Thoracolumbar Junction Dysfunction (Maigne Syndrome)
Pain over the hips is frequently a result of dysfunction in the thoracolumbar junction. Kellgren (1939) first established that injection of the thoracolumbar interspinous ligaments in healthy volunteers resulted in pain over the hips. Later, McCall et al (1979) produced similar patterns by injecting the upper lumbar facet joints.
Maigne syndrome is defined as dysfunction of the thoracolumbar junction marked by pain in the territory of the associated dermatomes of T11-L1 or 2.
Background Anatomy
The T12 and L1 ventral rami (subcostal & illiohypogastric nerves respectively) give rise to the lateral cutaneous branch over the lateral aspect of the hip, which terminates at the greater trochanter. Similalry, the dorsal rami of T12 and L1 traverse the iliac crest, with the L1 dorsal rami crossing consistently 7cm from the midline over the iliac crest.
Pain Syndromes of the Thoracolumbar Junction (TLJ)
In thoracolumbar dysfunction the pain can refer to the low back (cutaneous dorsal rami), groin (subcoastal or illiohypogastric nerve) or in the lateral aspect of the hip (lateral cutaneous rami of the subcoastal or illiohypogastric nerve).
Low back pain is the most common symptom of TLJ dysfunction. The pain normally traverses laterally from the spine across the lumbar region towards the hips. On examination a crestal point will be palpable on the iliac crest. This is a precise focal point of palpable tenderness where the cutaneous branch of L1 passes. There will also be a positive pinch and roll test in the affected dermatomes. Examination of the facet joints of the thoracolumbar junction will demonstrate palpable tenderness at the corresponding segment.
Groin pain may accompany low back pain or appear as an isolated entity. On examination there will be a positive pinch and roll test and pain on palpation of the super aspect of the pubis.
Pain over lateral hip comes from the lateral cutaneous branch of either the subcostal or illiohypogastric nerves. On examination there will be a positive pinch and roll test and positive lateral crestal point. This is found 10-13cm posterior to anteriorsuperiorilliac spine.
Causes
The most common cause is a dysfunction at T10/T11, T11/T12 or T12/L1.
This area is vulnerable as it provides a large percentage of the total rotation in the spine comes from the TLJ. As such when other segments become restricted the TLJ may be over utilised in rotation either acutely or chronically resulting in dysfunction within the motion segment,
Treatment
Typically, according Maigne (1996) these patients respond well to manipulation of the dysfunctional segment. Therapeutic injections may also be required.
If you would like to discuss any of these details in more depth please email me at kieran@kieranmacphail.com, comment below or consult the excellent in depth article by Maigne (1996). The full reference is included below.
References
Kellgren, J.H., 1939. On the distribution of pain arising from deep somatic structures with charts of segmental pain areas. Clin. Sci., 4, 35-46.
Maigne, J.Y., 1996. Thoracolumbar Junction and Thoracolumbar Spinal pain syndromes. Physical Medicine, Hotel-Dieu Hospital, 75181 Paris Cedex 04, France. Available from; http://www.sofmmoo.com/english_section/4_thoracolumbar_junction/thoracolumbar_junction_australie.htm [Accessed 9th September 2011].
McCall, I.W. Park, W.M. O’Brien, J.P., 1979. Induced pain referral from posterior lumbar elements in normal subjects. Spine, 4, 441-6.
and greater trochanter. kieran macphail, cutaneous branch, facet joints, interspinous ligaments, l1, maigne, maigne syndrome, maigne's syndrome, t12, thoracolumbar dysfunction, thoracolumbar joint dysfunction, ventral rami
Dawn
OMG This is exactly what I have. This has been going on for about three weeks now. Is it worth going to the doctor for or will it just heal on its own?
Kieran Macphail
Get in to see a good physiotherapist, chiropractor or osteopath. They should be able to help you manage this. If it is a pure Maigne’s syndrome you should get better very quickly with the right exercises and manual therapy can sometimes accelerate recovery.
All the best
Kieran
Michele
This describes exactly what I have had now going on 4 months. The pain in the lateral hip and inguinal area are so excruciating that its all I can think of. I have seen my GP and an orthopedic doctor and they haven’t yet diagnosed me. What is the timeline and prognosis for this and what do you mean by manipulation of the dysfunctional segment? Is that surgical?
Thanks! I would do anything for relief right now!
Kieran Macphail
Where in the world are you based? Thoracolumbar dysfunction as a primary cause of the symptoms you describe is less likely than muscular and lumbar spine causes.
kstart
It looks like what I have been suffering through. The exercises they give seem to exacerbate the issue…is that normal. I’ve been complaining about this for 10 years with no one knowing what is going on. I’ve been in physical therapy for 5 years and no one has diagnosed it as maignes or thoracolumbar dysfunction but give me the same pelvic floor and hip lift exercises with no pain relief. I’ve been to multiple chiropractors, dry needle therapists, acupuncture–I feel desperate.
Kieran Macphail
Hi Kim,
Where are you based?
My preference is that all exercises directly improve symptoms, in some cases things can be so sensitive that there may be some pain, but this should decrease over time if pain is the primary focus.
I will shortly be publishing a self assessment and treatment algorithm you can follow to treat yourself on this page.