| Archives of Physical Medicine and Rehabilitation, 1980;61:389-95 Low Back Pain of Thoracolumbar Origin Robert Maigne, MD, Physical Medicine, Hotel-Dieu Hospital, 75181 Paris Cedex 04, France |
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Abstract: Low back pain arising from the apophyseal joints of the thoracolumbar region is common and is often erroneously attributed to pathologic changes i the low back. The diagnosis is made on pure clinical grounds. Classic signs are: a positive "iliac-crest point" test, a positive skin-rolling test, localized tenderness over a certain spinous process at the thoracolumbar junction and tenderness over the involved apophyseal joint. The diagnosis is confirmed by a periapophyseal joint block using a local anaesthetic. Of 350 patients seen in a back pain clinic, 40% were found to have pain of thoracolumbar origin. Treatment included manipulation, infiltration with corticosteroids, electrocoagulation and/or surgical denervation of the involved apophyseal joint.
Pain in the lumbosacroiliac or gluteal regions is usually attributed to disorders of the lower lumbar or lumbosacral spine. The author's clinical experience indicates that this pain is commonly derived from irritation of the posterior branches of the lower thoracic and/or the first lumbar spinal nerves. This irritation takes place at the corresponding zygoapophyseal joints of the same segments with which these nerves are anatomically related.
Diagnosis of this form of low back pain is strictly clinical. Findings on x-ray examination and computerized tomography of the lower thoracic and upper lumbar spine are usually normal. The clinical picture may frequently be confused by the finding of radiologic abnormalities at the lumbosacral region to which the cause of the low back pain is erroncously attributed.
Review
of the literature |
The thoracolumbar junction bas attracted the attention of surgeons because of the frequency of fractures at that level.10,35 Its role as a hinge and the transitional character of T12 has been studied.23,28 The anatomy of the posterior primary rami of the spinal nerves has been well reviewed.9,11,12,14,16,24,33 The significance of the role of the posterior primary rami in the pathogenesis of back pain has been discussed by Lazorthes and Gaubert15 and by the author.17,20 However, it was the interapophyseal joints and posterior primary rami of the lower lumbar region which continued to attract the interest of physicians. In 1974, it was realized that the thoracolumbar junction frequently played a role in the causation of low back pain.20 Before the discovery of disc pathology21,28 low back pain was attributed to the muscles or interapophyseal joints of the lower lumbar region.6,7,26 Many authors continued to consider low back pain to be discogenic and the role of the posterior articulations was neglected.2,17,22 Although some anatomic studies were devoted to these articulations14,16,24,25, they were not considered as a cause of pain unless they manifested radiologic change in the form of degenerative, traumatic or congenital malformations. A revival of interest in back pain of articular origin occurred following the report of Rees27 on the relief of back pain by facet denervation in the lower lumbar region. Similar results were reported by Shealy29 and others.
However, disc and lower lumbar facet joint disease does not account for all cases of low back pain.32 Some cases are probably due to strain of the lumbosacral ligaments (interspinous, iliolumbar or sacroiliac).8 The sacroiliac joint has been certainly incriminated.3 These opinions are controversial. There are cases of back pain due to myofascial origin, static or postural problems.4,30,31,34 Awad1 demonstrated abnormal amounts of acid mucopolysaccharides in the muscles in patients having myofibrositis. Kraus13 described muscular insufficiency, and the role of psychogenic factors has also been verified.5 However, when all these causes are excluded, there remains a number of cases of back pain which cannot be explained.18,19 The purpose of this paper is to direct attention to low back pain of thoracolumbar origin.
Anatomic
considerations |
The posterior primary rami of the thoracolumbar spinal nerves. These rami innervate the skin of the back and the intrinsic muscles of the apophyseal joints and the supra and interspinous ligaments. Each posterior ramus separates at right angles from a merging spinal nerve. The ramus passes about the apophyseal joint along the superior articular apophysis of the underlying vertebra (fig 1).
Fig. 1: The anterior (A) and posterior (P) branches of a spinal thoracic nerve and the division of the latter into medial and lateral branches. Note the close relationship of (P) and its contribution to the apophyseal joint.
Each ramus divides immediately into two branches: a lateral branch which carries motor and sensory fibers and becomes subcutaneous several vertebral levels below its origin, and a medial branch which is almost exclusively motor and is distributed to the multifidus, rotatory muscles and interspinous muscles. The cutaneous branches penetrate the lumbar fascia, descend in the subcutaneous tissue and end in the skin of the lower lumbar area. Anastomoses between these branches are frequent.
Classically the cutaneous innervation of the lower lumbar and gluteal regions has been attributed to the lateral branches of L1, L2 and L3. The author has, however, more often observed cutaneous innervation of the gluteal region derived from higher levels of the throacolumbar region, T11-L1. Anastomoses between these nerves are also common.
Apophyseal joints of the thoracolumbar junction. The direction and extent of motion in the vertebral column are determined at each vertebral segment by the orientation and form of the exterior articulations. In the cervical spine, the articular plane exhibits an inclination of 45° from the horizontal plane. In the thoracic spine the inclination reaches 60° and is 90° in the lumbar region. In the cervical and thoracic spine, the posterior articulations are approximately in the frontal plane, while in the lumbar spine they are in the sagittal plane. As a result of this organization, forward flexion and extension are essentially all that is permitted in the lumbar spine. The thoracic spine, however, by virtue of the orientation of the facets should have a high degree of mobility, especially that of rotation. The ribs, however, prevent much of this rotatory movement. No rotation is possible in the lumbar spine also by virtue of the facet orientation and form. It is apparent, therefore, that during rotation the thoracic spine essentially moves as one segment and the lumbar spine as another. Therefore, the greatest degree of rotation and lateral flexion must take place at the level of the thoracolumbar junction. T12 is considered to be an intermediate vertebra with its superior joints acting as those of the thoracic spine and its inferior joints as those of the lumbar spine.
Material
and Methods |
In 350 patients having back pain referred to the Rehabilitation Medicine Back Pain Clinic at Hôtel-Dieu Hospital in Paris, the origin of pain was found to be thoracic or thoracolumbar in 138 (40%), lumbosacral in 120 (34%), combined thoracic and lumbosacral in 62 (18%), and structures other than the spine in 30 (8%). This study is limited to the 138 patients with back pain of thoracic or thoracolumbar origin. All patients complained of pain in the low back, the duration of which varied between a few days to several months. Their ages and sex are shown in the table. Examination included range of motion and manual muscle testing of the back and the lower extremities. In addition, the deep tendon reflexes and the sensations were examined.
Age and Sex Distribution Among 138 Patients With Low Back Pain of Thoracolumbar Origin
| Age group, yr |
Males |
Females |
Total |
| < 20 |
2 |
3 |
5 |
| 20-35 |
13 |
12 |
25 |
| 35-50 |
20 |
17 |
37 |
| 50-65 |
19 |
23 |
42 |
| > 65 |
10 |
19 |
29 |
To confirm that the back pain originated in the thoracolumbar junction, five factors were found to be essential: (1) the "iliac crest point" sign, (2) positive skin-rolling test, (3) clinical evidence of specific level involvement in the thoracolumbar region, (4) tenderness to deep palpation over the involved apophyseal joints, and (5) specific responses to diagnostic block with procaine.
1. The "iliac crest point" sign. Pain and deep tenderness are located at the level of the iliac crest at a point which corresponds to the cutaneous emergence of the posterior branches of the affected spinal nerves. Pressure at this point causes a sharp pain similar to the patient's complaint. This sign requires careful, precise localization. The patient is placed across the examining table, lying upon a pillow placed under the abdomen to flex the back and cause him to be in a relaxed position (fig 2). The examiner places his finger along the iliac crest with moderate pressure being exerted every half centimetre in an attempt to isolate the exquisite tender point. The examiner moves his finger slightly laterally, medially and vertically in a probing manner (fig 3). Once the irritated nerve is located, deep pressure and gentle movement arouse marked hypersensitivity that is clearly demonstrated by the patient's reaction. The opposite iliac crest is usually examined in a similar manner and is commonly not affected.
 |
 |
Fig 2. The position of the patient for examining the thoracolumbar spine.
Fig 3. How to look for the "iliac crest point."
2. Skin-rolling test. Thickening and hypersensitivity of the skin and subcutaneous tissues of the gluteal and iliac crest region are noted when a fold of the skin and subcutaneous tissues is taken gently between the thumb and fore finger of the examining hand and rolled (fig 4). The area of painful, thickened skin found on the involved side differs from the contralateral region where the skin is normal in texture and sensitivity. This sign is difficult to elicit in an obese patient or if the examination is hurried.
Fig 4. The skin-rolling test.
3. Clinical evidence of specific level involvement in the thoracolumbar region. The thoracolumbar spine segments from T10 to L5 are examined with the patient prone. Pressure is applied vertically by the thumb upon the spinous processes one by one and tangentially in a slow, prolonged manner (fig 5). At each spinal segment pressure is applied both to the left and to the right. Upon reaching the involved segment, tenderness is unequivocably elicited. Pressure must be exerted upon the posterior spine of the vertebra and not on the skin so that the manoeuvre leaves no question as to the source of tenderness. This examination manoeuvre exerts a rotatory force upon the vertebra. At the segment which is the source of pain, the patient responds with a unilateral, painful response. Rarely is pain noted upon movement of the same vertebra in the opposite direction (20%).
Fig 5. Lateral pressure on the side of the spinous process of the thoracolumbar vertebrae.
4. Palpation of the apophyseal joints. To confirm the diagnosis, tenderness to deep palpation over the corresponding apophyseal joints can be elicited. Pressure is applied in a direct, deep, vertical manner, approximately, 1 cm lateral to the spinous processes and is followed by a slow, gentle rubbing movement of the fingers (fig 6). In this manner, the pressure is exerted over the facet joint of the specific vertebral segment.
Fig. 6: Method of palpation of the apophyseal joints for tenderness.
5. Diagnostic block with procaine. That the pain is referred from the thoracolumbar region to the iliogluteal region can be confirmed by infiltration of a local anaesthetic around the painful apophyseal joint. The anaesthetic (2ml) is injected l cm lateral to the spinous process (fig 7), directly into the joint region. The injection should, within minutes, suppress the pain and discomfort previously initiated by the patient's rotatory movement, eliminate the tenderness over the "iliac crest point," and diminish or relieve the cutaneous tenderness and thickening of the subcutaneous tissue and skin previously detected by the skin-rolling test.
Fig 7. Method of injection of the periapophyseal joint tissues. The cross indicates the region of pain and tenderness.
Results |
In 138 patients with the diagnosis of low back pain of thoracolumbar origin, 115 (83%) had a positive and 23 (17%) a negative "iliac crest point" test. However, those having a negative test had a positive skin-rolling sign. Among all patients the skin-rolling was markedly painful in 39 (28%), painful in 45 (33%), and moderately painful in 30 (22%). In 24 (17%) this test was negative.
On palpation in 82 patients (59%), only one vertebral level was involved; T9-10 in 4 cases (5%), T10-11 in 10 cases (12%), T11-12 in 34 cases (42%), T12-L1 in 28 cases (34%), and L1-2 in 6 cases (7%). Thus, in the majority of these cases (76%), the findings were limited to T11-12 or T12-Ll. In 36 patients (26%), two vertebral levels were affected, and in 20 (15%), three levels were involved.
Treatment of our patients included manipulation (fig 8, 9), infiltration with corticosteroids, electrocoagulation, a combination of these methods, and in some cases, surgical denervation of the involved zygapophyseal joints.
In general, 86 (62%) patients had excellent relief of pain, 32 (23%) had satisfactory relief and 20 (14%) showed no change. In the excellent recovery group, the treatment was found to be as follows: 28 had manipulation of the spine, 32 had combined manipulation and infiltration, 22 had injections, 2 had electrocoagulation of the facet joint innervation and two had surgical denervation of the same joints.
 |
 |
Fig 8. Manipulation for relief of dorsolumbar disorders.
Fig 9. Manipulation in extension.
Discussion |
The distribution of the lower thoracic nerves and L1 with emergence of sensory branches at the iliac crest has been verified in our dissection laboratory (fig 10) and is well substantiated.
Fig 10. Dissection in a cadaver of the sensory branches of the 12th thoracic nerve (arrow) as it crosses over the iliac crest (I.C.).
The mechanism of the thoracolumbar involvement is manifested by the history of the patient who usually relates the onset of pain to a rotatory twisting movement. The lack of pain radiation into the lower extremity (L4-5, Sl) suggests a site of pain other than the lumbosacral region. The absence of scoliosis or an antalgic spine also mitigates against lumbosacral disease. The straight leg raising test is usually negative.
Localization of tenderness by tangential movement of T10, 11, 12 or L1 vertebrae, facet joint sensitivity by digital pressure, and elimination of all the symptoms and signs by a local infiltration of an anaesthetic agent confirm. the diagnosis.
It has been the author's clinical experience over the last 20 years that many patients adequately treated for lumbosacral disease who have had persistence of low back pain that could not be explained by subsequent examinations and treatments, have proven to have referred pain from the thoracolumbar region. Many patients who have had persistent back pain following lumbar surgical procedures may have this condition coexisting with lumbar discogenic syndrome.
Acknowledgment: The author expresses his sincere thanks to Dr. Essam A. Awad for the translation of this paper from the French manuscript.
References
1. Awad EA: Interstitial myofibrositis: hypothesis of mechanism. Arch Phys Med Rehabil 54: 449-453, 1973
2. Badgley CE: Articular facets in relation to lowback pain and sciatic radiation. J Bone Joint Surg 23: 481-496, 1941
3. Baer WS: Sacroiliac strain. Bull Johns Hopkins Hosp 28: 159-163, 1917
4. Brugger A: Les syndromes vertébraux radiculaires et pseudo-radiculaires. Basle Documenta Geigy 18, 2 vol. 1957
5. Forrest AJ, Wolkind SN: Masked depression in men with low back pain. Rheumatol Rehabil 13: 148-153, 1974
6. Ghormley RK: Low back pain with special reference to articular facets with presentation of operative procedure. JAMA 1773,1933
7. Goldthwait JE: Lumbosacral articulation: explanation of many cases of "lumbago", "sciatica" and paraplegia. Boston Med Surg J 164: 365-372, 1911
8. Hackett GS: Ligament and Tendon Relaxation Treated by Prolotherapy. Ed 3, Springfield, IL, Charles C Thomas Publishers, 1958
9. Hadley LA: Anatomico-roentgenographic studies of posterior spinal articulations. Amer J Roentgenol 86: 270-276, 1961
10. Hollinshead WH: Textbook of Anatomy. Ed 3, Hagerstown, MD, Harper & Row Publishers Inc, 1974
11. Hovelacque A: Anatomie des Nerfs Craniens et Rachidiens et du Système Grand Sympathique chez l'Homme. Paris, Gaston Doin et Cie Éditeurs, 1927
12. Johnston HM: Cutaneous branches of posterior primary divisions of spinal nerves, and their distribution in skin. J Anat Physiol 43: 80-92, 1909
13. Kraus H: Clinical Treatment of Back and Neek Pain. New York, McGraw-Hül Book Company, 1970
14. Lazorothes G, Gaubert J: Les innervations des articulations vertébrales interapophysaires. In "Compte-Rendu de la 43eme Réunion de l’Association des Anatomistes." Lisbonne, 1956, 688
15. Lazorthes G, Gaubert J: Le syndrome de la branche postérieure des nerfs rachidiens. Presse Méd 64: 2022, 1956
16. Lewin T, Moffett B, Vidik A: Morphology of lumbar synovial intervertébral joints. Acta Morphol Neerl Scand 4: 299-319, 1962
17. Maigne R: Articulations interapophysaires et pathologie douloureuse du rachis. Ann Méd Phys 15: 262, 1972
18. Maigne R: Douleurs d'Origine Vertébrale et Traitements par Manipulations. Ed 4, Paris, Expansion Scientifique Francaise, 1968, vol 1
19. Maigne R: Les Manipulations Vertébrales. Ed 3, Paris, Expansion Scientifique Francaise, 1960, vol 1
20. Maigne R: Origine dorso-lombaire de certaines lombalgies basses: rôle des articulations interapophysaires et des branches postérieures des nerfs rachidiens. Rev Rhum Mal Osteoartic 41: 781-789, December 1974
21. Mixter WJ, Barr JS: Rupture of intervertebral disc with involvement of spinal canal. N Engl J Med 211: 210-215, 1934
22. Mooney V, Robertson J: Facet syndrome. Clin Orthop 115: 149-156, 1976
23. Paturet G: Traité d'Anatomie Humaine. Tome I: Ostéologie, Arthrologie, Myologie. Paris, Masson Cie Éditeurs, 1951
24. Pedersen HE, Blunck CFJ, Gardner E: Anatomy of lumbosacral posterior rami and meningeal branches of spinal nerves (sinu-vertebral nerves). J Bone Joint Surg Am 38-A: 377-391, 1956
25. Penning L, Tondury G: Entstehung, Bau und Funktion der meniskoiden Strukturen in den Halswirbelgelenken. Z Orthop 98: 1-14, 1963
26. Putti V: Lombartrite e Sciatica Vertébrale. Bologna, Capelli, 19 36, Vol 1
27. Rees WES: Multiple bilateral subcutaneous rhizolysis of segmental nerves in treatment of intervertebral disc syndrome. Ann Gen Prac 26: 126, 1971
28. Schmorl G, Junghanns H: Die gesunde und kranke wirbelsaiile im Ré;ntgenbild. Leipzig, g. Thieme 1932, vol 1
29. Shealy CN: Percutaneous radiofrequency denervation of spine facets: treatment for chronic back pain and sciatica. J Neurosurg 43: 448-451, 1975
30. Simons DG: Muscle pain syndromes-part 1. Am J Phys Med 54: 289-311, 1975
31. Simons DG: Muscle pain syndromes-part 2. Am J Phys Med 55: 15-42, 1976
32. St. Clair FG: President's address: debunking dise. Proc Roy Soc Med 59: 952-956, 1966
33. Stillwell DL Jr. Nerve supply of vertebral column and its associated structures in monkey. Anat Rec 125: 139-169, 1956
34. Travell J, Travell W: Therapy of low back pain by manipulation and of referred pain in lower extremity by procaine infiltration. Arch Phys Med Rehabil 27: 537-547, 1946
35. Watson-Jones R: Fractures and Joint Injuries. Ed 4, Edinburgh, E & S Livingston Ltd, 1952-1955, 2 vols