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The sonoanatomy of lumbar erector spinae and its iliac attachment – the potential substrate of the iliac crest pain syndrome, an ultrasound study in healthy subjects

Plamen Todorov
Plamen Todorov
, 
Rodina Nestorova
Rodina Nestorova
 and 
Anastas Batalov
Anastas Batalov
   | Mar 30, 2018
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Article Category: research-article
Published Online: Mar 30, 2018
Page range: 16 - 21
Received: Nov 18, 2017
Accepted: Jan 03, 2018
DOI: https://doi.org/10.15557/jou.2018.0003
Keywords
© 2018 Plamen Todorov et al., published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Fig. 1

Caudal part of the left ES muscle (deep part) with its attachment to the PMIC in a cadaver (left side of the image is lateral). Erector spine enthesis spans between the red marks, depicted by the red dashed line. (**: the caudal part of the deep ES muscle; ++: posterior medial iliac crest; #: gluteus maximus muscle origin; ##: multifidus muscles, *: erector spinae aponeurosis (reflected); quadratus lumborum muscle is marked in green, the spinous process of the forth lumbar vertebra is marked in white)
Caudal part of the left ES muscle (deep part) with its attachment to the PMIC in a cadaver (left side of the image is lateral). Erector spine enthesis spans between the red marks, depicted by the red dashed line. (**: the caudal part of the deep ES muscle; ++: posterior medial iliac crest; #: gluteus maximus muscle origin; ##: multifidus muscles, *: erector spinae aponeurosis (reflected); quadratus lumborum muscle is marked in green, the spinous process of the forth lumbar vertebra is marked in white)

Fig. 2

Position of the ultrasound probe for scanning of the right ES enthesis in the transverse plane (left side of the image is medial)
Position of the ultrasound probe for scanning of the right ES enthesis in the transverse plane (left side of the image is medial)

Fig. 3

Position of the ultrasound probe for scanning of the right ES enthesis in the longitudinal plane (left side of the image is medial)
Position of the ultrasound probe for scanning of the right ES enthesis in the longitudinal plane (left side of the image is medial)

Fig. 4

US image of the normal distal part of the right ES muscle with its enthesis on the iliac crest in the longitudinal plane (left side of the image is cranial). The superior and inferior margins of the enthesis are outlined with the dashed white line. (#: erector spinae aponeurosis; *: the enthesis of erector spinae aponeurosis; ##: the deep part of erector spinae muscle; **: the enthesis of the deep part of erector spinae muscle; ++: posterior medial iliac crest; &: superficial fat pad)
US image of the normal distal part of the right ES muscle with its enthesis on the iliac crest in the longitudinal plane (left side of the image is cranial). The superior and inferior margins of the enthesis are outlined with the dashed white line. (#: erector spinae aponeurosis; *: the enthesis of erector spinae aponeurosis; ##: the deep part of erector spinae muscle; **: the enthesis of the deep part of erector spinae muscle; ++: posterior medial iliac crest; &: superficial fat pad)

Fig. 5

US image of the normal enthesis of the right ES muscle (superficial and deep parts) in the transverse plane (left side of the image is medial). The enthesis is outlined by the dashed white line. (*: the enthesis of the lateral part of the erector spinae aponeurosis; **: the enthesis of the deep part of erector spinae muscle; #: the medial part of the erector spinae aponeurosis; ##: multifidus muscles; ###: gluteus maximus muscle; ++: posterior superior iliac spine; +: dorsal surface of sacrum; &: superficial fat pad; <: sacroiliac joint; <<: long posterior sacroiliac ligament)
US image of the normal enthesis of the right ES muscle (superficial and deep parts) in the transverse plane (left side of the image is medial). The enthesis is outlined by the dashed white line. (*: the enthesis of the lateral part of the erector spinae aponeurosis; **: the enthesis of the deep part of erector spinae muscle; #: the medial part of the erector spinae aponeurosis; ##: multifidus muscles; ###: gluteus maximus muscle; ++: posterior superior iliac spine; +: dorsal surface of sacrum; &: superficial fat pad; <: sacroiliac joint; <<: long posterior sacroiliac ligament)

Sonopathological features (based on Terslev L. et al.(13) and Long S. et al.(3)) identified in the studied ES entheses

Sonopathological features with descriptions: Left ESE (N = 25) Right ESE (N = 25) Total (N = 50)
Presence of calcification foci in the enthesis 0 0 0
Major irregularities of the bony contour at the tendon insertion 3 4 7
Hypoechoic appearance of the enthesis 2 3 5
Altered normal fibrillar structure of the terminal tendon/enthesis 1 0 1
Presence of well-defined anechoic zones in the terminal tendon substance within 10 mm from the insertion 0 2 2

Thickness, width and depth of ES entheses in the study population (all values are in millimeters ± SD)

Parameter Thickness Width Width
US plane Longitudinal Transverse Longitudinal Transverse Transverse
Structure ESE-L ESE-R ESE-L ESE-R ESAE-L ESAE-R ESE-L ESE-R ESAE-L ESAE-R
Men (N13) 5,1 ± 0,6 5,5 ± 0,6 4,4 ± 0,6 4,4 ± 0,8 2,2 ± 0,4 2,3 ± 0,5 15,4 ± 2,7 15,5 ± 2,5 7,9 ± 3,1 8,2 ± 2,7
Women (N12) 4,5 ± 0,5 4,8 ± 0,7 4,3 ± 0,6 4,4 ± 0,7 1,9 ± 0,3 2,1 ± 0,5 17,0 ± 2,7 15,8 ± 2,7 13,0 ± 10,2 11,9 ± 9,7
All subjects (N25) 4,9 ± 0,6 5,2 ± 0,7 4,3 ± 0,6 4,4 ± 0,7 2,1 ± 0,4 2,2 ± 0,5 16,3 ± 2,8 15,7 ± 2,3 10,8 ± 7,3 10,6 ± 6,2
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