Kambin's triangle and the position of the dorsal nerve root in the lumbar neural foramen.

INTRODUCTION: As a result of the increased utilization of neurosurgical arthroscopic techniques, investigations into population and sex-specific trends of anatomical considerations have become increasingly important. This study aimed to investigate and describe aspects of the neuroanatomical morphometry of lumbar spines in a cadaveric and magnetic resonance imaging (MRI) sample. MATERIALS AND METHODS: Twenty white adult (>18 years) cadavers (9 males; 11 females) were obtained under Ethical clearance. The lumbar regions were dissected and the position of the dorsal root ganglion (DRG) and dimensions of Kambin's triangle were determined. Twenty-six black adult (>18 years) MRI scans (17 males; 9 females) were obtained from an Academic Hospital and were used to determine the dimensions of the neural foramen and the DRGs within. RESULTS: The ganglia were mostly at the midline of the caudal pedicle. Similar to previous studies, the diagonal measurement from Kambin's triangle was the largest and the vertical measurement the shortest. Skeletal and soft-tissue measurements indicated distinct trends when moving caudolaterally in the spine. Soft-tissue parameters from the current study were within the upper limits of those from previous studies, whereas skeletal parameters were in agreement with those reported by previous authors. CONCLUSIONS: Results from this study suggest a variation of certain parameters between studies with varying population groups and therefore supports the need for and the importance of possible population-specific trends of anatomical parameters considered during surgical procedures.

Analysis of S1 DRG Programming to Determine Location of the DRG and Ideal Anatomic Positioning of the Electrode.

INTRODUCTION: Dorsal root ganglion (DRG) stimulation has been established as a therapy in the treatment of chronic pain. Ideal electrode placement is guided by proper identification of the location of the DRG. The location of the S1 DRG is not well delineated and can be variable making ideal location of the electrode placement difficult based on fluoroscopic imaging. METHODS: This is a retrospective analysis of postoperative programming of S1 DRG leading across two centers. There were 34 lead placements in 24 patients included in this study. Programming parameters and contacts used were evaluated based on the position of the electrode in reference to the sacral border. RESULTS: The majority of the patient programming parameters were recorded at six weeks following the implant. Most commonly, the programming used a simple continuous bipole configuration. Of the 34 leads programmed, 17 (50%) had programming on the sacral border, 14 (41%) were considered posterior, and 3 (9%) were anterior to the sacral border. CONCLUSION: This analysis of S1 DRG programming demonstrates that ideal positioning of the majority of the contacts for the electrode should be posterior and along the sacral border on fluoroscopic imaging. These findings also suggest that the S1 DRG may be located most reproducibly at the border of the intraforaminal and intracanalicular region.

Unique Characteristics of the Dorsal Root Ganglion as a Target for Neuromodulation.

OBJECTIVE: The dorsal root ganglion (DRG) is a novel target for neuromodulation, and DRG stimulation is proving to be a viable option in the treatment of chronic intractable neuropathic pain. Although the overall principle of conventional spinal cord stimulation (SCS) and DRG stimulation-in which an electric field is applied to a neural target with the intent of affecting neural pathways to decrease pain perception-is similar, there are significant differences in the anatomy and physiology of the DRG that make it an ideal target for neuromodulation and may account for the superior outcomes observed in the treatment of certain chronic neuropathic pain states. This review highlights the anatomy of the DRG, its function in maintaining homeostasis and its role in neuropathic pain, and the unique value of DRG as a target in neuromodulation for pain. METHODS: A narrative literature review was performed. RESULTS: Overall, the DRG is a critical structure in sensory transduction and modulation, including pain transmission and the maintenance of persistent neuropathic pain states. Unique characteristics including selective somatic organization, specialized membrane characteristics, and accessible and consistent location make the DRG an ideal target for neuromodulation. Because DRG stimulation directly recruits the somata of primary sensory neurons and harnesses the filtering capacity of the pseudounipolar neural architecture, it is differentiated from SCS, peripheral nerve stimulation, and other neuromodulation options. CONCLUSIONS: There are several advantages to targeting the DRG, including lower energy usage, more focused and posture-independent stimulation, reduced paresthesia, and improved clinical outcomes.

The short and midterm outcomes of lumbar transforaminal epidural injection with preganglionic and postganglionic approach in lumbosacral radiculopathy: a systematic review and meta-analysis.

The purpose of this study was to compare clinical outcomes after preganglionic versus ganglionic epidural steroid injection (ESI) using a systematic review and network meta-analysis. A systematic review and meta-regression was performed to compare postoperative outcomes between the two difference injection techniques. Relevant randomized controlled trials were identified from Medline and Scopus up to September 24, 2016. Sixteen out of 598 studies were eligible; 3, 2, and 3 studies were included in the pooling of outcomes including effectiveness, visual analog score (VAS), and complications (nerve root, injury, dural puncture, and intraneural injection). Preganglionic ESI has a 2.38 (95% CI 1.12, 5.04) times statistically significantly higher chance of effectiveness when compared to ganglionic ESI. There were differences in pain VAS and complications in lumbar radiculopathy, but these displayed no statistical significance. This meta-analysis indicated that preganglionic ESI has a statistically significantly higher chance of effectiveness when compared to ganglionic ESI. In terms of pain score and complications, there were no statistically significant differences between the two groups. These results were generally homogeneous and with little publication bias, thus should be generalizable.

Morphological anatomy of thoracolumbar nerve roots and dorsal root ganglia.

The aim of this study is to ascertain the anatomic parameters of the spinal roots and dorsal root ganglia and to demonstrate their clinical significance. Samples from 24 adult autopsy subjects were obtained from roots and dorsal root ganglia at levels L1 through L5. The anatomic parameters of epidural nerve roots: the distance between the epidural nerve roots and the proximal edge of the dorsal root ganglia and the average diameter of the nerve root gradually, increased from L1 to L5. The midline nerve root angle gradually decreased from L1 to L5. The anatomic parameters of subarachnoid nerve roots: the length of subarachnoid nerve roots and both the ventral and dorsal roots' diameter, increased from L1 to L5. The number of ventral and dorsal rootlets per nerve root ranged from one to three. The anatomic parameters of dorsal root ganglia: the length and width of the thoracic and lumbar dorsal root ganglia, gradually increased from L1 to L5. The locations of the dorsal root ganglia were recorded as the intraspinal, intraforaminal and extraforaminal using some bony landmarks. Most dorsal root ganglia located intraforaminally, and the extraforaminal type is more common in the L5 root than other thoracic and lumbar roots, regardless of age. This knowledge is a must not only to avoid complications but also for the success, safety and effectiveness of microsurgical operations.

Distribution pattern of dorsal root ganglion neurons synthesizing nitric oxide synthase in different animal species.

The main aim of the present review is to provide at first a short survey of the basic anatomical description of sensory ganglion neurons in relation to cell size, conduction velocity, thickness of myelin sheath, and functional classification of their processes. In addition, we have focused on discussing current knowledge about the distribution pattern of neuronal nitric oxide synthase containing sensory neurons especially in the dorsal root ganglia in different animal species; hence, there is a large controversy in relation to interpretation of the results dealing with this interesting field of research.

Variations of the accessory nerve: anatomical study including previously undocumented findings-expanding our misunderstanding of this nerve.

INTRODUCTION: The anatomy of the accessory nerve has been well described but continued new clinical and anatomical findings exemplify our lack of a full understanding of the course of this nerve. Therefore, this study aimed to expand on our knowledge of the course of the 11th cranial nerve via anatomical dissections. METHODS: Fifty-six cadavers (112 sides) underwent dissection of the accessory nerve from its cranial and spinal origins to its emergence into the posterior cervical triangle. Immunohistochemistry was performed when appropriate. RESULTS: Our findings included two cases (1.8%) where the nerve was duplicated, one intracranially and one extracranially. One accessory nerve (0.9%) was found to enter its own dural compartment within the jugular foramen. The majority of sides (80%) were found to have a cranial root of the accessory nerve. Thirty-one sides (28%) had connections to cervical dorsal roots medially and three sides (2.7%) laterally. Medial connections were most common with the C1 nerve. Medial components of these dorsal root connections were all sensory in nature. However, lateral components were motor on two sides (1.8%). Nerves traveled anterior to the internal jugular vein on 88% of sides. One (0.9%) left side nerve joined an interneural anastomosis between the dorsal rootlets. Macroganglia were found on the spinal part of the intracranial nerve on 13% of sides. The lesser occipital nerve arose directly from the accessory nerve on two sides (1.8%) and communicated with the accessory nerve on 5.4% of sides. One side (0.9%) was found to communicate with the facial nerve with both nerves innervating the sternocleidomastoid muscle. CONCLUSIONS: Additional anatomical knowledge of the variants of the accessory nerve may benefit patient care when this nerve is pathologically involved.

Relevant Anatomy, Morphology, and Implantation Techniques of the Dorsal Root Ganglia at the Lumbar Levels.

OBJECTIVES: While dorsal root ganglion (DRG) stimulation has been available in Europe and Australia for the past five years and in the United States for the past year, there are no published details concerning the optimal procedures for DRG lead implantation. MATERIALS AND METHODS: We describe several techniques that can be applied to implant cylindrical leads over the DRG, highlighting some tips and tricks according to our experiences. Focus is mainly shifted toward implantations in the lumbar area. We furthermore give some insights in the results we experienced in Spain as well as some worldwide numbers. IMPLANT TECHNIQUES AND RESULTS: A 14-gauge needle is placed using a "2-Level Technique (2-LT)" or exceptionally a "1-Level Technique (1-LT)" or a "Primary- or Secondary Technique" at the level of L5. The delivery sheath, loaded with the lead, is advanced toward the targeted neural foramen. The lead is placed over the dorsal aspect of the DRG. A strain relief loop is created in the epidural space. Sheath and needle are retracted and the lead is secured using an anchor or anchorless technique. In Spain, 87.2% (N = 78) of the selected patients have been successfully implanted. Seven (8.9%) had a negative trial and three (4.2%) were explanted. Average VAS score decreased from 8.8 to 3.3 and on average 94.5% of the pain area was covered. In our center's subjects (N = 47 patients, 60.3% of all implanted patients in Spain), VAS scores decreased from an average of 8.8-1.7 and pain coverage averaged 96.4%. We used an average of 1.8 electrodes. Worldwide more than 4000 permanent cases have been successfully performed. CONCLUSIONS: We present implantation techniques whereby a percutaneous lead is placed over the DRG through the use of a special designed delivery sheath. Further investigation of the safety, efficacy, and sustainability of clinical outcomes using these devices is warranted.

Axolotls with an under- or oversupply of neural crest can regulate the sizes of their dorsal root ganglia to normal levels.

How animals adjust the size of their organs is a fundamental, enduring question in biology. Here we manipulate the amount of neural crest (NC) precursors for the dorsal root ganglia (DRG) in axolotl. We produce embryos with an under- or over-supply of pre-migratory NC in order to find out if DRG can regulate their sizes during development. Axolotl embryos are perfectly suitable for this research. Firstly, they are optimal for microsurgical manipulations and tissue repair. Secondly, they possess, unlike most other vertebrates, only one neural crest string located on top of the neural tube. This condition and position enables NC cells to migrate to either side of the embryo and participate in the regulation of NC cell distribution. We show that size compensation of DRG in axolotl occurs in 2 cm juveniles after undersupply of NC (up-regulation) and in 5 cm juveniles after oversupply of NC (down-regulation). The size of DRG is likely to be regulated locally within the DRG and not via adaptations of the pre-migratory NC or during NC cell migration. Ipsi- and contralateral NC cell migration occurs both in embryos with one and two neural folds, and contralateral migration of NC is the only source for contralateral DRG formation in embryos with only one neural fold. Compensatory size increase is accompanied by an increase in cell division of a DRG precursor pool (PCNA+/SOX2-), rather than by DRG neurons or glial cells. During compensatory size decrease, increased apoptosis and reduced proliferation of DRG cells are observed.

Dispersal pattern of injectate following CT-guided perineural infiltration in the canine thoracolumbar spine: a cadaver study.

An increasing proportion of canine patients are presented with chronic thoracolumbar back pain and without compressive spinal lesions. In humans, spinal perineural infiltrations have been reported to have a favorable effect on pain control. The purpose of this prospective cadaver study was to describe the dispersal pattern of injectate following CT-guided spinal perineural infiltration in the canine thoracolumbar region. Seven fresh canine cadavers were first scanned using multislice CT and then CT-guided spinal perineural infiltration was performed at 42 sites from T13/L1 to L6/L7. The injectate for each site was a mixture of new methylene blue and iodinated contrast medium. Immediately following CT-guided injection, cadavers were frozen, cut, and dissected macro- and mesoscopically (using a magnifying glass) to identify anatomic structures that were infiltrated. In the majority of sites (64.3%), complete epidural and hypaxial staining of spinal nerve components (including the spinal ganglion, trunk, and ventral branch) was successfully achieved. However, no (11.9%) or unpredictable staining (9.5%) of nervous tissue occurred in some sites despite careful CT guidance and the application of relatively large volumes of injectate. Optimal results were achieved when the needle tip was positioned periforaminally ventral to the cranial contour of the cranial articular process. Findings from this ex vivo study indicated that CT-guided spinal perineural infiltration is feasible for testing in the canine thoracolumbar region and that successful nerve tissue infiltration would likely occur in the majority of sites. Future in vivo studies are needed to determine the safety and efficacy of this technique.

Anatomy of the spinal dorsal root entry zone: its clinical significance.

BACKGROUND: The posterolateral sulcus (PLS) is an important surgical landmark, especially for DREZ (dorsal root entry zone) operations. METHODS: The present study aimed to show the variations of the PLS using human spinal cord histological sections and report the variability in the number of dorsal rootlets of the spinal nerves in each the spinal cord segment. Further, measure the height and width of the dorsal horn on histological sections for cervical, thoracic, and lumbar levels. RESULTS: The results of the present study showed various patterns of PLS 1.clearly present PLS, 2. short PLS, 3. absent PLS or 4. irregular PLS. Height and width measurements of the dorsal horn showed that the average width was greatest at lower cervical (0.48 ± 0.04 mm) and least at lower thoracic levels (0.41 ± 0.04 mm), whereas the average height was greatest at upper cervical (3.0 ± 0.06 mm) and smallest at lower lumbar levels (1.8 ± 0.08 mm). The average number of rootlets varied considerably, at cervical level it was 7.6 ± 1.4 mm, at thoracic 6.6 ± 0.8 mm and at lumbar 6.1 ± 0.4 mm. CONCLUSIONS: The detailed anatomy of the variations of the PLS and the average number of rootlets at each spinal level can increase the success of regional surgery. Further, fine measurements on histological sections can give detailed knowledge on the size necessary for lesioning in DREZ operations.

Morphological structure and variations of lumbar plexus in human fetuses.

The objective of this study is to study the anatomy of lumbar plexus on human fetuses and to establish its morphometric characteristics and differences compared with adults. Twenty lumbar plexus of 10 human fetal cadavers in different gestational ages and genders were dissected. Lumbar spinal nerves, ganglions, and peripheral nerves were exposed. Normal anatomical structure and variations of lumbar plexus were investigated and morphometric analyses were performed. The diameters of lumbar spinal nerves increased from L1 to L4. The thickest nerve forming the plexus was femoral nerve, the thinnest was ilioinguinal nerve, the longest nerve through posterior abdominal wall was iliohypogastric nerve, and the shortest nerve was femoral nerve. Each plexus had a single furcal nerve and this arose from L4 nerve in all fetuses. No prefix or postfix plexus variation was observed. In two plexuses, L1 nerve was in the form of a single branch. Also, in two plexuses, genitofemoral nerve arose only from L2 nerve. Accessory obturator nerve was observed in four plexuses. According to these findings, the morphological pattern of the lumbar plexus in the fetus was found to be very similar to the lumbar plexus in adults.

Spinal afferent innervation in flat-mounts of the rat stomach: anterograde tracing.

The dorsal root ganglia (DRG) project spinal afferent axons to the stomach. However, the distribution and morphology of spinal afferent axons in the stomach have not been well characterized. In this study, we used a combination of state-of-the-art techniques, including anterograde tracer injection into the left DRG T7-T11, avidin-biotin and Cuprolinic Blue labeling, Zeiss M2 Imager, and Neurolucida to characterize spinal afferent axons in flat-mounts of the whole rat stomach muscular wall. We found that spinal afferent axons innervated all regions with a variety of distinct terminal structures innervating different gastric targets: (1) The ganglionic type: some axons formed varicose contacts with individual neurons within myenteric ganglia. (2) The muscle type: most axons ran in parallel with the longitudinal and circular muscles and expressed spherical varicosities. Complex terminal structures were observed within the circular muscle layer. (3) The ganglia-muscle mixed type: some individual varicose axons innervated both myenteric neurons and the circular muscle, exhibiting polymorphic terminal structures. (4) The vascular type: individual varicose axons ran along the blood vessels and occasionally traversed the vessel wall. This work provides a foundation for future topographical anatomical and functional mapping of spinal afferent axon innervation of the stomach under normal and pathophysiological conditions.

Axonal degeneration is regulated by the apoptotic machinery or a NAD+-sensitive pathway in insects and mammals.

Selective degeneration of neuronal projections and neurite pruning are critical for establishment and maintenance of functional neural circuits in both insects and mammals. However, the molecular mechanisms that govern developmental neurite pruning versus injury-induced neurite degeneration are still mostly unclear. Here, we show that the effector caspases 6 and 3 are both expressed within axons and that, on trophic deprivation, they exhibit distinct modes of activation. Surprisingly, inhibition of caspases is not sufficient for axonal protection and a parallel modulation of a NAD(+)-sensitive pathway is required. The proapoptotic protein BAX is a key element in both pathways as its genetic ablation protected sensory axons against developmental degeneration both in vitro and in vivo. Last, we demonstrate that both pathways are also involved in developmental dendritic pruning in Drosophila. More specifically, the mouse Wld(S) (Wallerian degeneration slow) protein, which is mainly composed of the full-length sequence of the NAD(+) biosynthetic Nmnat1 enzyme, can suppress dendritic pruning in C4da (class IV dendritic arborization) sensory neurons in parallel to the fly effector caspases. These findings indicate that two distinct autodestruction pathways act separately or in concert to regulate developmental neurite pruning.

Inflammation and axon regeneration.

PURPOSE OF REVIEW: The inflammatory response that accompanies neural injury involves multiple cell types and effector molecules with both positive and negative effects. Inflammation is essential for normal regeneration in the peripheral nervous system, and here we review evidence that augmenting inflammation can enhance regeneration in areas of the central nervous system in which it normally does not occur. RECENT FINDINGS: Within the spinal cord, inflammation enables transplanted sensory neurons to regenerate lengthy axons and enhances the ability of a trophic factor to promote corticospinal tract sprouting. Induction of inflammation in the eye supports survival of retinal ganglion cells and enables them to regenerate injured axons through the optic nerve. These effects are linked to an atypical trophic factor, oncomodulin, along with other, better known molecules. Induction of inflammation within dorsal root ganglia, when combined with other treatments, enables peripheral sensory neurons to regenerate axons into the spinal cord. However, inflammation also has negative effects that impede recovery. SUMMARY: In light of the importance of inflammation for neural repair, it is important to identify the specific cell types and molecules responsible for the positive and negative effects of inflammation and to develop treatments that tip the balance to favor repair.

Primary sensory neurons with dichotomizing axons projecting to the facet joint and the low back muscle in rats.

BACKGROUND: Clinically, the origin of low back pain is unknown. The pain may originate from the lumbar muscles directly, or it may be referred pain from the spine. Dorsal root ganglion (DRG) neurons with dichotomizing axons have been reported in several species and are thought to be related to referred pain. However, these neurons, which have dichotomizing axons to the lumbar facet joints and to the lumbar muscle, have not been fully investigated. METHODS: Two neurotracers - 1,1'-dioctadecyl-3,3,3',3'- tetramethyl-indocarbocyanine perchlorate (DiI) and fluorogold (FG) - were used in the present double-labeling study. DiI crystals were placed in the right L5/6 facet joint, and FG was applied to right multifidus muscles at the L5 level in 10 rats. Two weeks later, bilateral DRGs from L1 through L6 were harvested, sectioned, and observed under a fluorescence microscope. RESULTS: DiI-labeled DRG neurons innervating the L5/6 facet joint (5.17% of the total DRG neurons) were distributed from L1 to L6. FG-labeled DRG neurons innervating the lower back muscle (15.9% of the total) were also distributed from L1 to L6. Double-labeled DRG neurons were found from L1 to L6. The ratio of total double-labeled/total DiI-labeled DRG neurons was 17% and that of total double-labeled/total FG-labeled DRG neurons was 7%. Approximately 17% of all DRG neurons innervating the facet joints had other axons that extended to the lower back muscle. CONCLUSIONS: This finding provides a possible neuroanatomical explanation for referred low back muscle pain from the lower facet joints.

Dorsoventral organization of sensory nerves in the lumbar spine as indicated by double labeling of dorsal root ganglion neurons.

BACKGROUND: Referred pain due to lumbar disc disorders can be analyzed using the stereoscopic structure of the peripheral sensory nervous system. The rostrocaudal structure has been clarified. The dorsoventral structure of the lumbar spine would be useful for mapping areas of pain perception in spinal disorders. METHODS: The neurotracer 1,1-dioctadecyl-3,3,3,3-tetramethylindocarbocyanine perchlorate (DiI) was applied to the lateral portion of the L5/6 intervertebral disc in rats to examine the dorsoventral organization of the sensory nervous system in the lumbar spine and related tissues. Fluorogold (FG) was applied to reference sites located at the spinous process of the L5 vertebra, the L5/6 facet joint, the psoas muscle at the L5 level, or the rectus abdominis muscle at the pubic symphysis. FG was also applied to the lateral portion of the disc (DiI application site) at L5 or at the L5 level as controls for the double labeling. Labeled neurons were counted in dorsal root ganglia (DRGs) from L1 through L4. RESULTS: The proportion of neurons double-labeled with DiI and FG in the total number of DiI-labeled and FG-labeled neurons was 32.9% in the control group; 0% in the spinous process, 0.6% in the facet joint, 2.3% in the psoas muscle, and 0.1% in the rectus abdominis muscle. DRG neurons with dichotomizing afferent fibers were most prevalent (2.3%) between the lateral disc and the psoas muscle at the groin; they were rare or absent between the disc and other reference sites. CONCLUSIONS: Dorsoventral organization of the primary sensory system in the lumbar body trunk was suggested from the proportion of DRG neurons with dichotomizing afferent fibers innervating the lumbar disc and other tissues. The present findings provide a pathomechanism of groin referred pain in lumbar disc disorders.

A video protocol for rapid dissection of mouse dorsal root ganglia from defined spinal levels.

OBJECTIVE: Dorsal root ganglia (DRG) are heterogeneous assemblies of assorted sensory neuron cell bodies found in bilateral pairs at every level of the spinal column. Pseudounipolar afferent neurons convert external stimuli from the environment into electrical signals that are retrogradely transmitted to the spinal cord dorsal horn. To do this, they extend single axons from their DRG-resident somas that then bifurcate and project both centrally and distally. DRG can be dissected from mice at embryonic stages and any age post-natally, and have been extensively used to study sensory neuron development and function, response to injury, and pathological processes in acquired and genetic diseases. We have previously published a step-by-step dissection method for the rapid isolation of post-natal mouse DRG. Here, the objective is to extend the protocol by providing training videos that showcase the dissection in fine detail and permit the extraction of ganglia from defined spinal levels. RESULTS: By following this method, the reader will be able to swiftly and accurately isolate specific lumbar, thoracic, and cervical DRG from mice. Dissected ganglia can then be used for RNA/protein analyses, subjected to immunohistochemical examination, and cultured as explants or dissociated primary neurons, for in-depth investigations of sensory neuron biology.

The Anatomical Study and Clinical Significance of the Sinuvertebral Nerves at the Lumbar Levels.

STUDY DESIGN: A dissection-based study of 10 embalmed human cadavers. OBJECTIVE: The purpose of this study was to describe the sinuvertebral nerves at the lumbar level and to discuss their possible clinical significance. SUMMARY OF BACKGROUND DATA: Discogenic low-back pain is mediated by the sinuvertebral nerves. However, the detailed descriptions of the sinuvertebral nerves at the lumbar level are lacking. METHODS: One hundred L1-L5 intervertebral foramina from 10 embalmed cadavers were studied. The presence of the sinuvertebral nerves was noted. The quantity, origin, pathway, innervation range, and spatial orientations of the sinuvertebral nerves in the L1-L5 intervertebral foramina were examined. RESULTS: A total of 450 sinuvertebral nerves were identified in the 100 lumbar intervertebral foramina; sinuvertebral nerves were observed in 100.00% of the intervertebral foramina. The sinuvertebral nerves were routinely divided into the following two types: the sinuvertebral nerve deputy branch and sinuvertebral nerve main trunk. Three hundred twelve sinuvertebral nerve deputy branches were found; on average, there were approximately 3.12 (range, 1-8) branches in each intervertebral foramen. One hundred thirty-eight sinuvertebral nerve main trunks were found, and sinuvertebral nerve main trunks were observed in 97.00% of the intervertebral foramina. The initial portion of the sinuvertebral nerve was located along the posterior-lateral edge of the disc to the spinal canal. Sixty-one (44.20%) sinuvertebral nerve main trunks originated from the starting point of the gray ramus communicans of the nerve root; 77 (55.80%) sinuvertebral nerve main trunks originated from the anterior surface of the spinal ganglia of the nerve root. CONCLUSION: This is a systematic anatomy study that describes the sinuvertebral nerve at the lumbar level and may be of clinical importance to spinal surgeons. A comprehensive understanding of the distribution of sinuvertebral nerves may lead to significant benefits for patients undergoing percutaneous endoscopic treatment for discogenic low-back pain. LEVEL OF EVIDENCE: 4.

Immunohistochemical localization of phosphodiesterase 2A in multiple mammalian species.

Phosphodiesterases (PDEs) comprise a family of enzymes that regulate the levels of cyclic nucleotides, key second messengers that mediate a diverse array of functions. PDE2A is an evolutionarily conserved cGMP-stimulated cAMP and cGMP PDE. In the present study, the regional and cellular distribution of PDE2A in tissues of rats, mice, cynomolgus monkeys, dogs, and humans was evaluated by immunohistochemistry. A polyclonal antibody directed to the C-terminal portion of PDE2A specifically detected PDE2A by Western blotting and by immunohistochemistry. The pattern of PDE2A immunoreactivity (ir) was consistent across all species. Western blot analysis demonstrated that PDE2A was most abundant in the brain relative to peripheral tissues. PDE2A ir was heterogeneously distributed within brain and was selectively expressed in particular peripheral tissues. In the brain, prominent immunoreactivity was apparent in components of the limbic system, including the isocortex, hippocampus, amygdala, habenula, basal ganglia, and interpeduncular nucleus. Cytoplasmic PDE2A staining was prominent in several peripheral tissues, including the adrenal zona glomerulosa, neurons of enteric ganglia, endothelial cells in all organs, lymphocytes of spleen and lymph nodes, and pituitary. These studies suggest that PDE2A is evolutionarily conserved across mammalian species and support the hypothesis that the enzyme plays a fundamental role in signal transduction.