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.
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.
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,
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 firstname.lastname@example.org, comment below or consult the excellent in depth article by Maigne (1996). The full reference is included below.
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.
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