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INNERVATION OF ZYGAPOPHYSEAL JOINT SYNOVIAL FOLDS IN LOW-BACK PAIN
692 HBV may be involved in the immunopathogenesis in some cases of IgA nephropathy in endemic areas.M Experiments with serum sickness induced by immunisation with bovine serum albumin in rabbits show that small immune complexes are deposited on the epithelial side of the glomerular basement membrane, whereas the larger immune complexes are deposited mainly in the mesangium.9 If HBV antigens with lower molecular weight induce membranous nephropathy while mesangial deposits of HBV antigens with higher molecular result in weight mesangial proliferative glomerulonephritis with IgA deposits, a mixed picture of membranous and IgA nephropathy should be seen in HBVassociated glomerulonephritis, since immune complexes with different molecular weights may be present in these patients. IgA nephropathy and membranouse nephropathy associated with HBV antigenaemia has been reported from Canadal0 and Hong Kong." The ultrastructural finding of spherical viral particles and finely granular viral particles in the masangium and glomerular basement membrane respectively is consistent with this concept.’o Interestingly, the Canadian patient’o was a Chinese immigrant. These findings support your editorial view that the properties of the antigen may be a more important determinant of the type of glomerulonephritis than the immune response. Confirmation of this concept is of more than theoretical importance in the understanding of immune-complex glomerulonephritis. Departments of Medicine and Morbid Anatomy, Prince of Wales Hospital, Shatin, Hong Kong
K. N. LAI F. M. LAI J. VALLANCE-OWEN
Levy M, Kleinknecht C Membranous glomerulonephritis and hepatitis B virus infection. Nephron 1980; 26: 259-65. 2. Furuse A, Hattori S, Terashima T, et al. Circulating immune complex in glomerulonephritis associated with hepatitis B virus infection. Nephron 1982, 31: 1.
212-18.
Y, Tanaka M, Miyakawa Y, et al. Free ’small’ and IgG-associated ’large’ hepatitis Be antigen in the serum and glomerular capillary walls of two patients with membranous glomerulonephritis N Engl J Med 1979; 300: 814-19 4. Hirose H, Udo K, Matsuda I, et al. Deposition of hepatitis Be antigen in membranous glomerulonephritis: Identification by F(Ab)2 fragments of monoclonal antibody. 3. Takehoshi
Kidney Int 1984; 26: 338-41. 5. Sluzarczyk J, Michalak T, Nozarewicz-de Mezer T, et al. Membranous glomerulopathy associated with hepatitis B core antigen immune complexes in children. Am J Pathol 1980; 98: 29-39 6. Lai KN, Lai FM, Chan KW, et al. The clinico-pathologic features of hepatitis B virus associated glomerulonephritis. Quart J Med 1987; 63: 323-33 7. Lai KN, Lai FM, Lo S, Leung A. Is there a pathogenetic role of hepatitis B virus in lupus nephritis? Arch Pathol Lab Med 1987; 111: 185-88. 8. Nagy J, Bajtai G, Sule T, Ambrus M, Deak G, Hamon A. The role of hepatitis B surface antigen in the pathogenesis of glumerulopathies. Clin Nephrol 1979; 12: 109-16. 9. Germuth FG,
Rodriguez E. The immunopathology of the renal glomerulus. Boston:
Little, Brown, 1973. 10. Magil A, Webber D, Chan V. Glomerulonephritis associated with hepatitis B surface antigenemia Report of a case with features of both membranous and IgA nephropathy. Nephron 1986, 42: 335-39. 11. Lai KN, Lai FM, Lo S, Lam C. IgA nephropathy and membranous nephropathy associated with hepatitis B surface antigenemia. Hum Pathol 1987; 18: 411-14.
INNERVATION OF ZYGAPOPHYSEAL JOINT SYNOVIAL FOLDS IN LOW-BACK PAIN
SiR,—Discussions of low-back pain (with or without leg pain) have tended to emphasise the intervertebral disc as a major cause of symptoms, since no nerves are thought to be present in lumbar zygapophyseal joint synovial folds. However, transmission electron microscopy and silver and gold chloride impregnation techniques have lately demonstrated that the synovial folds (particularly the large lumbosacral zygapophyseal joint synovial folds 1) have 0-2-0.4 tm paravascular nerves2-4 and 06-12 lun myelinated nerves which are remote from blood vessels.3,4 Substance P immunofluorescent nerves were demonstrated in human lumbosacral zygapophyseal joint synovial folds.5 Substance P, a physiologically potent neuropeptide, is thought to participate in nociceptive transmission of nerve impulses.6 Therefore, in the absence of positive radiographic findings, innervation of the synovial folds may have clinical significance in low-back pain, should the synovial folds become pinched between the facet surfaces, with resulting traumatic synovitis. The innervation may explain why fluoroscopically controlled injections of steroids and anaesthetic
into zygapophyseal joints can give relief from low back pain with or without sciatica.7,g The innervation may also explain why gentle mobilisation of the zygapophyseal joints provides relief in some cases of low-back pain-presumably as a result of freeing synovial folds which have become trapped between the facets. Department of Anatomy and Human Biology, University of Western Australia, Nedlands, Western Australia 6009
L. G. F. GILES
LGF, Taylor JR. Intra-articular synovial protrusions in the lower lumbar apophyseal joints. Bull Hosp Joint Dis 1982; 42: 248-55. Giles LGF, Taylor JR, Cockson A. Human zygapophyseal joint synovial folds. Acta
1. Giles 2.
Anat 1986; 126: 110-14 3. Giles LGF, Taylor JR. Innervation of lumbar zygapophyseal joint synovial folds. Acta Orthop Scand 1987; 58: 43-46.
LGF, Taylor JR. Human zygapophyseal joint capsule and synovial fold innervation. Br J Rheumatol 1987; 26: 93-98. 5. Giles LGF, Harvey AR. Immunohistochemical demonstration of nociceptors in the capsule and synovial folds of human zygapophyseal joints. Br J Rheumatol (m 4. Giles
6. 7.
8.
press). Jessell TM. Pain. Lancet 1982; ii 1084-88. Kirkaldy-Willis WH. A comprehensive outline of treatment. In: Kirkaldy-Willis WH, ed. Managing low back pain. Edinburgh: Churchill Livingstone, 1963: 147-60. Aprill C. Lumbar facet joint arthrography and injection in the evaluation of painful disorders of the low back. International Society for the Study of the Lumbar Spine (Dallas, 1986) abstr.
MULTIPLE PREGNANCY AND ASSISTED REPRODUCTION
SIR,--Our main concern about the Voluntary Licensing Authority’s (VLA’s) 1987 guidelines is that a non-statutory authority is seeking to impose strict limitations on the clinical treatment which infertility patients receive. Separate, but of equal importance, to this fundamental issue is the concern that the VLA’s directives have been made without taking into account, or publishing, analysis of all the UK data available to them. It is, for example, unsatisfactory to state there is evidence to show that only 3, or exceptionally 4, oocytes ensure an optimal outcome with gamete intrafallopian transfer (GIFT) without producing the evidence. A statistical analysis of over 1000 GIFT procedures performed in our Unit is readily available to the VLA. The VLA’s recommendation on the number of embryos to transfer after in-vitro fertilisation (IVF) is based upon concerns about multiple pregnancies of high order, but no evidence is presented on what proportion of multiple births in the UK result from IVF. It has always been our opinion that natural conception, associated with medical induction of ovulation, is a major contributor to multiple births of high order, as it was for the septuplets delivered in Liverpool last month. We have done a survey on multiple births (triplets or more) in 1984-86 by asking special care baby units (SCBUs) whether conceptions had been natural, natural after medical induction of ovulation, or IVF. Questionnaires were sent to 192 SCBUs of which 62 (322%) have replied to date. In 27 (44%) there had been no admissions of triplets or higher multiple births. The results (table) confirm that IVF is a very small contributor to multiple pregnancy births of high order resulting in SCBU admissions in the UK. 13% of admissions of quadruplet births or greater followed IVF treatment, and if triplet births are added the proportion falls to 7%. In terms of total cots only 7% were occupied by babies conceived following IVF. The outcome of fertility treatment is likely to be different in women with different types of fertility problem. The risk of a multiple pregnancy of high order is likely to be far greater after natural conception in hypogonadotropic women and some others NUMBERS OF SETS OF TRIPLETS, QUADRUPLETS, QUINTUPLETS, AND SEXTUPLETS ADMITTED TO 35 SPECIAL CARE BABY UNITS IN
1984-86
K. N. LAI F. M. LAI J. VALLANCE-OWEN
Levy M, Kleinknecht C Membranous glomerulonephritis and hepatitis B virus infection. Nephron 1980; 26: 259-65. 2. Furuse A, Hattori S, Terashima T, et al. Circulating immune complex in glomerulonephritis associated with hepatitis B virus infection. Nephron 1982, 31: 1.
212-18.
Y, Tanaka M, Miyakawa Y, et al. Free ’small’ and IgG-associated ’large’ hepatitis Be antigen in the serum and glomerular capillary walls of two patients with membranous glomerulonephritis N Engl J Med 1979; 300: 814-19 4. Hirose H, Udo K, Matsuda I, et al. Deposition of hepatitis Be antigen in membranous glomerulonephritis: Identification by F(Ab)2 fragments of monoclonal antibody. 3. Takehoshi
Kidney Int 1984; 26: 338-41. 5. Sluzarczyk J, Michalak T, Nozarewicz-de Mezer T, et al. Membranous glomerulopathy associated with hepatitis B core antigen immune complexes in children. Am J Pathol 1980; 98: 29-39 6. Lai KN, Lai FM, Chan KW, et al. The clinico-pathologic features of hepatitis B virus associated glomerulonephritis. Quart J Med 1987; 63: 323-33 7. Lai KN, Lai FM, Lo S, Leung A. Is there a pathogenetic role of hepatitis B virus in lupus nephritis? Arch Pathol Lab Med 1987; 111: 185-88. 8. Nagy J, Bajtai G, Sule T, Ambrus M, Deak G, Hamon A. The role of hepatitis B surface antigen in the pathogenesis of glumerulopathies. Clin Nephrol 1979; 12: 109-16. 9. Germuth FG,
Rodriguez E. The immunopathology of the renal glomerulus. Boston:
Little, Brown, 1973. 10. Magil A, Webber D, Chan V. Glomerulonephritis associated with hepatitis B surface antigenemia Report of a case with features of both membranous and IgA nephropathy. Nephron 1986, 42: 335-39. 11. Lai KN, Lai FM, Lo S, Lam C. IgA nephropathy and membranous nephropathy associated with hepatitis B surface antigenemia. Hum Pathol 1987; 18: 411-14.
INNERVATION OF ZYGAPOPHYSEAL JOINT SYNOVIAL FOLDS IN LOW-BACK PAIN
SiR,—Discussions of low-back pain (with or without leg pain) have tended to emphasise the intervertebral disc as a major cause of symptoms, since no nerves are thought to be present in lumbar zygapophyseal joint synovial folds. However, transmission electron microscopy and silver and gold chloride impregnation techniques have lately demonstrated that the synovial folds (particularly the large lumbosacral zygapophyseal joint synovial folds 1) have 0-2-0.4 tm paravascular nerves2-4 and 06-12 lun myelinated nerves which are remote from blood vessels.3,4 Substance P immunofluorescent nerves were demonstrated in human lumbosacral zygapophyseal joint synovial folds.5 Substance P, a physiologically potent neuropeptide, is thought to participate in nociceptive transmission of nerve impulses.6 Therefore, in the absence of positive radiographic findings, innervation of the synovial folds may have clinical significance in low-back pain, should the synovial folds become pinched between the facet surfaces, with resulting traumatic synovitis. The innervation may explain why fluoroscopically controlled injections of steroids and anaesthetic
into zygapophyseal joints can give relief from low back pain with or without sciatica.7,g The innervation may also explain why gentle mobilisation of the zygapophyseal joints provides relief in some cases of low-back pain-presumably as a result of freeing synovial folds which have become trapped between the facets. Department of Anatomy and Human Biology, University of Western Australia, Nedlands, Western Australia 6009
L. G. F. GILES
LGF, Taylor JR. Intra-articular synovial protrusions in the lower lumbar apophyseal joints. Bull Hosp Joint Dis 1982; 42: 248-55. Giles LGF, Taylor JR, Cockson A. Human zygapophyseal joint synovial folds. Acta
1. Giles 2.
Anat 1986; 126: 110-14 3. Giles LGF, Taylor JR. Innervation of lumbar zygapophyseal joint synovial folds. Acta Orthop Scand 1987; 58: 43-46.
LGF, Taylor JR. Human zygapophyseal joint capsule and synovial fold innervation. Br J Rheumatol 1987; 26: 93-98. 5. Giles LGF, Harvey AR. Immunohistochemical demonstration of nociceptors in the capsule and synovial folds of human zygapophyseal joints. Br J Rheumatol (m 4. Giles
6. 7.
8.
press). Jessell TM. Pain. Lancet 1982; ii 1084-88. Kirkaldy-Willis WH. A comprehensive outline of treatment. In: Kirkaldy-Willis WH, ed. Managing low back pain. Edinburgh: Churchill Livingstone, 1963: 147-60. Aprill C. Lumbar facet joint arthrography and injection in the evaluation of painful disorders of the low back. International Society for the Study of the Lumbar Spine (Dallas, 1986) abstr.
MULTIPLE PREGNANCY AND ASSISTED REPRODUCTION
SIR,--Our main concern about the Voluntary Licensing Authority’s (VLA’s) 1987 guidelines is that a non-statutory authority is seeking to impose strict limitations on the clinical treatment which infertility patients receive. Separate, but of equal importance, to this fundamental issue is the concern that the VLA’s directives have been made without taking into account, or publishing, analysis of all the UK data available to them. It is, for example, unsatisfactory to state there is evidence to show that only 3, or exceptionally 4, oocytes ensure an optimal outcome with gamete intrafallopian transfer (GIFT) without producing the evidence. A statistical analysis of over 1000 GIFT procedures performed in our Unit is readily available to the VLA. The VLA’s recommendation on the number of embryos to transfer after in-vitro fertilisation (IVF) is based upon concerns about multiple pregnancies of high order, but no evidence is presented on what proportion of multiple births in the UK result from IVF. It has always been our opinion that natural conception, associated with medical induction of ovulation, is a major contributor to multiple births of high order, as it was for the septuplets delivered in Liverpool last month. We have done a survey on multiple births (triplets or more) in 1984-86 by asking special care baby units (SCBUs) whether conceptions had been natural, natural after medical induction of ovulation, or IVF. Questionnaires were sent to 192 SCBUs of which 62 (322%) have replied to date. In 27 (44%) there had been no admissions of triplets or higher multiple births. The results (table) confirm that IVF is a very small contributor to multiple pregnancy births of high order resulting in SCBU admissions in the UK. 13% of admissions of quadruplet births or greater followed IVF treatment, and if triplet births are added the proportion falls to 7%. In terms of total cots only 7% were occupied by babies conceived following IVF. The outcome of fertility treatment is likely to be different in women with different types of fertility problem. The risk of a multiple pregnancy of high order is likely to be far greater after natural conception in hypogonadotropic women and some others NUMBERS OF SETS OF TRIPLETS, QUADRUPLETS, QUINTUPLETS, AND SEXTUPLETS ADMITTED TO 35 SPECIAL CARE BABY UNITS IN
1984-86