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Why does the buttock hurt despite a vertebral fracture? The relationship between fracture type and pain site revealed

Super Human | 理学療法士／保健学博士 Ph.D.

📖 Literature Information and Abstract Translation

Association between pain site and fracture type in acute osteoporotic thoracolumbar vertebral fractures

Zhang, Haiping, et al. "Pain Location Is Associated with Fracture Type in Acute Osteoporotic Thoracolumbar Vertebral Fracture: A Prospective Observational Study." Pain Medicine 23.2 (2022): 263-268.

🔗 DOI, PubMed, Google Scholar

✅ Prerequisite knowledge: Definitions of fracture types used in this study
- Type 1: Upper endplate type
- Type 2: Central type
- Type 3: Lower endplate type
- Type 4: Burst type

Slide 2

📕 Lotz et al. Global spine journal 3.3 (2013): 153-163. >>> doi.

[Background/Objective] This study examined the relationship between pain site and fracture type in patients with acute osteoporotic vertebral fractures (OVF).

[Methods] Prospective observational study design. The subjects were 306 patients with acute OVF. Methods: The pain site of each patient was recorded, and they were divided into a group with pain at the fracture site (Group 1) and a group with pain at a non-fracture site (Group 2). Fractures were classified into four types: Type I: upper endplate, Type II: central, Type III: lower endplate, Type IV: burst.

[Results] Group 1 consisted of 146 patients, of whom 20.55% (30/146) had Type I fractures, 33.56% (49/146) had Type II, 15.75% (23/146) had Type III, and 30.14% (44/146) had Type IV. Group 2 consisted of 227 patients, of whom 57.27% (130/227) had Type I fractures, 5.29% (12/227) had Type II, 35.24% (80/227) had Type III, and 2.20% (5/227) had Type IV.There was a statistical difference in the distribution of fracture types between the two groups (P < 0.05). The Visual Analog Scale score at the initial visit was higher in Group 1 than in Group 2 (P < 0.05).

Slide 3

[Conclusion] In cases of acute osteoporotic vertebral fractures, the site of pain is associated with the type of fracture.Pain at the fracture site is more common in central and burst types, while pain at non-fracture sites is more common in upper and lower endplate types. When OVF is suspected, X-ray evaluation of the thoracic and lumbar spine is recommended to better detect fractures that may cause pain distal to the fracture site.

🌱 So What?: What did I find interesting?

I have always wondered about this.

Why does the groin, abdomen, buttock, or even the thigh hurt despite a vertebral fracture?

This study suggested one of the mechanisms for this.
Namely, the involvement of the vertebral endplate.
When damage is observed in the vertebral endplate, referred pain is more likely to occur in non-fracture areas.
...
However, why is that?
Solving one 'why' leads to the next 'why' at a deeper level.
After studying it, I found a way forward in anatomical factors.
That path is the relationship between the vertebral endplate and two different nerve innervations: 'nerves that directly innervate the vertebral body' and 'nerves that innervate the intervertebral disc'.

Slide 4

📗Mini-review ①: Vertebral nerve (nerve directly innervating the vertebral body)
- The vertebral nerve supplies nerves to the cancellous bone of the vertebral body.
- It was confirmed that the nerves enter the vertebral body through the centrally located posterior vascular foramen and accompany the basivertebral vessels. Branches from these nerves were found to travel to both the central and peripheral parts of the vertebral body (📕Antonacci, 1998 >>> doi).
- Most of the nerves were adjacent to the vessel walls, and as a result, the nerve distribution closely resembled the previously established vascular patterns (📕Bailey, 2011 >>> doi).

📗Mini-review ②: Sinovertebral nerve (nerve innervating the intervertebral disc)
- The sinovertebral nerve is a recurrent nerve arising from the ventral ramus, which re-enters the spinal canal via the intervertebral foramen and innervates multiple meningeal and non-meningeal structures (📕Shayota, 2019 >>> doi).
- Among 120 patients whose chief complaint was low back pain, 26% (95% CL, 18%, 34%) of patients were identified as having discogenic pain (📕Manchikanti, 2001 >>> site).
- As a characteristic of pain due to disc degeneration, the pain may spread to the buttocks, groin, and upper thighs. This pain is usually felt as soreness or dullness, ranging from mild to severe (🌍 Reference site >>> site).
- In a case with pain in the back, left buttock, and posterior thigh, endoscopic superficial laser ablation was performed on the L5-S1 (outer edge of the intervertebral disc). During irradiation, the patient complained of severe pain in the lower back and lower limbs, and after ablation of the hot spot by the laser, the pain was reduced and improvement in motor function was observed (📕Choi, 2018 >>> doi).

From the mini-review, the sinovertebral nerve is a nerve highly likely to cause referred pain and radiating pain.
And the vertebral endplate is a site innervated by both the vertebral nerve and the sinovertebral nerve.
On the other hand, the central part of the vertebral body has less innervation by the sinovertebral nerve.
Based on the above, since the vertebral endplate is significantly involved with the sinovertebral nerve that causes referred and radiating pain, it may be that pain in non-fractured areas is likely to occur when it is damaged is a reasonable inference.
I have just ordered the full text of the article, and I am looking forward to the details of the methods and the author's discussion.
This paper was incredible...
It greatly expanded the anatomical territory regarding vertebral bodies and intervertebral discs, and also provided me with the weapon of image analysis.
And the resolution of this one "why," as is often the case, has given birth to the next "why."
Alright, let's research!!!

Every new beginning comes from some other beginning’s end.
Every new beginning comes from some other beginning’s end.
Seneca

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