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      Ultrasound-guided injection of the erector spinae enthesis for iliac crest pain syndrome

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          Abstract

          Sir, A 40-year-old female patient applied to our clinic with chronic low back pain, especially on the left side of the lumbar spine, for the past 2 years. The pain was worse in a prolonged sitting position and during lateral bending of the trunk. Radiographs showed decreased lumbar lordosis with no facet pathologies. She denied any trauma and declared that oral anti-inflammatory drugs, massage, laser therapy, and low back school had been partially effective. Physical examination revealed intense pain on palpation of the paraspinal muscles and the posterior medial iliac crest on the left side. Active motions of the lumbar spine were painful especially during extension and right lateral bending. Straight leg raising and Wasserman tests were negative on both sides. Based on the clinical findings, the patient was diagnosed with chronic “nonspecific” low back pain with a remarkable myofascial pain component. Due to the failure of previous conservative therapies, ultrasound (US) examination using a high-frequency linear probe (4–16 MHz) was performed to correctly identify the superficial painful structures (i.e., pain generators) before an eventual local injection therapy.[1 2 3] With the probe positioned in a longitudinal oblique plane and using the posterior superior iliac spine as the bony landmark [Figure 1a], two muscular structures were identified under the thoracolumbar fascia: erector spinae muscle (ESM) and multifidus muscle [Figure 1b].[4] Of note, at the sacral level, the ESM is mainly constituted of longissimus (thoracis) muscle with a small contribution from iliocostalis lumborum. Tilting the probe in the proximity of the painful site, the two components of erector spinae enthesis were visualized: the attachment sites of the erector spinae aponeurosis (ESA) and the deep tendon of the ESM [Figure 1b]. Figure 1 Black rectangle illustrates the probe positioning in the longitudinal oblique plane over the left posterior superior iliac spine. Black dotted line indicates the anatomical site of the erector spinae muscle. Red area shows the attachment site of the erector spinae aponeurosis and the green area shows the attachment site of the deep tendon of the erector spinae muscle. (a) Corresponding ultrasound image shows the thoracolumbar fascia (white dotted line), the erector spinae aponeurosis and its enthesis (single asterisk), the erector spinae muscle and its deep enthesis (double asterisks), the multifidus muscle (M) and the needle's direction in a craniocaudal direction (red arrow) (b). Schematic drawings show the lateral bending test eliciting pain over the opposite posterior medial iliac crest and the irradiation along the cranial portion of the erector spinae muscle (c); the footprint of the erector spinae aponeurosis (red line) and the footprint of the deep tendon of the erector spinae muscle (green line) over the posterior superior iliac spine (d).f = Fat tissue; f-ESA = Footprint of the erector spinae aponeurosis; f-dpESM = Footprint of the deep tendon of the erector spinae muscle Based on the US findings, we planned the local injection in a craniocaudal direction [Figure 1b], using a 22-gauge needle (0.70 mm × 30 mm) and advancing it until the tendon-bone junction. The perientheseal injections were performed once a week for 2 weeks with a total volume of 4 mL for each procedure (2 mL of lidocaine hydrochloride 10 mg/mL and 2 mL of betamethasone disodium phosphate 4 mg/2 mL). Betamethasone disodium phosphate has been used because it is a freely water soluble preparation (i.e., nonparticulate with no microcrystalline suspension)[5] that has a high diffusion capacity and low risk of deposition inside soft tissues (which might otherwise cause iatrogenic damage to the enthesis). In addition, we also prescribed a personalized rehabilitation program with manual therapy and stretching focusing on the thoracolumbar fascia and the ESA. 4 weeks later, the patient reported a significant reduction of myofascial lumbar pain and improvement of active motion ranges of the lumbar spine [Figure 1c]. The iliac crest pain syndrome has been identified very frequently in patients with chronic “nonspecific” low back pain, and different authors showed that the principle pain generator coincides with the attachment site of the ESM to the posterior medial iliac crest [Figure 1d];[6] alone or in combination with other painful anatomical structures such as the sacroiliac joint, (short and long) posterior sacroiliac ligaments, lumbar facet joints, superior cluneal nerves, and the trigger points of gluteal muscles.[4] The latter is often associated with erector spinae enthesopathy; yet there is anatomical contiguity between the thoracolumbar fascia and the superficial fascia of gluteus maximus muscle.[4] In clinical practice, injections of the erector spinae enthesis are not commonly performed due to the difficulty in identifying the aponeurotic and tendinous structures of the pelvic girdle by manual palpation. In this sense, we imply that “sonopalpation” can readily provide prompt visualization of the (painful) attachment sites of the ESM for safer interventions. This way, any vascular (e.g., bleeding), neural (e.g., superior cluneal nerve injury), or tendinous (e.g., intratendinous steroid injection) complications can easily be avoided as well. Last but not least, US examination can also allow the physician to readily evaluate the eventual fibro-adipose changes within the paraspinal muscles (e.g., reduced thickness and increased echogenicity)[7] which would also/possibly contribute to the “nonspecific” low back pain of the patient. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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          The thoracolumbar fascia: anatomy, function and clinical considerations.

          In this overview, new and existent material on the organization and composition of the thoracolumbar fascia (TLF) will be evaluated in respect to its anatomy, innervation biomechanics and clinical relevance. The integration of the passive connective tissues of the TLF and active muscular structures surrounding this structure are discussed, and the relevance of their mutual interactions in relation to low back and pelvic pain reviewed. The TLF is a girdling structure consisting of several aponeurotic and fascial layers that separates the paraspinal muscles from the muscles of the posterior abdominal wall. The superficial lamina of the posterior layer of the TLF (PLF) is dominated by the aponeuroses of the latissimus dorsi and the serratus posterior inferior. The deeper lamina of the PLF forms an encapsulating retinacular sheath around the paraspinal muscles. The middle layer of the TLF (MLF) appears to derive from an intermuscular septum that developmentally separates the epaxial from the hypaxial musculature. This septum forms during the fifth and sixth weeks of gestation. The paraspinal retinacular sheath (PRS) is in a key position to act as a 'hydraulic amplifier', assisting the paraspinal muscles in supporting the lumbosacral spine. This sheath forms a lumbar interfascial triangle (LIFT) with the MLF and PLF. Along the lateral border of the PRS, a raphe forms where the sheath meets the aponeurosis of the transversus abdominis. This lateral raphe is a thickened complex of dense connective tissue marked by the presence of the LIFT, and represents the junction of the hypaxial myofascial compartment (the abdominal muscles) with the paraspinal sheath of the epaxial muscles. The lateral raphe is in a position to distribute tension from the surrounding hypaxial and extremity muscles into the layers of the TLF. At the base of the lumbar spine all of the layers of the TLF fuse together into a thick composite that attaches firmly to the posterior superior iliac spine and the sacrotuberous ligament. This thoracolumbar composite (TLC) is in a position to assist in maintaining the integrity of the lower lumbar spine and the sacroiliac joint. The three-dimensional structure of the TLF and its caudally positioned composite will be analyzed in light of recent studies concerning the cellular organization of fascia, as well as its innervation. Finally, the concept of a TLC will be used to reassess biomechanical models of lumbopelvic stability, static posture and movement.
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            Injectable corticosteroid and local anesthetic preparations: a review for radiologists.

            Corticosteroids and local anesthetics are some of the most commonly administered medications in radiology departments. These medications have marked variability in their formulations, which may increase their adverse event profile for specific procedures. In particular, certain corticosteroid preparations are associated with adverse central nervous system (CNS) sequelae. This is most likely due to distal embolization by particulate formulations. Nonparticulate steroid formulations are not associated with such events. Local anesthetics have severe CNS and cardiac adverse effects if injected intravascularly and have recently been associated with intraarticular chondrolysis if used in large doses. This review discusses these medications with particular emphasis on their established and postulated adverse effects. The administering radiologist should be aware of these potential effects and how best to reduce their occurrence.
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              Sonographic tracking of trunk nerves: essential for ultrasound-guided pain management and research

              Delineation of architecture of peripheral nerves can be successfully achieved by high-resolution ultrasound (US), which is essential for US-guided pain management. There are numerous musculoskeletal pain syndromes involving the trunk nerves necessitating US for evaluation and guided interventions. The most common peripheral nerve disorders at the trunk region include thoracic outlet syndrome (brachial plexus), scapular winging (long thoracic nerve), interscapular pain (dorsal scapular nerve), and lumbar facet joint syndrome (medial branches of spinal nerves). Until now, there is no single article systematically summarizing the anatomy, sonographic pictures, and video demonstration of scanning techniques regarding trunk nerves. In this review, the authors have incorporated serial figures of transducer placement, US images, and videos for scanning the nerves in the trunk region and hope this paper helps physicians familiarize themselves with nerve sonoanatomy and further apply this technique for US-guided pain medicine and research.
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                Author and article information

                Journal
                J Res Med Sci
                J Res Med Sci
                JRMS
                Journal of Research in Medical Sciences : The Official Journal of Isfahan University of Medical Sciences
                Wolters Kluwer - Medknow (India )
                1735-1995
                1735-7136
                2019
                28 August 2019
                : 24
                : 69
                Affiliations
                [1 ]Department of Biomedical and Neuromotor Science, Physical and Rehabilitation Medicine Unit, IRCCS Rizzoli Orthopaedic Institute, Bologna, Italy
                [2 ]Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
                Author notes
                Address for correspondence: Dr. Vincenzo Ricci, Department of Biomedical and Neuromotor Science, Physical and Rehabilitation Medicine Unit, IRCCS Rizzoli Orthopaedic Institute, Bologna, Italy. E-mail: vincenzo.ricci58@ 123456gmail.com
                Article
                JRMS-24-69
                10.4103/jrms.JRMS_1034_18
                6734669
                5d02336c-0d1d-47a5-99a4-33219874db09
                Copyright: © 2019 Journal of Research in Medical Sciences

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

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