Review Question - QID 215564

Lumbar Spine Anatomy QID: 215564 (OBQ20.153)

QID 215564 (Type "215564" in App Search)

A 51-year-old male presents to the orthopedic spine clinic with a 4 week history of low back pain. The pain is dull in nature and is improved when lying supine. Pain is exacerbated when sitting in a chair or bending forward. He denies paresthesias or weakness. On exam, he has a negative straight leg raise test, with normal reflex, motor, and sensory exam bilaterally. MRI of his low back is demonstrated in Figure A. Given the most likely diagnosis, which of the following most accurately describes the pain pathway associated with his lumbar pathology?

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Innervation of the annulus fibrosus by the sinu-vertebral nerve

54%

766/1416

Innervation of the annulus fibrosus by the dorsal root ganglion

18%

255/1416

Innervation of the nucleus pulposus by the sinu-vertebral nerve

14%

194/1416

Innervation of the nucleus pulposus by the dorsal root ganglion

93/1416

Innervation of the dura by the intradural communicating nerve

97/1416

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This patient presents with axial low back pain with classic symptoms of discogenic pathology. The sinu-vertebral nerve innervates the superficial fibers of the annulus fibrosus and is responsible for the pain pathway associated with disk pathology.

Low back pain affects up to 80% of all people at some point in his/her lifetime. While discogenic back pain and its' management is controversial, discogenic back pain is important to differentiate from other causes of low back pain. Discogenic back pain is defined as axial low back pain without radicular symptoms. Classic symptoms include pain with bending, sitting, or axial loading without neurologic symptoms.

Bogduk reviewed the innervation of the lumbar spine and describes the anatomy and neural pathways by which pain is transmitted from the low back. He describes the innervation of the intervertebral disk occurs via the sinu-vertebral nerve and notes these pain receptors are only present along the periphery of the annulus fibrosus.

García-Cosamalón et al. reviewed the pain pathway of the intervertebral disc and its' role in discogenic back pain. They found that the innervation of the intervertebral disk is primarily sensory and mostly nociceptive. They also reiterate these nerve fibers are only found in the periphery of the disk within the annulus fibrosus.

Figure A: T2 sagittal MRI demonstrating degenerative disc disease without evidence of dural or nerve root impingement.

Incorrect Answers:
Answer 2: Although the sinu-vertebral nerve communicates with the dorsal root ganglion, direct innervation of the disk occurs via the sinu-vertebral nerve.
Answers 3 and 4: Pain receptors are present in the annulus fibrosus, not the nucleus pulposus
Answer 5: The intradural communicating nerve is responsible for pain transmission seen with impingement of the dura mater (e.g. central disk herniation)