Marked sympathetic component in the perivascular innervation of the dorsal
paratendinous tissue of the patellar tendon in arthroscopically treated
tendinosis patients.

Danielson P, Andersson G, Alfredson H, Forsgren S.

The nerve component of this neurovascular pain fuzz is of Sympathetic nervous system origin – ie. This is the part of the nervous system activated in Complex Regional Pain Syndrome (CRPS aka RSD). Involvement of this part of the nervous system creates extreme allodynia (pain) and so it is not surprizing these areas are persistenatly painful.

Disc Rim Lesions
It seems to me, neurovascular growth seems to be the key to discogenic pain as well. With disc damage, tears that occur in the annulus (outer rim). This outer rim can become inflamed because the disc center is actually foreign to the body and if it leaks out to the edge a brisk inflammatory reaction can ensue. If this rim faces the spine cord side, chronic back pain develops, much like a chronic tennis elbow. There is intense neurovascular growth there too – called a rim lesion. If the tear/ rim lesion faces one side near the spinal cord, then you can have typical sciatica (even reflex, strength and EMG changes) without any disc bulging/protrusion. This has now been dubbed “Chemical Radiculitis” and I feel occurs very often. This area of cracked rim can be seen one MRI but lots of people have this “Hyperintense Zone” without the accompaning inflammation so again MRI’s are more or less useless.

My 1/2 Red Neck Patient:

I had a patient with considerable pain unilaterally in the subcutaneous (skin fatty tissue) tissues of the neck. Picking up the tissues between my fingers was very tender. The most tender spots were areas the superficial dorsal nerves of the neck penetrated – upper cervical near midline at top and C3 somewhat lower 1-2 cm from middle. When I ran the same ultrasound imager the tennis elbow imaging study used, the blood vessels showed the same sort of pattern! Using a dumbed down sclerosant (concentrated dextrose) into these superficial tissues cleared those vessels on imaging, like in the tennis elbow study, and later afforded some relief. This skin relief was blunted by the fact he has significant other neck issues not so skin deep. What was interesting, was the red neck was unilateral on the side of his problems, so the thought of these neurovascular growths will always remind me of this red neck syndrome…

Micro nerve entrapments
Some of the pain in the red neck skin version represents in my mind, nerve microentrapments. I believe they are common contributor to low back pain in the form of cluneal nerve entrapments often seen above the iliac crest. Injecting them will help the pain for a while and can drop back pain by 2/10 for several weeks; but does not deal with the central issue that causes this neurogenic inflammation process. I find doing that helpful in post-laminectomy cases where the spinal sensitization and scar are things that are not fixed easily.

This is getting to be a hot topic as
- discs are being fried (IDET) and more recently injected with methylene blue in attempt to disable this rim lesion.
- Some skin microentrapments (trapezius tip, supraorbital) are now being surgically released – a group in Nebraska with Dr. Nystrom

- It is now clear why bulging disc and rim lesions are NOT accurate estimation of pain – they need to be inflammed. I have one lady with numbness mid fingers hand with a very postive Spurling sign – pressing on sidebend neck increases numbness = 92 – 100% accurate re radiculitis in neck. She has NO pain – so the disc can press but it takes the inflammation to make it hurt. She’s Irish – makes me wonder if some of the increased pain tolerance in Irish is due to lack of inflammatory response…

There is lots to talk about here – any discussion?