Sciatica of the Thoracolumbar Junction

What is it?

AKA Maigne syndrome typically results from irritation of the thoracolumbar posterior ramus nerves between T9 and L2. Facet joint dysfunction and degeneration are common culprits as well.


Maigne syndrome usually coexists with a superior cluneal nerve entrapment. The purely sensory superior cluneal nerves are divided into three branches, the medial, intermediate, and lateral. Maigne syndrome involves irritation of the dorsal root near the spine, while cluneal nerve entrapment is a more peripheral neuropathy.



Maigne syndrome or cluneal nerve entrapment may be a causative or contributory factor in up to 40% of low back pain cases. That prospect increases as symptoms extend over the posterior iliac crest.


Clinical Presentation

Symptoms include pain, numbness, or paresthesia usually in the lumbosacral region, iliac crest, or groin. Symptoms are typically described as chronic, constant, and unilateral. It is commonly exacerbated by activities that stress the thoracolumbar junction.


A sustained slouch sitting posture can increase dural tension, resulting in posterior rami irritation. Prolonged walking is also a known trigger for Maigne syndrome, particularly when there is peripheral cluneal nerve entrapment. Cluneal nerve entrapment can be exacerbated by transitional movements, like standing up from a seated position, rolling in bed, squatting, lateral bending, and trunk rotation.


Clinical evaluation will often demonstrate tenderness to palpate at the thoracolumbar junction. Lower thoracic lateral translation (side to side) may provoke discomfort. Loss of stability is a common precipitating factor for Maigne syndrome.


Gait assessment may reveal contributory mechanics including diminished or asymmetrical arm swing, loss of hip extension, or short stride length.


Diagnosis

Imaging is rarely useful for establishing the diagnosis of Maigne syndrome. Plain film radiographs would be indicated in cases of acute trauma, or if bony pathology is suspected. Advanced imaging may be appropriate in the presence of red flags or suspicion of other pathology.


Management

Modalities, including electrical stimulation and ice may help decrease pain and inflammation in the early stages. The long-term treatment goals include restoring biomechanical function at the thoracolumbar junction and reestablishing normal peripheral neurodynamics.


Hypermobile joints require a focus on building stability, whereas hypomobile joints, particularly degenerated segments, prefer strategies that open the intervertebral foramen.


Manual therapy may help improve fascial movement and flexibility in patients with chronic back pain. Spinal manipulation of the thoracolumbar junction appears to provide benefit for Maigne patients. Manipulation and mobilization should address any joint restrictions throughout the kinetic chain, particularly in the lumbar, thoracic, and costovertebral regions.


Myofascial release should focus on the thoracolumbar region and distribution of the cluneal nerve. IASTM could help with the management of this condition. Stretching and myofascial release maneuvers should address any excessive tensions or functional shortening of the thoracolumbar fascia.


Mechanical cupping may be used prior to stretching for multi-dimensional release of the thoracolumbar fascia. Nerve mobilization of the dorsal rami and cluneal nerves may be helpful.


Active rehabilitation should be incorporated early in the process. Flexibility exercises should target the thoracolumbar erectors and iliopsoas, especially if the patient continues to be in a flexed posture most of the time. Active rehabilitation should focus on building strength in the hip and core stabilizers. Long-term resolution necessities restoration of normal breathing mechanics and correction of any other contributing functional deficits.


In rare cases, surgical intervention may be needed to release an entrapped nerve if conservative care fails.




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