Anatomical and histological study of human deep fasciae development

A novel approach to ultrasound-guided L3-4 thoracolumbar fascia injection for chronic pain after spine surgery: a prospective pilot study

BACKGROUND

Fascial tissues have been overlooked in the past, and there are only few studies on the thoracolumbar fascia and its treatment methods. The present study aimed to investigate the effectiveness and safety of ultrasound-guided bilateral L3-4 thoracolumbar fascia injection in treating postoperative low back pain.

METHODS

A prospective pilot study was conducted at a university hospital. Twenty-six patients with postoperative low back pain resistant to conservative therapies and US-guided bilateral L3-4 medial branch block (MBB) were included as participants. They were treated with US-guided L3-4 mid-thoracolumbar fascia injection. Using real-time fluoroscopy, we monitored the contrast medium's diffusion range and double-checked the needle tips' positions throughout the procedures. The pain numeric rating scales (NRS), lumbar anteflexion range of motion (ROM), and Oswestry disability index (ODI) were assessed through telephone interviews one, four, and twelve weeks after the procedures. All data were processed by SPSS software version 23.0 (IBM Corp., New York).

RESULTS

Compared with NRS at baseline, pain scores decreased throughout the observation period. Lumbar anteflexion range of motion of US-guided bilateral L3-4 mid-thoracolumbar fascia injection continuously improved during the first, fourth, and twelfth week. No intravascular injections or neurologic injuries were observed.

CONCLUSION

The US-guided bilateral L3-4 mid-thoracolumbar fascia injection facilitated a uniform dispersion of the medication, akin to the gentle spread of a goose feather, between the erector spinalis and quadratus lumborum muscles across the affected lumbar vertebrae. This technique demonstrated substantial clinical effectiveness in patients who were unresponsive to standard US-guided MBB.

Morphogenesis and functional aspects of the muscular layer of the middle deep cervical fascia in humans

BACKGROUND

In recent years, the fasciae of the human body have received significant attention because of their crucial role in the transmission of muscle force. However, studies on the development of the fasciae, particularly the cervical fascia, remain scarce.

PURPOSE

This study was performed to examine the development of the fascia of the infrahyoid strap muscles, also known as the middle layer of the deep cervical fascia (MDCF), in 17 human embryos aged 6-8 weeks and 20 human foetuses aged 9-14 weeks.

METHODS

Histological examination of serial sections was performed using conventional light microscopy.

RESULTS

Three stages in the development of the MDCF were identified: the initial, formation, and maturation stages. In the initial stage (week 6 of development, Carnegie stages 18-19), the mesenchymal primordium of the epimysium of the infrahyoid muscles was observed and found to be continuous with the mesenchymal primordium of the MDCF. The infrahyoid muscles already exhibited intramuscular fibres, the primordium of the perimysium, and the endomysium. In the formation stage (weeks 7-8 of development, Carnegie stages 20-23), fibroblast-like cells and collagen fibres appeared in the primordium of the muscle epimysium and in the MDCF. Intramuscular fibres had become very evident. In the maturation stage (from week 9 of development onward), further development and organisation of the fascial structures occurred.

CONCLUSION

Our results suggest that the MDCF of the neck develops in parallel with the mechanical activity of this region. The relationship between the MDCF and the lymphatic and venous structures of this region suggests that the MDCF may facilitate venous and lymphatic circulation.

Additional Effect of Interfascial Hydrodissection With Dextrose on Shoulder and Neck Function in Patients With Myofascial Pain Syndrome: A Randomized Control Trial

OBJECTIVE

The aim of the study is to evaluate whether the application of an interfascial injection with dextrose water could result in reduced pain and improved shoulder function and range of motion.

DESIGN

This is a double-blind randomized controlled trial. Thirty-five patients with chronic shoulder pain were randomly assigned to receive either an interfascial injection of 10 mL of 10% dextrose water guided by ultrasound or a sham injection of 0.5 mL of 10% dextrose water into the subcutaneous layer. All patients received education on a home program of self-massage and self-stretching. Shoulder pain, shoulder range of motion, and neck and shoulder function were measured before injection and at 4 and 12 wks after injection.

RESULTS

Both groups showed significant improvements in visual analog scale scores at 12-wk follow-up. The interfascial injection group exhibited a significant pain reduction compared with the sham group at the 12-wks follow-up. No between-group differences were observed in shoulder range of motion, pain threshold, and neck and shoulder function.

CONCLUSIONS

Interfascial injection is effective in decreasing pain in patients with myofascial pain syndrome.

Understanding frictional behavior in fascia tissues through tribological modeling and material substitution

The objective of this study is to develop a reliable tribological model to enable a more thorough investigation of the frictional behavior of fascia tissues connected to non-specific lower back pain. Several models were designed and evaluated based on their coefficient of friction, using a low-frequency, low-load reciprocating motion. The study found that two technical elastomers, layered on PDMS to simulate the fascia and underlying muscle, are suitable substitutes for biological tissue in the model. The influence of tribopair geometry was also examined, and the results showed that greater conformity of contact leads to a lower COF, regardless of the material combination used. Finally, the friction properties of HA of various molecular weights and concentrations were tested.

Compartments of the crural fascia: clinically relevant ultrasound, anatomical and histological findings

PURPOSE

Compartment syndrome is a surgical emergency that can occur in any part of the body and can cause cell necrosis when maintained over time. The resulting defects can affect the nerves, muscle cells, bone tissue, and other connective tissues inside the compartment, and fasciotomy has to be performed. The anatomical and histological characteristics of the leg make acute, chronic, and exertional compartment syndrome more likely in this limb. For these reasons, knowledge of the ultrasound, anatomical, and histological features of the crural fascia can help in the treatment of leg compartment syndrome.

METHODS

Twenty-one cryopreserved lower limbs from adult cadavers and from one 29-week-old fetus were obtained from the dissection room. They were examined by ultrasound and a subsequent anatomical dissection and microscopy to study the crural fascia and its relationship with the different muscles. Anthropometric measurements were taken of the distances from the head of the fibula and lateral malleolus to the origin of the tibialis anterior muscle in the crural fascia, the exit of the superficial fibular nerve, and the fascia covering the deep posterior muscles of the leg.

RESULTS

The crural fascia has very important clinical relationships, which can be identified by ultrasound, as the origin of the tibialis anterior muscle at 16.25 cm from the head of the fibula and the exit of the superficial fibular nerve that crosses this fascia at 21.25 cm from the head of the fibula. Furthermore, the presence of a septum that fixes the deep posterior muscles of the leg and the vessels and nerve can be seen by ultrasound and can explain the possible development of a posterior compartmental syndrome of the leg. Awareness of these features will help to keep these structures safe during the surgical treatment of compartment syndrome.

CONCLUSION

The ultrasound study allows identification of anatomical structures in the leg and, thus, avoids damage to them during surgery for compartmental syndromes.

Three-dimensional fine structures in deep fascia revealed by combined use of cryo-fixed histochemistry and low-vacuum scanning microscopy

Recent physiological studies have shown that the deep fascia has received much attention concerning clinical medicine; however, histological examination of the deep fascia has not been well established. In this study, we aimed to clarify and visualize the structure of the deep fascia by taking advantage of cryofixation techniques and low-vacuum scanning electron microscopy. As a result, the ultrastructural observations revealed three-dimensional stratification of the deep fascia composed of three layers: the first superficial layer consisting of collagen fibers extending in various directions with blood vessels and peripheral nerves; the second intermediate layer formed by single straight and thick collagen fibers with flexibility; and the third deepest layer, consisting of relatively straight and thin collagen fibers. We explored the use of two hooks to hold a piece of deep fascia in place through the course of cryo-fixation. A comparative observation with or without the hook-holding procedure would indicate the morphological adaptation to physiological stretch and contraction of the deep fascia. The present morphological approach paves the way to visualize three-dimensional ultrastructures for future biomedical studies including clinical pathophysiology.

The effect of deep tissue massage on respiratory parameters in healthy subjects—A non-randomised pilot study

Background

Deep tissue massage (DTM), based on deep palpation and elimination of fascia restrictions, can reduce symptoms resulting from fascial disorders. The goal of this study was the analysis of the DTM effect on respiratory parameters in healthy people.

Material and methods

The study involved a group of 40 people divided into two subgroups. The experimental group underwent a single DTM session. Classic massage was performed in the control group. Before and after treatment the chest circumference and oxygen saturation were measured and a spirometry test was performed.

Results

The chest expandability significantly increased in both groups with greater effect in DTM group. Vital capacity and saturation, significantly increased in the experimental group. No significant changes in dynamic parameters were noticed in the control group, while FVC slightly decreased in the experimental group.

Conclusions

In this study, deep tissue massage appeared to improve chest expendability and vital capacity with simultaneous decrease of FVC in healthy subjects. Further studies are needed to specify the effect of DTM on the respiratory system.

Fascia Layer-A Novel Target for the Application of Biomaterials in Skin Wound Healing

As the first barrier of the human body, the skin has been of great concern for its wound healing and regeneration. The healing of large, refractory wounds is difficult to be repaired by cell proliferation at the wound edges and usually requires manual intervention for treatment. Therefore, therapeutic tools such as stem cells, biomaterials, and cytokines have been applied to the treatment of skin wounds. Skin microenvironment modulation is a key technology to promote wound repair and skin regeneration. In recent years, a series of novel bioactive materials that modulate the microenvironment and cell behavior have been developed, showing the ability to efficiently facilitate wound repair and skin attachment regeneration. Meanwhile, our lab found that the fascial layer has an indispensable role in wound healing and repair, and this review summarizes the research progress of related bioactive materials and their role in wound healing.

Fetal Fascial Reinforcement Development: From "a White Tablet" to a Sculpted Precise Organization by Movement

Simple Summary

Nowadays, the number of studies concerning fasciae is increasing, but few studies focus on fetal fasciae development and there is no study on the retinacula. The latter are fascial reinforcements with a crucial role in proprioception and coordination. We aimed to identify their structural organization by qualitative and quantitative assessments, to establish their role in myofascial development, highlighting their appearance and organization. Our data strongly suggest that the movement models the fascial reinforcements, structuring the fascial system, particularly at the end of the pregnancy.

Abstract

Fasciae have received much attention in recent years due to their important role in proprioception and muscular force transmission, but few studies have focused on fetal fasciae development and there is no study on the retinacula. The latter are fascial reinforcements that play a key role in proprioception and motor coordination. Furthermore, it is still unclear if they are genetically determined or if they are defined by movements, and if they are present during gestation or if they appear only later in the childhood. We aim to identify their structural organization by qualitative and quantitative assessments to establish their role the myofascial development, highlighting their appearance and organization. Samples from the wrist retinacula, posterior forearm, ankle retinacula, anterior leg, iliotibial tract and anterior thigh of six fetus body donors (from 24th to 40th week of gestation) and histological sections were obtained and a gross anatomy dissection was performed. Sections were stained with hematoxylin-eosin to observe their overall structure and measure their thicknesses. Using Weigert Van Gieson, Alcian blue and immunostaining to detect Hyaluronic Acid Binding Protein (HABP), Collagens I and III (Col I and III) were realized to assess the presence of elastic fibers and hyaluronan. This study confirms that the deep fasciae initially do not have organized layers and it is not possible to highlight any reinforcement. The fascial development is different according to the various area: while the deep fascia and the iliotibial tract is already evident by the 27th week, the retinacula begin to be defined only at the end of pregnancy, and their complete maturation will probably be reached only after birth. These findings suggest that the movement models the retinacula, structuring the fascial system, in particular at the end of pregnancy and in the first months of life. The fasciae can be imagined, initially, as “white tablets” composed of few elastic fibers, abundant collagens and HA, on which various forces, u movements, loads and gravity, “write their history”.

Osteogenic Differentiation of Human Adipose-Derived Stem Cells Seeded on a Biomimetic Spongiosa-like Scaffold: Bone Morphogenetic Protein-2 Delivery by Overexpressing Fascia

Human adipose-derived stem cells (hADSCs) have the capacity for osteogenic differentiation and, in combination with suitable biomaterials and growth factors, the regeneration of bone defects. In order to differentiate hADSCs into the osteogenic lineage, bone morphogenetic proteins (BMPs) have been proven to be highly effective, especially when expressed locally by route of gene transfer, providing a constant stimulus over an extended period of time. However, the creation of genetically modified hADSCs is laborious and time-consuming, which hinders clinical translation of the approach. Instead, expedited single-surgery gene therapy strategies must be developed. Therefore, in an in vitro experiment, we evaluated a novel growth factor delivery system, comprising adenoviral BMP-2 transduced fascia tissue in terms of BMP-2 release kinetics and osteogenic effects, on hADSCs seeded on an innovative biomimetic spongiosa-like scaffold. As compared to direct BMP-2 transduction of hADSCs or addition of recombinant BMP-2, overexpressing fascia provided a more uniform, constant level of BMP-2 over 30 days. Despite considerably higher BMP-2 peak levels in the comparison groups, delivery by overexpressing fascia led to a strong osteogenic response of hADSCs. The use of BMP-2 transduced fascia in combination with hADSCs may evolve into an expedited single-surgery gene transfer approach to bone repair.

Cutting into wound repair

The skin is home to an assortment of fibroblastic lineages that shape the wound repair response toward scars or regeneration. In this review, we discuss the distinct embryonic origins, anatomic locations, and functions of fibroblastic lineages, and how these distinct lineages of fibroblasts dictate the skin's wound response across injury depths, anatomic locations, and embryonic development to promote either scarring or regeneration. We highlight the supportive role of the fascia in dictating scarring outcomes; we then discuss recent findings that indicate fascia mobilization by its resident fibroblasts supersede the classical de novo deposition program of wound matrix formation. These recent findings reconfigure our traditional view of wound repair and present exciting new therapeutic avenues to treat scarring and fibrosis across a range of medical settings.

Fetal development and growth of the human erector spinae with special reference to attachments on the surface aponeurosis

PURPOSE

The longissimus (LO) and iliocostalis (IC) of adults consist of myofibers extending from the superolateral to the inferomedial side of the back and, because of the same course, they are fused in the thoracolumbar region. The LO also has a medial attachment to the long myofibers of the transversospinalis (TS) showing a course from the superomedial to the inferolateral side. However, there is apparently no information regarding when and how these similar longitudinal muscles differentiate from a cluster of dorsomedial myotome cells.

METHODS

We examined sagittal and horizontal sections of the trunks of 39 human embryos and fetuses (18-330 mm crown-rump length).

RESULTS

At 6-7 weeks gestational age (GA), the surface aponeurosis appeared prior to and independent of the thoracolumbar fascia. At 6-9 weeks GA, the LO myofibers had a postero-inferior course, from the transverse process to the initial aponeurosis, whereas the TS myofibers had a postero-superior course, from a lateral extension of the intertransverse ligament to the aponeurosis. However, the IC consisted of supracostal longitudinal myofibers and was distant from the LO until 12 weeks GA. Because of the lack of ligamentous attachments and ribs, myofibers of the TS, LO, and IC took a similar inferior course in the lumbar region. When the early TS was represented by the transverso-aponeurotic muscle, consequently, the LO corresponded to the aponeuro-transversal muscle and was independent from the IC.

CONCLUSION

The classical model of TS and LO development does not recognize the essential role of the aponeurosis identified here.

Ultrasound and Anatomical Study of Accessing the Nerves in the Knee by Fascial Planes

The fascia is an undifferentiated mesenchymal tissue related to the peripheral nerves. Both can be identified by ultrasound, which is useful when performing peripheral nerve blocks. However, there is no unanimity about the approaching point of each nerve, nor is there a consensus on how to name the appropriate infiltration zone, although the paraneural zone is frequently mentioned. The aims of this study were to determine if ultrasound is accurate for identifying the fascial planes and the paraneural space of the nerves in the knee, infiltrating them, and achieving a correct anatomical diffusion, as well as for establishing access routes to avoid intraneural infiltration. The study was performed in 16 cryopreserved lower extremities of the dissection room of the Faculty of Medicine and Health Sciences, University of Barcelona. Nerves of the knee were injected with colorant guided by ultrasound after they were visualized. Correct location of the nerves by ultrasound was achieved in 98.75% of the cases, correct visualization of the needle by ultrasound in 82.5%, the hypoechogenic image around the nerve after infiltration in 82.5%, and a correct paraneural infiltration in 76.25% of cases. With these results, we can conclude that high-definition ultrasound enables location of the peripheral nerves and adjacent structures as well as the fasciae that surround them, and therefore allows performance of infiltrations in the paraneural spaces.

Study Group of the Muscle and Tendon System from the Spanish Society of Sports Traumatology, Balius R, Blasi M, Pedret C, Alomar X, Peña-Amaro J, Vega JA, Pruna R, Ardèvol J, Álvarez G, de la Fuente J, Fernández-Jaén T, Järvinen TA, Rodas G. A Histoarchitectural Approach to Skeletal Muscle Injury: Searching for a Common Nomenclature

In recent years, different classifications for muscle injuries have been proposed based on the topographic location of the injury within the bone-tendon-muscle chain. We hereby propose that in addition to the topographic classification of muscle injuries, a histoarchitectonic (description of the damage to connective tissue structures) definition of the injury be included within the nomenclature. Thus, the nomenclature should focus not only on the macroscopic anatomy but also on the histoarchitectonic features of the injury.

Investigations of Human Fascia Lata Elemental Composition-the Effect of Different Preservation and Mineralisation Methods

Influence of fixation medium and storage conditions as well as impact of sample mineralisation procedure on determination of minerals in human fascia lata was examined and discussed. Freezing and storage in 10% neutral buffered formalin solution and in 2.5% glutaraldehyde were used as the preservation methods of the samples. The concentrations of, both essential and toxic, elements were measured by ICP-OES method in fascia lata samples mineralised with concentrated nitric acid in a closed microwave system and in open vessels heated on a hot plate. Freezing was found as the best preserving method of fascia lata samples because of the number of elements determined and determination precision. The trace element (Cd, Cr, Cu, Fe, Ni, Sr, Zn) concentrations obtained in samples decomposed using the conventional hot plate were different from analogous measurements in solutions obtained after application of closed vessels and microwave energy assistance. Differences between the mineral compositions of fascia samples variously preserved and mineralised were statistically evaluated and discussed. Interelement correlations were analysed taking into account an impact of various methods of sample conservation. Strong, positive association between element content was discovered for Cr-Ba, Mn-Ba, P-Ba, Sr-Ba, Sr-Ca, Zn-Ca, Mn-Cr, Pb-Cr, Sr-Cr, Mg-Fe, P-Fe, Pb-Ni, Ti-Ni and Sr-P pairs of elements.

New Proposal to Define the Fascial System

At the beginning of the third millennium, we still do not have a definition of 'fascia' recognized as valid by every researcher. This article attempts to give a new definition of the fascial system, including the epidermis, by comparing the mechanical-metabolic characteristics of the connective tissue and the skin. In fact, according to the latest classification deriving from the Fascia Nomenclature Committee, the outer skin layer is not considered as part of the fascial continuum. This article highlights the reasons for taking the functional characteristics of the tissue into consideration, rather than its mere structure. A brief discussion will address the questions as to what is considered as fascial tissue and from which embryonic germ layer the epidermis is formed. The notion that all the layers intersect will be highlighted, demonstrating that quoting precise definitions of tissue stratification in the living organism probably does not correspond to what happens in vivo. What we propose as a definition is not to be regarded as a point of arrival but as another departure.