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C h e c k o u t A B M P 's l a t e s t n e w s a n d b l o g p o s t s . Av a i l a b l e a t w w w. a b m p . c o m . 99 extremity, is often felt in the muscles and other tissues closest to the spine, which, ironically, are not innervated by fibers from the ventral nerve branches. The dorsal rami (Image 1) are smaller nerve branches that come off the posterior aspect of the nerve root and are less vulnerable to disc compression than the ventral branches because of the location of the disc. The dorsal rami are called "mixed nerves" because they carry both motor and sensory fibers. The motor fibers innervate the paraspinal muscles, such as the three divisions of the erector spinae group, as well as the smaller intrinsic muscles like the multifidus. Sensory fibers from the dorsal rami supply the skin along the spine, as well as deep connective tissues of the vertebrae, such as the posterior longitudinal ligament. While very small, the dorsal rami of spinal nerves can carry up to 200,000 nerve fibers, so there is still a great deal to be affected when these nerves are subjected to increased compression or tension. 2 Because they are very short, the dorsal rami don't travel through any major tunnels or have nearby anatomical obstructions that often impact other nerves. However, that doesn't mean they can't be bound, restricted, or pulled. Many people report pain in their paraspinal muscles that is aggravated with additional pressure or stretching. It is likely that sensory fibers of the dorsal rami may be aggravated in many of these complaints. Massage therapists help people with paraspinal muscle pain by using long, gliding strokes along the length of the muscles. This treatment helps reduce muscle tightness and increases blood flow to superficial capillaries and tissues that experience ischemia. Gentle approaches, such as those used in myofascial release techniques, apply traction to the skin, which decreases tensile forces on the dorsal rami nerve fibers. Taking tension off the fibers helps reduce the noxious signals sent back to the central nervous system and can greatly reduce back pain. Next time you are working on a client's paraspinal muscles, try visualizing the location of the dorsal rami and consider how your massage techniques may be used to the greatest advantage in helping them function more effectively. INFERIOR, MEDIAL, AND SUPERIOR CLUNEAL NERVES In the last column ("Unraveling the Complexities of Piriformis Syndrome," September/October 2016, page 98), we explored some of the nerves of the pelvic region that may be involved in gluteal pain problems and the role of the piriformis muscle. Piriformis syndrome is most commonly suspected when a person has serious gluteal pain. Yet, there is another set of superficial sensory nerves that innervate the gluteal region and should also be considered for gluteal pain: the inferior, medial, and superior cluneal nerves (Image 2). The cluneal nerves innervate superficial tissues in the entire gluteal region, yet they are rarely mentioned in references on pelvic or low-back pain. It is likely you haven't even heard of them. The cluneal nerves are sensory, not motor. The inferior division branches off the posterior femoral cutaneous nerve (PFCN). As a result, it could be affected by piriformis compression of the PFCN, which was discussed in the last issue. The medial cluneal nerve is derived from the dorsal branches of S1–S3. It supplies innervation to the skin over the middle buttock region. Other S1–S3 nerve roots supply innervation to the lower leg. Sometimes a barrage of sensory input in one region can spill over to adjacent nerve fibers that are derived from the same level. As a result, lower leg pain that is being reported to the S1–S3 nerve roots can extend into the buttock region because of spillover to the medial cluneal nerves. Superior, medial, and inferior cluneal nerves. Image is from 3D4Medical's Essential Anatomy 5 application. 2 Inferior Medial Superior