This also called Maigne Syndrome or Dorsal Ramus Syndrome. It is caused by the unexplained activation of the primary division of a posterior ramus of a spinal nerve.
In absence of any radiological signs, the diagnosis is made clinically.
The thoracolumbar junction (TLJ) is comprised of the T10-11, T11-12 and T12-L1 motion segments. This transitional area, interposed between the thoracic and lumbar spine, is often the source of a characteristic pain syndrome characterized by a referral of the pain in the related dermatomes (T10 to L1).
Anatomy of Posterior Rami
The thoracolumbar primary rami divide after a few millimeters into medial and lateral branches.
The medial branch runs dorsally along the angle between the transverse and zygapophyseal processes of the corresponding vertebra and gives off branches supplying the facet at that level.
A second inconsistent branch runs caudally to supply the facet at the level below. The medial branch then passes along the spinous process, supplying the periosteum of both the lamina and the spinous process prior to terminating at the tip of the latter.
It also innervates the multifidus muscle, one or two levels distal to their vertebral exit.
The lateral branch is directed caudally, laterally and dorsally, supplying the erector spinae and passing through the thoracolumbar fascia two to four levels caudal to their exit where it becomes superficial. This branch gives cutaneous innervation to the subcutaneous tissues of the lumbar and buttock area as distal as the greater trochanter.
Causes
The most common cause of the this syndrome is a minor intervertebral dysfunction at the thoraco lumbar junction.
The nature of this dysfunction remains unknown, although the involvement of either the facets or the disc is very likely. More than any other part of the spine, the TLJ is involved in rotatory movements.
This may lead to an overuse of the motion segment which could initiate disc or facet degeneration. Disc herniation or a collapse of the vertebral body of T11, 12 or L1 may also be responsible.
Other causes are entrapment of cutaneous dorsal ramus of L1 when it crosses the iliac crest and becomes superficial by perforating a rigid fibro-osseous tunnel formed by the thoracolumbar fascia above and the rim of the crest below.
Similarly, entrapment of the lateral cutaneous branch of the iliohypogastric nerve may cause the pain.
Clinical Presentation
Depending on the branch involved, the pain could refer to
- Low back (cutaneous dorsal rami)
- The groin (subcostal or iliohypogastric nerve)
- Lateral aspect of the hip (lateral cutaneous rami of the subcostal or iliohypogastric nerve)
All combination of these clinical presentations are possible.
Low Back Pain is certainly the most frequently encountered pain complaint. The pain is usually spread in the lateral part of the low back without corresponding exactly to a specific dermatome.
Rarely, the pain is bilateral
The pain is usually acute, of less than 2 or 3 months duration, often appearing after a rotatory movement of the trunk, prolonged strenuous posture, lifting and occasionally, without any obvious precipitating factors.
Less commonly, the pain may have a more chronic course.
The pain is frequently increased by contra lateral side bending.
On examination, there is pain and tenderness in iliac crest at a point which is consistently located seven centimeters from the mid line. Pressure at this point causes a sharp excruciating pain similar to the patient’s complaint.
The opposite iliac crest is commonly unaffected.
The pinch-roll test is usually positive. It can be revealed by gently grasping a fold of skin between the thumbs and forefingers, lifting it away from the trunk and rolling the subcutaneous surfaces against one another in a pinch and roll fashion. On the involved side the skin overlying the buttock and iliac crest is found to be tender when compared to the opposite side.
Hyperalgesia is responsible for this test.
Examination of thoracolumbar junction area may produce tenderness.
The affected posterior ramus ends cutaneously causing trophic changes of the skin referred to as cellulalgia consisting of thickening or nodularity of the skin and hair loss or swollen puffy appearance.
Radio-imaging
Third, radiographic is non-contributory. MRI, CT and myelography are inconclusive.
Diagnostic block
The pain gets relieved by injection of local anesthetic into the correct facet joint. This diagnostic procedure can also be therapeutic.
Treatment
The treatment involves administration of anti inflammatory drugs, spinal manipulation and anesthetic blocks.
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After many pain meds, multiple surgeries, and lots of pain, I think thoracolumbar joint syndrome is my problem!! I am looking for a doctor, anywhere in MD, DE, PA, VA who helps with this condition! Please!!
Dr Arun Pal Singh Reply:
September 2nd, 2010 at 6:43 am
@Susan Robinson,
You would need to find the help from your local medical authorities.
Take care.
Like Susan, for the past 9 months have been thru the gauntlet with treatments, medications, injections and exercises all focusing on my SI Joint. 6 months ago I read about Maigne Syndrome and it summarily dismissed by my PT without tests or examination. The ache in my right posterior iliac crest area is almost constant. Rotation moves….legs to the left, twist torso to the right is very painful. Doing bird/dog stability exercises is painful on the right crest area. Rolling down from a bridge will also illicit the pain.
I am confused as to whether this could be the Iliolumbar ligament or Dorsal Ramus. Either way, I am ready to be rid of it.
What are the best treatment options for this type of pain? Are there any exercises or stretches that will help? Massage helps tremendously, but temporarily. The focus of the massages have been QL and periformis.
Any direction would be really appreciated.
Dr Arun Pal Singh Reply:
September 27th, 2010 at 11:26 pm
@Nellie,
First thing is always to establish a diagnosis or to find the cause of the pain.
From your writing it seems that you are making assumptions.
Did you see a specialist?