This is an article written in GERMAN titled Mechanische neuritis der rami dorsales und fettgewebehernien als ursache von akuten und chronischen ruckenschmerzen (Mechanical Neuritis of the Dorsal Rami and Adipose Tissue as Cause of Acute and Chronic Back Pain). (Mechanical neuritis = nerve entrapment) (fettgewebehernien = fat hernias or back mice)
After a review of the literature, Richter presents and discusses the anatomical bases for peripheral compressions of posterior cutaneous nerve branches, “the dorsal rami”(also knsown as CLUNEAL NERVES at the lumbar level). He thinks that the etiological factors are related to: the course of the nerves through the different layers of the musculature/fascia, trauma and working positions, fibrosis of the fascia associated to age, and in the lumbar region the fatty tissue hernias (also known as back mice). He warns that in these cases the “degenerative processes of the spine” wouldn’t be related.
Richter is convinced that “the pain syndromes” related to the affection of the nerve entrapment of the “dorsal rami” is a common condition in practice, which can be easily diagnosed with circumscribed pressure tenderness. He warns that the accompanying pseudoradicular radiated signs can lead to difficult differential diagnosis (especially if it radiates to distant areas).
The treatment consists of local anesthetic injection and surgery liberation of the nerves if necessary. Prognostic is good.
Mechanische neuritis der rami dorsales und fettgewebehernien als ursache von akuten und chronischen ruckenschmerzen
[Entrapment Neuropathies of the Primary Dorsal Branches: a Cause of Dorsal and Lumbar Backache]
By Hs. R. Richter
Ther Umsch. 1977 Jun; 34(6): 435-8. German. PubMed PMID: 141751.
From the Neurologische Universitatsklinik Basel, Switzerland
Richter’s introduction: a review of literature
In 1961, The Lancet raised the question of whether mechanical effects on peripheral nerves could even lead to pain. Kelly said that this question hasn’t been answered for the last ninety years (reference). He pointed out that biomechanical changes are probably responsible for the pain. The fact that some tumors do not cause pain leads to confusion.
Regarding the etiology of back pain, Richter points out that there are widely differing views in the literature. Even the names to describe that back pain as a syndrome are diverse.
The author thinks that the term mechanishe neuritis der rami dorsales [entrapment neuropathies of the primary dorsal branches or called CLUNEAL NERVES at the lumbar level] could be a right name for certain cases of akuten und chronischen ruckenschmerzen [acute or chronic low back pain].
Other names for back pain have been: fibrositis (especially in Anglo-Saxon literature), myofascial pain syndrome (Bonica), Panniculitis or Adiposalgie (in a more systemic fatty tissue affection).
Copeman tried to summarize all these symptoms in a generic term, non-articular rheumatism, and related it to the adipose tissue dysfunction or fatty hernias.
On the other hand, Kopell and Thompson called them peripheral entrapment neuropathies (reference of a book: Peripheral Entrapment Neuropathies -Harvey P. Kopell, Walter A. L. Thompson -ISBN: 0882752146).
Several specialists deal with these patients: orthopedists, neurologists, internists, rheumatologists and anesthesiologists.
Bonica (1960), a famous anesthesiologist known for the treatment of pain, pointed out that they could obtain great results with pain management from the peripheral nerve blocks (reference).
In 1948 Veraught tried to arouse the interest of the physicians with his monograph Rucken des Menschen for different syndromes that in literature are often neglected (references).
Moll stated that fibrositis could be treated by Finnish sauna.
Copeman thought that a temporary edematous swelling of the adipose tissue could be the pathological substrate. Copeman could not determine specific neuritis in the operated specimens.
In America Hench has labeled certain generalized cases as psychogenic rheumatism. Anyway, there was not the explanation why the mental factor could play a role in triggering pain.
Richter’s CASE REPORTS about nerve entrapment and chronischen ruckenschmerzen -chronic back pain-
First he presents TWO CASE REPORTS of Thorakales Ramus-dorsalis-syndrom or Thoracic dorsalis syndrome
Mechanical neuritis of the medial dorsal T6-left for 15 years. Presented as pseudoradicular syndrome of both arms with postural exacerbations.
A 29-year-old housewife complained of back pain between the scapulas, which she had been suffering from the puberty. In the morning the pain was relatively bearable, from midday it increased with radiation diffusely all over the back and into both arms. In the evening the patient cried of pain. She did different conservative treatments even with physiotherapy.
Out of the woman’s hopelessness, the husband injected eight local anesthetic injections in the painful spots with a temporary relief.
There were not really pathological findings on the examination except from circumscribed paramedian pressure tenderness at the parascapular region of the left side. X-Rays showed a convex lumbar scoliosis.
A local anesthetic test with 2 cc of 1% novocaine gave her immediate pain relief. Then they indicated that the nerve should be decompressed surgically. They liberated the dorsal nerve rami, the tissue surrounding it was found to be adipose tissue traversed with small nerve clusters. For at least six years, the patient was free from pain.
Mechanical neuritis of the dorsal ramus T4 right side. Right brachialgia with postural exacerbations.
A 30-year-old patient with recurring brachialgia for years, with several severe episodes of pain. The patient was examined in an English hospital and was diagnosed of a “cervical rib”. Surgical removal of it was recommended but not done. The pain was radiating along the forearm and hand.
Examination showed asthenia. At the level of the right scapula, there was a circumscribed area of tenderness. X-Rays did not confirm any cervical rib.
They performed anesthetic test with local anesthesia. The result was a complete freedom of pain.
They operated her to decompress the dorsal rami that was surrounded by adipose tissue. The patient got complete relief, even the local pain around the wrist disappeared for at least 4 years.
A 40-year-old patient. Recurrent lumbago with pseudoradicular complaints by lumbar fatty hernia. He suffered left lumbar back pain that radiated to the leg. The pain was worst after sitting for a long time.
The patient had a severe episode of pain. The surgeon thought the patient had psychogenic pain.
After a local injection in the tender spot the pain was dramatically free of pain and could bend over. The outcome was good.
Anatomical and etiological considerations from Richter about the cutaneous nerve entrapment as they cross the fascias to cause chronischen ruckenschmerzen or chronic back pain:
Richter provides a diagram where the dorsal rami cross the deep fascia to become superficial and where they can suffer different types of nerve compression.
Distribution of the dorsal rami nerves. The nerves cross several structures where they can be entrapped.
As Copeman’s studies show, especially at the lumbar level there is the possibility that the deep fatty tissue herniates through the fascia through the nerve foramina and causes a nerve neuropathy.
Published in September 2018 by Marta Cañis Parera
- Richter HR. [Entrapment Neuropathies of the Primary Dorsal Branches: a Causeof Dorsal and Lumbar Backache (author’s transl)]. Ther Umsch. 1977 Jun; 34(6): 435-8. German. PubMed PMID: 141751.
- KELLY M. Does pressure on nerves cause pain? Med J Aust. 1960 Jan 23; 47(1): 118-21. PubMed PMID: 14405306
- Peripheral Entrapment Neuropathies -Harvey P. Kopell, Walter A. L. Thompson 1963 -ISBN: 0882752146)
- Bonica J.J.: Clinical applications of diagnostic and therapeutic nerve blocks. Charles C. Thomas, Blackell Scientific Publications, Oxford, 1960.