Thoracolumbar Syndrome | Diagnosis & Treatment
Introduction & Pathophysiology
Patient’s who present with low back pain, but also ipsilateral gluteal and groin pain may be experiencing referred pain from spinal nociception from the thoracolumbar junction, abbreviated as TLJ. Robert Maigne first described thoracolumbar syndrome in 1974, which is why this syndrome is commonly known as Maigne’s syndrome.
The TLJ may be more susceptible to biomechanical disturbance due to lower stability compared to the thoracic spine as the last two ribs not being attached to the sternum. Furthermore, it is an area where the alignment of the facet joints changes from the frontal plane in the thoracic facets to the Sagittal plane in the lumbar facets. This transitional position might make the TLJ more susceptible to overload.
The pathomechanism is similar to that of lumbar facet syndrome. Irritation of the facet joints and/or articular capsule and/or excessive paraspinal muscle tone may cause irritation of neural structures and produce clinical symptoms.
These neural structures are the dorsal rami, but also the ventral rami of the lower thoracic and upper lumbar nerve roots from T11 to L2.
Clinical Picture & Examination
Next to tenderness upon palpation and pressure of the TLJ, irritation of the dorsal rami in the TLJ area can refer pain to the unilateral iliac crest and upper gluteal region. Irritation of the ventral rami of the TLJ region can lead to unilateral pseudovisceral pain in the hypogastric area, false sciatic neuralgia, tenderness of the pubic symphysis, and hypersensitivity of the intestines.
Pain is triggered by extension and/or rotation and does not cross the body’s midline as the nociceptive structures are only innervated unilaterally.
Be aware that Maigne’s syndrome is a rather rare clinical pattern. It is therefore advisable to first exclude the lower lumbar spine, the SI joint, and the hip as the responsible areas of nociception. The following orthopedic tests or test batteries are recommended to exclude these areas:
- A quick screening test for all 3 regions: Menell Test
- Sacroiliac Joint: Cluster of Laslett
- Hip Joint: FADDIR Test
- Lumbar Spine: PIVMS in prone position
Next to tenderness of palpation of the TLJ, the iliac crest should be palpated for tenderness. Move 7 centimeters laterally from the midline and rub the crest in an up-and-down motion on the posterior iliac crest point. This should elicit sharp pain as the irritated cutaneous branches of T11-L1 are compressed.
Maigne suggests comparing the sensitivity difference on the iliac crest, the inguinal canal, or the greater trochanter by rolling and tightening the skin on both sides. In the Kibler Fold Test, the examiner raises a fold of skin between the thumb and forefinger and rolls it along the trunk perpendicular to the course of dermatomes. The patient should experience more tenderness and hyperesthesia on the affected side compared to the healthy one.
At last, it has to be mentioned that TLJ syndrome is diagnosed clinically as most radiological studies will be normal and false positive results are common. Only a diagnostic nerve block in which the affected facet joint is injected with local anesthesia is described to be useful to confirm the hypothesis.
Originally, Maigne proposed manipulative therapy for the TLJ region. Furthermore, Alptekin et al. (2017) showed that steroid injections and exercise were able to decrease pain. No hard recommendations can be given at this point as hard evidence is rather scarce.
The following thoracic mobilization exercises might be a treatment option:
Alptekin, K., Örnek, N. I., Aydın, T., Alkan, M., Toprak, M., Balcı, L. A., & Alptekin, J. Ö. (2017). Effectiveness of exercise and local steroid injections for the thoracolumbar junction syndrome (The Maigne’s syndrome) treatment. The open orthopaedics journal, 11, 467.
Kozera, K., Ciszek, B., & Szaro, P. (2017). Posterior branches of lumbar spinal nerves-part III: spinal dorsal ramus mediated back pain-pathomechanism, symptomatology and diagnostic work-up. Ortopedia, traumatologia, rehabilitacja, 19(4), 315-321.
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