and MNCV in rabbits with lumbar nerve root compression].

OBJECTIVE: To observe the effects of electroacupuncture on the muscle condition and electrophysiology of the muscle in rabbits with lumbar nerve root compression and to explore potential mechanisms. METHODS: Twenty-four New Zealand white rabbits were randomly divided into a normal group, a model group, a medication group and an electroacupuncture group. The rabbit model with lumbar nerve root compression was established in the model group, the medication group and the electroacupuncture group. The model and the treatment were not produced in the normal group. The medication group was treated with oral administration of Loxoprofen tablets at a dose of 30 mg each day for 14 days. The electroacupuncture group was treated with electroacupuncture at "Jiaji" (EX-B 2) of L5 and L6 for 14 days. The hibateral muscle condition before and after making model and after treatment was detected and the electromyogram and the nerve conduction velocity (NCV) were observed. RESULTS: The spontaneous potential and the insertion potential were increased in the model group, the medication group and the electroacupuncture group after making model. The value of the activation and the relaxed condition of the strength-creep (ARCSC) in the right muscle was significantly decreased. The motor nerve conduction velocity (MNCV) and the wave amplitude of evoked potential (WAEP) were significantly decreased in the model group, the medication group and the electroacupuncture group after treatment, but the value of MNCV and WAEP in the electroacupuncture group, and ARCSC in the right muscle in the electroacupuncture group and the medicine group were closed to those level in the normal group, among them, the relaxed condition in the electroacupuncture group was more close to the level in the normal group. CONCLUSION: Electroacupuncture can improve the strength-creep condition of the muscle that damage nerve place controls and the electrophysiology of the muscle can recover the MNCV and the wave amplitude of evoked potential in the compression nerve root.

Can the human lumbar posterior columns be stimulated by transcutaneous spinal cord stimulation? A modeling study.

Stimulation of different spinal cord segments in humans is a widely developed clinical practice for modification of pain, altered sensation, and movement. The human lumbar cord has become a target for modification of motor control by epidural and, more recently, by transcutaneous spinal cord stimulation. Posterior columns of the lumbar spinal cord represent a vertical system of axons and when activated can add other inputs to the motor control of the spinal cord than stimulated posterior roots. We used a detailed three-dimensional volume conductor model of the torso and the McIntyre-Richard-Grill axon model to calculate the thresholds of axons within the posterior columns in response to transcutaneous lumbar spinal cord stimulation. Superficially located large-diameter posterior column fibers with multiple collaterals have a threshold of 45.4 V, three times higher than posterior root fibers (14.1 V). With the stimulation strength needed to activate posterior column axons, posterior root fibers of large and small diameters as well as anterior root fibers are coactivated. The reported results inform on these threshold differences, when stimulation is applied to the posterior structures of the lumbar cord at intensities above the threshold of large-diameter posterior root fibers.

[Effect of electroacupuncture on expression of ionotropic glutamate receptor subunits and their genes in lumbar segments of spinal cord in rats with neuropathic pain].

OBJECTIVE: To observe the effect of electroacupuncture (EA) on the expression of ionotropic glutamate receptor (iGluR) subunits and their mRNAs in the lumbar segments of spinal cord in rats with neuropathic pain, so as to explore its underlying mechanism in relieving spinal hyperalgesia. METHODS: Thirty SD rats were randomly divided into control, model, and EA groups, with 10 rats in each. The spared nerve injury (SNI) model was established by ligature of the sural nerve after cutting off the common peroneal nerve and anterior tibial nerve. EA (2 Hz, 1 mA) was applied to "Huantiao" (GB 30) and "Weizhong" (BL 40) for 30 min, once daily for 7 days. Mechanical pain threshold was detected before and after modeling and before and after EA treatment. The expression levels of N-methyl-d-aspartic acid (NMDA) receptor subunits NR1 and NR 2 B,and AMPA receptor subunit GluR 1 of iGluR and their genes were assayed by Western blot and reverse transcription polymerase chain reaction (RT-PCR) separately. RESULTS: In comparison with control group, the mechanical pain thresholds were decreased significantly on day 2, 7 and day 14 following modeling in the model group (P < 0.05, P < 0.01). While compared with the model group, the pain threshold was increased considerably on day 14 in the EA group (P < 0.01). Compared with the control group, the expression levels of lumbar spinal cord NR 2 B and NR 2 B mRNA in the model group were increased significantly (P < 0.05), and those of lumbar spinal cord NR 1 and NR 1 mRNA, GluR 1 and GluR 1 mRNA in the model group increased slightly (P > 0.05). In comparison with the model group, the expression levels of lumbar spinal cord NR 2 B and NR 2 B mRNA in the EA group were downregulated remarkably (P < 0.05), and those of lumbar spinal cord NR 1 and NR 1 mRNA, GluR 1 and GluR 1 mRNA in the EA group down-regulated slightly (P > 0.05). CONCLUSION: EA can significantly suppress pain reaction in rats with neuropathic pain probably through down-regulating the expression of lumbar spinal cord NR 2 B protein and NR 2 B mRNA.

The migratory fascia hypothesis.

When treating pelvic obliquity, the author has noticed apparent ridging of soft issue in the gluteal region. In an effort to understand this phenomenon, an informal field study involved searching athletes for common movement patterns that might induce pelvic distortion, including torsion around the vertical axis. The author was curious about consequent fascial involvement and its influence on lower back pain. The author respectfully reports a subjective palpatory observation; a thin palpable fibrous element of superficial fascia presumed to work similarly to a trouser belt. This apparently lies parallel and medially deep to the iliac crest, extending from the lumbosacral junction laterally, passing the antero-superior aspect of the PSIS, then continuing medio-laterally to merge with the upper portion of the inguinal ligament. It is suggested that injury-related displacement of this element, and the adjacent superficial fascia laterally across the iliac crest, resulting from sacrificial damage to crural elements in the inguinal area, could produce fascial strain patterns, contributing to iliolumbar pain symptoms. Displacement, or migration, of fascia in this manner is suggested by the author to result in a fascial fold aligned with the ASIS and PSIS landmarks, where aponeurotic reinforcement may arrest further caudal displacement of fascia. The appearance of the fold varies with the amount of relinquished inguinal tension, the thickness of the folded tissue, and with the extent of fascial migration. For example, a migration across the entire crest may result in a fold that directly bridges about 80% of the ASIS-PSIS axis, flattening out at the ends. The correct relocation of the fascia over appropriately aligned pelvic bones may then result in the disappearance of the fold, which can measure up to 20mm midway. The intention of this paper is to encourage more collaborative efforts between clinicians and scientists to further understand this apparent phenomenon, and its possible implications for lumbo-pelvic function. Although a review of anatomy atlases has failed to reveal mention of migratory fascia, the author respectfully suggests that dissection, specifically aimed at this task, may demonstrate its presence. It is also suggested that a retrospective review of lumbo-pelvic MRI records be initiated to identify the presence of this proposed fascial feature in the general population. Finally, magnetic resonance elastography may be useful in defining areas of increased muscular tension, in order to test the migratory fascia hypothesis.

Sensibility testing in patients with a lumbosacral radicular syndrome.

OBJECTIVE: To examine whether there is a significant difference in gnostic sensibility between affected and unaffected legs of patients suffering from lumbosacral radicular syndrome (LRS) resulting from a disc herniation and to determine the validity of the sensibility test for detecting a disc herniation. DESIGN: Observer blind study of sensibility testing. SETTING: Four general hospitals (neurology department) and one practice of physical and manual therapy. SUBJECTS: Fifty-one patients with radicular pain in the lumbosacral nerve roots for at least 4 wk and/or neurological deficits. METHODS: The gnostic sensibility of 51 patients with a unilateral LRS was tested using Semmes-Weinstein monofilaments for the L4, L5 and S1 dermatomes. RESULTS: Gnostic hypoesthetic impairments in the L4, L5 and S1 dermatomes were found in 84.6% of the 43 patients in which the presence of disc herniation was confirmed by CT. There was significant difference in gnostic sensibility between the affected and unaffected legs in the L4, L5, and S1 dermatomes for disc herniation at the L4-L5 level and for the L5 and S1 dermatomes for a disc herniation at the L5-S1 level. There was no significant difference in gnostic sensibility in the L4 dermatome for a disc herniation at the L5-S1 level. CONCLUSION: The gnostic sensibility of the affected leg is hypoesthetic compared with the unaffected leg. The specificity of the sensibility test using monofilaments is acceptable, but the sensitivity is not. The monofilament test is a useful and practical tool for excluding the presence of a disc herniation at dermatomes L4, L5 and S1 and disc herniations at the L4-L5, L5-S1 level.

Innervation of posterior structures in the lumbar spine of the rat.

OBJECTIVE: To determine the nature and distribution of afferent fibers to the interspinous tissues and facet joints of the lumbar spine in the rat. DESIGN: Dissection and photography of medial branch of the primary dorsal ramus; histological and electron microscopic examination of the medial branch; measurement of conduction velocities of fibers within the medial branch; recording of compound nerve activity in medial branch in response to mechanical and chemical stimulation of interspinous tissues and facet joints. RESULTS: In the rat, the medial branch of the primary dorsal ramus of lumbar spinal nerves is normally distributed to the facet joints and interspinous tissues one and two segmental levels caudad to its origin. This nerve contains unmyelinated and myelinated afferents with conduction velocities within the ranges of C fibers, and A-delta and A-beta fibers. The tissues served by this nerve are sensitive to mechanical and noxious chemical stimulation. CONCLUSIONS: There are many structural and functional similarities in the innervation of the lumbar spine in rats and humans. However, there are anatomical variants and, in rats, the medial branch of the primary dorsal ramus, which serves the interspinous tissues and facet joints, is distributed more caudally than in humans. This information should be taken into account in extrapolating experimental results from rats to the human situation.

Pelvic pain and organic dysfunction in a patient with low back pain: response to distractive manipulation: a case presentation.

Many patients with low back pain demonstrate pelvic symptomatology attributable to lower sacral nerve root compression. Lower sacral nerve root compression has been identified as a cause of pelvic pain and pelvic organ dysfunction. Pelvic symptomatology secondary to lower sacral nerve root compression is given. Lower sacral nerve root compression is most commonly the result of lumbosacral disc lesion. A case of low back pain accompanied with pelvic symptomatology is presented along with its response to distractive manipulation. chiropractic treatment may be an effective means of treating pelvic disorders secondary to lower sacral nerve root compression provided that the underlying disc lesion is dealt with, although further study is needed.

[Increasing the effectiveness of hyperbaric oxygenation in the treatment of patients with stage IV arterial occlusive diseases of the lower limbs]. / Povyshenie èffektivnosti giperbaricheskoi oksigenatsii pri lechenii bol'nykh s IV stadiei oblteriruiushchikh zabolevanii arterii nizhnikh konechnostei.

An analysis of treatment of 122 patients has shown that the effectiveness of HBO can be enhanced by a combination with continuous intraarterial infusions and lumbar sympathectomy. An important condition for reaching the maximum effect of HBO is an increase of the initially low cardiac output in such patients.

Urethral responses during selective electrostimulation of lumbosacral spinal nerve roots in the female spinal dog.

Urethral responses on the urethral pressure profile (UPP) during selective electrostimulation of the ventral or dorsal roots in a group of lower lumbar (L5-7) or sacral (S1-3) nerves were observed in female spinal (C1-transected) dogs. The UPPs were recorded by using a balloon catheter, and square pulse wave of 5 V, 10 Hz, 1 msec was applied for electrostimulation of the spinal nerve root. The UPPs were analyzed by dividing the functional profile length (FL) into three equal parts and comparing the height of maximal clossure pressure at each UPP segment. After lumbosacral rhizotomies proximal to the electrodes, stimulation of the lower lumbar ventral roots produced a marked elevation at the proximal third (bladder neck) of UPP, while similar response was found at the middle third (midsphincteric urethra) and distal third (external urethral sphincter) of UPP during the sacral ventral roots stimulation. The stimulation of the dorsal roots of the lower lumbar and sacral nerves also produced a similar response as that of the ventral roots stimulation though less in amplitude. So it could be concluded that in female dog the sphincteric urethra might receive a functional innervation from the lower lumbar and sacral spinal segments in somewhat different manners.