Dorsal Ramus: Anatomy & Clinical Presentation
Anatomy
Spinal cord --> dorsal root (sensory) & ventral root (motor) --> spinal nerve (mixed sensory & motor) --> ventral rami (motor > sensory) & dorsal rami (sensory > motor). Dorsal rami --> medial branch of dorsal rami & lateral branch of dorsal rami.
Saito et al (2013) described the L2 spinal nerve and ventral rami as a 'continuous stem' . This is opposed to the dorsal rami that was described as a 'branch of the spinal nerve'. These authors did not specify if this was unique to L2.
There are numerous anastomoses between adjacent dorsal rami, medial branches and lateral branches. Shuang et al (2015) confirmed the existence of the middle [intermediate] branch of the dorsal rami which connects the lateral branch to the communicating plexus. These authors acknowledge some might recognise the middle [intermediate] branch as a muscular sub-branch of the lateral branch, and generally, it is acceptable to divide the dorsal rami into the medial and the lateral branches.
The dorsal rami of the spinal nerves traverse the medial aspect of the middle thoracolumbar fascia* posterior to the quadratus lumborum muscle and then enters the erector spinae muscles.
*Middle layer of the thoracoulumbar fascia: attaches to the tips of the lumbar transverse processes. Passes between the paraspinal muscles and the quadratus lumborum muscle giving rise to the transverse abdominis and internal oblique aponeurosis.
The dorsal rami then enters the back through a foramen bounded by the superior border of the transverse process, the anterior aspect of the superior articular facet joint and the intertransverse ligament (Zhou et al 2012). It runs posteriorly on the medial aspect of the intertransversarri muscles (Shuang et al 2015).
The dorsal ramus then divides into the into medial and lateral branches at the junction of the facet joint and the proximal superior border of the transverse process (Zhou et al 2012). Bogduk and Long (1979) and Masini et al (2005) found the L1-L4 dorsal rami to divide into the medial and lateral branches within the intertransverse ligament.
Bogduk et al (1982) found different branching patterns for not just the medial and lateral branches of the dorsal rami but also the intermediate branches. The branching patterns varied depending on the spinal levels:
L1 & L2 dorsal rami: commonly double branching occurs. This includes a medial branch and a short common stem for the lateral and intermediate branches.
L4>L3 dorsal rami: commonly triple branching occurs. This includes the medial, intermediate and lateral branches.
L5 dorsal rami: gives rise to the medial and intermediate branches as it runs in the groove formed by the S1 superior articular process and the sacral ala. The L5 dorsal rami lacks a lateral branch as there is no attachment of the iliocostalis lumborum to L5 as it is replaced by the iliolumbar ligament.
Medial branch of the dorsal rami
As the medial branch of the dorsal rami passes through a groove formed between the root of the transverse process and root of the superior articular process Bogduk et al (1982) found it was bound to the periosteum by a layer of connective tissue which coated the superior articular process and transverse process.
The nerve then passes through a fibroosseous canal formed by the junction of the transverse process and the lateral aspect of the superior articular process with the roof of the canal being formed by the mammilloaccessory ligament. The medial branch of the dorsal rami then penetrates the deep fascia near the median line to enter the subcutaneous tissue.
*: Mammilloaccessory ligament is a part of the medial side of the intertransverse ligament. It extends from the mammillary process to the accessory process. It gives origin to the intertransversarii, multifidus, longissimus and iliocostalis muscles.
In the cervical spine (C3-8), where the dorsal rami bifurcates into medial and lateral branches, the tendons of origin of the semispinalis capitis separates these branches (Han 2021). The medial branch then runs in an anatomic tunnel posterolateral to the facet joint, the floor of which is formed from the neighbouring facet joint capsules, and the roof from the tendon of the semispinalis capitis (Zhang et al 2003). The medial branches that innervate the facet joint coursed between fibre bundles of the semispinalis capitis along with a tortuous vascular network (Han 2021). Subcutaneous or cutaneous branches of the medial branch penetrate the semispinalis capitis, and usually the trapezius, to supply the subcutaneous tissue and/or skin (Seichi et al 2012). Below the C5 or C6 spinous processes only two or three larger cutaneous nerves are discernible (Zhang et al 2003), with, in almost all cases, the C6 and C7 dorsal rami terminating in the semispinalis cervicis or capitis (Mizutamari et al 2010).
The medial branch of the dorsal rami innervates:
Facet joints: innervates the two to three adjacent facet joints e.g. the L4 facet joint is innervated by the L3 and L4 medial branches. To innervate the facet joint the proximal nerve runs between the intertransversarii and the most lateral fibres of multifidus; the distal nerve runs deep to the multifidus (Bogduk et al 1982).
Multifidus: Shuang et al (2015) found this innervation to be highly specific. They found each medial branch ran on the deep aspect of the multifidus and was solely innervated by this one branch without any communicating branches. This finding was disputed by Wu et al (1997) who found the multifidus to be polysegmentally innervated.
Interspinous ligament and muscle: the nerve weaves medially between the fascicles of the multifidus to reach the interspinous space (Bogduk et al 1982).
Supraspinous ligament.
Saito et al (2013) believed the intermediate branches are more widespread but have been regarded simply as muscular branches of the lateral branches. These authors described the anatomy of the dorsal rami as:
Medial branch: arises from the mammillary processes to enter the multifidus muscle.
Intermediate branch: arises from the accessory processes and enters the longissimus muscle.
Lateral branch: arises from the transverse processes and enters the iliocostalis.
Lateral branch of the dorsal rami (—> medial, intermediate & lateral branches)
Of particular interest in osteopathic practice the lateral branch of the dorsal rami form the cluneal nerves:
Superior cluneal nerve (SCN): T12-L4 lateral branch of dorsal rami. The lateral branch of dorsal rami lies in an osseous groove on the superior transverse process. It then sends branches that run within the iliocostalis and longissimus muscles. After piercing the iliocostalis, the main lateral branch descends approximately two vertebral segments before it pierces the superficial layer of the posterior thoracolumbar fascia lateral to the length of the erector spinae superior to the iliac crest (Przybycień et al 2023), crosses the iliolumbar membrane (Loukas et al 2008) and then descends to pass over the PSIS and pierce the gluteal fascia to supply the skin in the upper 2/3 of the posterolateral buttock. There are no cutaneous branches of L5 lateral branch.
The dorsal rami of L1: 75%; L2: 90%; L3: 95%; L4: 45%; L5: 10% (Iwanaga et al 2019) contribute to the SCN. These dorsal rami terminate in the medial (L1-3), intermediate and lateral branches that perforate the thoracolumbar fascia 5–20 mm superiorly from the iliac crest. The L4-5 lateral branch of the dorsal rami —> medial branch (Konno et al 2017) is often identified passing as through a rigid osseoaponeurotic orifice (osteofibrous canal) accounting for sciatic symptoms. Other authors have reported the incidence of branches of the SCN passing through the osteofibrous tunnel as being medial branch (39%), intermediate branch (28%) and lateral branch (13%) (Isu et al 2018).
The osteofibrous canal is formed at the insertion of the thoracolumbar fascia to the iliac crest at the posterolateral boarder of the quadratus lumborum (Visnjevac et al 2022). Netter (1997, pg 237) illustrates the nerves passing through the latissimus dorsi where it attaches to the ilium, just lateral to the paraspinal mass, and the osteofibrous tunnel just medial to this on the lateral side of the paraspinal mass, formed where the thoracoulumbar fascia attaches on to the iliac crest.\
Anastomosis between the SCN and MCN can sometimes be found in the subcutaneous tissues of the mid-buttock.
Middle cluneal nerve (MCN): S1-4 lateral branch dorsal rami. Innervates SIJ (with L5 lateral branch of dorsal ramus) and skin over coccyx and adjacent buttock. There are some communicating branches from the MCN to the superior gluteal nerve.
Inferior cluneal nerve (ICN): arise from the posterior cutaneous nerve of the thigh (S1-3). Innervates skin over lower gluteus maximus and perineum.
Distal anastomoses of the lateral branches of the dorsal rami have been noted < T11 and T12, T12 and L1, and L2 and L3.
The lateral branch innervates the tissues lateral to the facet joint line e.g:
Iliocostalis and longissimus muscles.
Cutaneous innervation of the back and pelvis.
Several authors regard the intermediate branch as a muscular branch of the lateral branch (Saito et al 2013). Those that classify the intermediate branch as a distinct branch of the dorsal rami found it to innervate the longissimus (refer 'intermediate branch of the dorsal rami').
Bogduk et al (1982) found:
L1 and L2 lateral branches of the dorsal rami: cross the iliac crest in the subcutaneous tissue in parallel with the T12 cutaneous branch. T12 and L1 innervate the dermatome just below the lateral iliac crest and posterior to the ASIS.
L1-3 lateral branches of the dorsal rami: emerge from the posterolateral surface of the iliocostalis lumborum, pierce the posterior layer of the thoracolumbar fascia and become cutaneous. L3 is bound down to the iliac crest by a bridge of connective tissue just lateral to the origin of iliocostalis lumborum, could this be the iliolumbar membrane detailed by Loukas et al (2008)? The medial branches of these rami pass to the skin of the buttocks passing through the osteofibrous tunnel (Konno et al 2017). L2 and L3 lateral branches innervate the skin over the buttocks.
L4-L5 lateral branches of the dorsal rami: there are no cutaneous branches of the L4 and L5 lateral branches. L4 lateral branch remains intramuscular. The L5 lateral branch typically communicates with the S1 dorsal ramus.
The lateral branch of the L5 dorsal ramus descends and merges into the S1 dorsal ramus (Zhou et al 2012).
Bogduk et al (1982) described the L5 dorsal ramus as lacking a lateral branch dividing the dorsal ramus at this level into the medial and intermediate branches. This was due to the absence of an attachment of the iliocostalis to L5 which is replaced by the iliolumbar ligament.
However both these authors also described the intermediate branch (Bogduk et al 1984) and lateral branch (Zhou et al 2012) of the L5 dorsal rami as innervating the longissimus thoracis as it attaches to the medial aspect of the dorsal segment of the iliac crest. Therefore both authors are probably describing the same nerve but under a different name.
Intermediate brach of the dorsal rami
The L3 and L4 dorsal rami (and sometimes L1 and L2) give off intermediate branches which supply the lumbar fibers of the longissimus thoracis (Zhou et al 2012) and mutifidus (L2 nerve, Saito et al 2013).
This branch passed between the longissimus and iliocostalis muscles and extended to the skin.
Soft tissue relations to the dorsal rami
Zhou et al (2012) found the most commonly affected area from dorsal rami pain is around the thoracolumbar region and involving the L1 and L2 dorsal rami (Zhou et al 2012). This was opposed to facet joint pain that most commonly affected the L4-5 and L5-S1 levels.
Intertransversarii, intertransverse ligament & middle layer of the thoracolumbar fascia
The dorsal rami of the spinal nerves traverse the medial aspect of the middle thoracolumbar fascia posterior to the quadratus lumborum muscle and then enters the erector spinae muscles. Attaching to the tips of the transverse processes and intertransverse ligaments the middle layer of the thoracoulmbar fascia passes between the paraspinal muscles and the quadratus lumborum giving rise to the transverse abdominis and internal oblique aponeurosis. Gilchrist et al (2003) also found the iliocostalis lumborum attaches on to the middle layer of the thoracolumbar fascia.
The dorsal rami then enters the back through a foramen bounded by the superior border of the transverse process, the anterior aspect of the superior articular facet joint and the intertransverse ligament (Zhou et al 2012). It runs posteriorly on the medial aspect of the intertransversarri muscles (Shuang et al 2015).
The L1-L4 dorsal rami to divide into the medial and lateral branches within the intertransverse ligament (Bogduk and Long 1979 & Masini et al 2005).
The intertransverse ligament frequently blends with the intertransversarii muscle and has been described as looking more like a part of the thoracolumbar fascia rather than a true ligament (Hirsch et al 1963).
The intertransversarii muscle and intertransverse ligament relation to the medial branch of the dorsal rami is:
The dorsal rami runs on the medial aspect of the intertransversarii muscle.
The medial branch of the dorsal ramus innervates the facet joint. To innervate the facet joint the proximal nerve runs between the intertransversarii and the most lateral fibres of multifidus; the distal nerve runs deep to the multifidus (Bogduk et al 1982).
Medial branch of the dorsal rami lies in the fibrosseous canal formed from the mamilloaccessory ligament that is associated with the intertransverse ligament and intertransversarri muscle.
There are three distinct intertransversarii muscles (Gilchrist et al 2003):
Intertransversarii laterales ventrales: traverses proximally and distally between neighbouring transverse processes. Innervated by the ventral ramus.
Intertransversarii laterales dorsales: lies medial to the intertransversarii laterales ventrales. Inserts proximally to the accessory process and distally to the medial third of the adjacent transverse process below.
Intertransversarii mediales: attaches proximally to the accessory process, mamillary process, and mamillary-accessory ligament. Distally it inserts into the mamillary process of the vertebrae below. Innervated by the medial division of the dorsal rami.
Due to their small size and medial location, the intertransversarii muscles are weak posterior sagittal rotators and lateral flexors of the lumbar spine. These muscles primary function may more proprioceptive in nature providing positioning feedback to the larger muscles of the spine that react to maintain proper spinal alignment.
The middle layer of the thoracolumbar fascia is the strongest layer of the thoracolumbar fascia and attaches to intertransverse ligaments. Hirsch et al (1963) described the intertransverse ligaments as being an extension of the thoracolumbar fascia rather than a ligament in its own right. This continuity from the middle layer of the thoracolumbar fascia to the intertransverse ligament allows tension from the transversus abdominis, internal oblique and external oblique to be transmitted via the middle layer of the thoracolumbar fascia to the transverse processes and intertransverse ligaments (Barker et al 2007). If the intertransversarii and intertransverse ligaments have a proprioceptive function then could this help explain how the lateral abdominal muscles influence segmental motion (Barker et al 2007)?
Multifidus
The multifidus relation to the medial branch of the dorsal rami includes:
Mammilloaccessory ligament is a point of attachment for the multifidus. This ligament forms the roof of the fibrosseous tunnel that the medial branch of the dorsal ramus runs through.
The medial branch of the dorsal ramus innervates the facet joint. To innervate the facet joint the proximal nerve runs between the intertransversarii and the most lateral fibres of multifidus; the distal nerve runs deep to the multifidus (Bogduk et al 1982).
The medial branch of the dorsal ramus weaves medially between the fascicles of the multifidus to reach the interspinous space (Bogduk et al 1982).
The multifidus arises from the spinous process of L5 to as low as the fourth sacral foramen, PSIS and dorsal sacroiliac ligament. The longest fibers of the multifidus run from the spinous processes of L1 and L2 to the dorsal segment of the iliac crest.
The multifidus is tightly adhered to the erector spinae aponeurosis at the lumbar (close to the midline) and sacral levels (Creze et al 2018). Johnson and Zang (2002) found the multifidus, longissimus thoracis and thoracolumbar fascia to be contributers to the supraspinous and interspinous ligaments.
Paralleling the multifidus relation with the medial branch of the dorsal rami the sacral attachment of the multifidus is also tightly adhered to the medial branches of the sacral dorsal rami. To illustrate how tight this adherence is when the multifidus was removed piecemeal many of these nerves were removed along side with it (Cox & Fortin 2014).
The multifidus also, through directly tensing the erector spinae apoenurosis can influences tension of the fibres of the thoracolumbar fascia that the SCN (L1-3) passes through (Loubsetr et al 2015). The stretching of these fibers, and a rigid fascial edge (?iliolumbar membrane Loukas et al 2008), can cause entrapment of the SCN (L1-3) (Yuruk et al 2022).
Masaki et al (2019) paralleled the work of Macintosh & Bogduk (1986) and found the lumbar multifidus is stretched effectively in trunk flexion. The addition of lateral flexion or ipsilateral rotation to flexion did not alter the effectiveness of the stretch. Flexion will also stretch the interspinous space.
Osteofibrous tunnel
T12-L4 lateral branch of dorsal rami (superior cluneal nerve) —> medial branch —> osteofibrous tunnel —> skin of upper 2/3 buttocks
Osteofibrous tunnel (7-8cm lateral to midline, at the posterolateral boarder of the quadratus lumborum) is where the medial branch of the SCN crosses over the iliac crest to penetrate the gluteal fascia. It is bound by the iliac crest posteriorly, the thoracolumbar fascia anteriorly and where the fascia attaches on the iliac crest inferiorly (Konno et al 2017). Netter (1997, pg 237) illustrates the nerves passing through the ilium attachments of the latissimus dorsi, just lateral to the paraspinal mass, and the osteofibrous tunnel, just medial to this on the lateral end of the paraspinal mass. Predominantly it’s the L4 and L5 lateral branches of the dorsal rami (medial branch) that run through the osteofibrous tunnel accounting for sciatic symptoms caused at this level (Konno et al 2017).
Other reports showed that the medial branch of the SCNs passing through the osteofibrous tunnel most commonly arose from L1 (60%) & L2 (27%) (Maigine et al ) and L3-5 (Anderson et al 2022) nerve roots. The intermediate and lateral branches of the SCN either pierce the thoracolumbar fascia or pass through an orifice or fissure in the thoracolumbar fascia (Lu et al 1998). Whilst the medial branch is the most common branch to pass through the osteofibrous tunnel (39%), the intermediate (28%) and lateral branches (13%) can also pass through the tunnel (Isu et al 2018).
The nerve is subject to mechanical forces at the osteofibrous tunnel with hip flexion and stretching of the gluteus maximus, leading to edema, irritation, inflammatory cell infiltration, scarring, and subsequent entrapment. Another site of compression of this nerve is where it pierces the iliocostalis muscle (Anderson et al 2022).
Iliolumbar membrane
L1-3 lateral branch of dorsal rami (superior cluneal nerve) —> medial branch —> iliolumbar membrane —> skin of upper 2/3 buttocks.
The iliolumbar membrane is a connective tissue membrane originating from fibres of the thoracolumbar fascia at the lateral boarder of the erector spinae and resembles a fibrous septum. From here it fans out laterally dividing into fascial septa that traverse the subcutaneous tissue to attach on to the superficial fascia. Along its course it fuses with (i) the gluteus medius fascia at the iliac crest; (ii) along its lateral boarder with the deep fascia over the lateral boarder of the latissimus dorsi and external oblique (Loukas et al 2008).
Bogduk (1982) found a similar ‘bridge of connective tissue’ extending lateral to the origin of the iliocostalis lumborum that held the L3 lateral branch of the dorsal rami down to the iliac crest. A similar ‘rigid fascial edge’ has been described as causing entrapment of the SCN (Yuruk et al 2022). Obesity has been postulated as a potential cause of hypertrophy of the iliolumbar membrane accounting for SCN pain (Loukas et al 2008).
Psoas
Tubbs et al (2010) found the SCN to pass through the psoas major and paraspinal muscles running posterior to the quadratus lumborum.
Paraspinal muscles/Thoracolumbar fascia/Latissimus Dorsi
Posterior aponeurosis (thick fibres of latissimus dorsi and the posterior layer of the thoracolumbar fascia) is attached to the posterior iliac crest. The SCN passes through the paraspinal muscles (Tubbs et al 2010), ilium attachment of the latissimus dorsi (Netter 1997) and thoracolumbar fascia (Loubster et al 2015).
Contraction of the latissimus dorsi muscle (and flexion and extension of the hip joint) influences tension of the fibres of the thoracolumbar fascia that the SCN (L1-3) passes through (Loubsetr et al 2015). The stretching of these fibers, and a rigid fascial edge, can cause entrapment of the SCN (L1-3) (Yuruk et al 2022). The medial branches of the SCN that passes through these fibres innervates the cutaneous area over the medial part of the central buttock (Loubster et al 2015).
Presentation of superior and middle cluneal nerve
Irritation of the nerve leads to pain arising from the nerve’s surface and changes in the axon plasma flow. Nerves are innervated by nervi nervorum, and impingement may reactively release both substance P and calcitonin gene related peptide (CGRP), thereby amplifying C nerve fiber nociception (Knight et al 2022).
MCN disorders comprised 13% of low back pain patients, whilst SCN disorders comprised 12% of patients with low back pain and/or leg symptoms with approximately 50% of SCN patients having lower extremity symptoms. Cluneal neuralgia pain between the costal margin and inferior gluteal folds with tenderness at the iliac crest, decreased sensation of the buttocks below the iliac crest, and leg pain usually radiating to the ipsilateral leg (Anderson et al 2022). Other authors have described symptoms as low back and buttock pain radiating diffusely over the flank or buttock, often accompanied by a less severe aching felt in the lower anterior abdomen, trochanteric region, groin, or anterior, lateral, or posterior thigh, with rarely, less intrusive paraesthesia below the knee mimicking sciatica (Knight wwt al 2022). It is a common presentation in post-partum mothers and is common with spinal kyphosis (e.g. wedge fractures) that stretches the SCN in this position (Anderson et al 2022).
Irritation of the cluneal nerves can cause trigger points, including (Knight et al 2022):
Superior cluneal trigger points: where the SCN passes over the iliac crest*.
Lateral cluneal nerve trigger points: formed by more lateral elements of the superior cluneal nerve being located above, on, or below the iliac crest, lateral to the iliac crest tubercle*.
*: Superior and lateral cluneal nerve trigger points produce pain and paresthesia radiating through the buttock, trochanteric region and along the anterolateral thigh to the knee and, on rarer occasions, the symptoms pass into the shin and the foot, mimicking sciatica.
Paravertebral cluneal nerve trigger points: occur along the lateral border of the erector spinae as the nerve emerges from the muscle and thoracolumbar fascia lateral to the line of the facet joints. Produces principally buttock pain but also pain and paresthesia in the paravertebral region, flank, or over the pelvic rim or groin or proximal anterior thigh.
MCN trigger points: occur along the LPSL or posterior iliac crest: produce deep buttock, deep medial groin, posterior thigh, calf, and foot pain, and sacral–pudendal pain which may be misdiagnosed as pain arising from the sacroiliac joint.
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