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Thoracolumbar Junction Pain Syndrome: a Cause of Low Back, Hip, Pubic & Pseudovisceral Pain

While dysfunction of the thoracolumbar junction (TLJ) is a common occurrence in adult patients,1,2 there seems to be a paucity of evidence for how to conservatively manage the condition.3 While the TLJ has traditionally been thought to span T12-L1, various studies suggest that it may extend from T9-L2.4-6 Robert Maigne first proposed the existence of Thoracolumbar Junction (TLT) Pain Syndrome in 1972.7,8 In doing so, he found that TLJ Pain Syndrome commonly presents as low back, hip, pubic, autonomic and/or pseudovisceral pain (i.e. gynecologic, urologic, testicular and lower GI pain) originating from dysfunction of the TLJ.8 Thus, while the TLJ may be the primary culprit of the patient’s problem, it is not typically the patient’s primary complaint. Furthermore, given that radiographs commonly reveal changes in the lower lumbar region or hip with insignificant findings for the TLJ, clinicians often overlook this spinal region as a possible cause of the patient’s symptoms.3,8

PATHOPHYSIOLOGY OF TLJ PAIN SYNDROME

Maigne suggested that the symptoms associated with TLJ Pain Syndrome originate from “Painful, Minor Intervertebral Dysfunction” (PMID).3,7 PMID may result in localized or referred pain due to “a form of a self-sustaining minor strain of the vertebral segment,” but it is “generally reversible”  with the right treatment approach.3 The TLJ is uniquely structured, as it connects the lumbar spine, which is structurally designed for flexion-extension, and the thoracic spine, which has a greater capacity for rotation. While the “tethering effects” of the ribs limit the thoracic spine, this is not the case at T11-T12. As such, T12 is often considered a “transitional vertebrae” with rotation available at its thoracic-interfacing upper facets (frontal plane), and limited rotation at the lumbar-interfacing lower facets (coronal plane).8-10

The TLJ, therefore, experiences a significant amount of motion, activity, and rotational distress throughout the course of daily life and sports, making it susceptible to stress and degenerative changes.3,8 In addition to its bony spinal components, the TLJ has attachments to 12th rib, diaphragm, erector spinae, iliopsoas, quadratus lumborum and latissimus dorsi muscles along with the transverse ligament, thoracolumbar fascia,1 and corresponding nerves (i.e. dorsal rami, and superior cluneal nerves)4

The symptoms associated with TLJ Pain Syndrome and PMID are consistent with the dorsal rami and cutaneous dorsal rami dermatome patterns associated with the facets joints from T11-L1.3,7,9 The anterior rami (motor and sensory components) innervate the lower portion of the abdomen, groin, pubic region and superomedial thigh (60% of cases), while the lateral cutaneous branch innervates the trochanteric region from the “seam of trousers” to the mid-thigh (50% of cases).11 The posterior rami innervate the superior gluteal and inferior lumbar subcutaneous tissues.11

Occasionally, a posterior branch will go through an osteoaponeurotic channel, which is defined as the space between the iliac crest below and dorso-lumbar fascia above, which can result in entrapment neuropathy and pain.12,13 Notably, the pain and sensory disturbances associated with TLJ Pain Sydrome often correspond with branches of the T12 and L1 spinal nerve roots, resulting in referred, and often misleading, pain in the back, hip, and groin. Previous studies have demonstrated that saline injections into the ligamentous structures of T12 and L1 reproduce low back pain that radiates into the buttock and greater trochanter,3 further validating the potential role of the TLJ in low back and hip pain.

It is worth noting that the only part of the spine below the TLJ that is capable of providing rotation is the lumbosacral juncture, as the superior and inferior facets of L5 occupy the coronal and frontal planes, respectively. As the only two areas of the lower spine that facilitate rotation, restriction in the TLJ could result in increased movement of the lumbosacral facet joints and vice versa. Hypomobility of the TLJ could, therefore, result in added movement and excess pressure at the lumbosacral joints, thereby propagating pain and irritation “downstream” from the original source.10

DIAGNOSING TLJ PAIN SYNDROME

Clinicians should first rule out red flags and ask the patient to subjectively describe their pain.  Clinical symptoms associated with TLJ Pain Syndrome include low back, hip and/or pseudovisceral pain along with possible pubic tenderness, autonomic disturbance, and restricted motion. Additionally, patients often present with stiffness and loss of motion in the vertebral segments of the TLJ, which often contributes to loss of function and discomfort. Pain is usually described as “deep.”3,4 Clinicians should examine spinal mobility and rule out neurologic and/or hip pathology, to include:

  • Prone examination of the upper lumbar joints and lower thoracic joints for hypomobility, tenderness and symptom reproduction.3,7 Maigne specifically recommended assessment of the TLJ segments in a four-step manner: (1) forced rotation of potentially affected segments by applying pressure over the spinous process, from left to right, and then right to left (generally painful); (2) slow, deep posterior-anterior pressure over the spinous process (may or may not be painful); (3) pressure over the facet joints (1-2 fingerbreadths lateral to the spinous process) usually causes unilateral pain; and (4) pressure over the interspinous ligament between spinous processes (not always painful)3

  • Bilateral palpation of the soft-tissue along the posterior and anterior rami at the level of the corresponding spinal nerve for textural and sensitivity changes. This includes “taut bands” of tissue, tenderness, pain to pressure, increased sensitivity, thickening of skin and subcutaneous tissue. Given that TLJ Pain Syndrome often presents unilaterally, clinicians may find it valuable to test and compare tissue texture and sensitivity via the “pinch and roll” skin maneuver on both sides of the spine.3,14 Notably, reproduction of hip symptoms are often reproduced via the cluneal nerve by grasping and rolling the skin over the midpoint of the iliac crest.7,14

  • Hip mobility and strength testing often reveals minimal to no impairments.7

  • Lower-quarter neurologic and neurodynamic (i.e., neural tissue provocation testing) examination are typically normal.7,10

  • Lumbar spine and seated thoracic spine range of motion are reduced and/or unilaterally symptomatic (rotation, side bending, and extension greatest).14

TREATMENT OF TLJ PAIN SYNDROME

While there is presently limited, high-quality research to identify the most appropriate treatment for TLJ Pain Syndrome, the existing literature seems to agree that the condition is responsive to spinal manipulation therapy, defined as mobilization and manipulation.3,8,11,15-19 Spinal manipulation has the capacity to modify the discharge rate of Type I and II afferent fibers, thereby reducing the sensitivity of mechanoreceptors and decreasing pain.4,19,20

In a recent literature review published in the Journal of the American Osteopathic Association, Lewis found HVLA thrust manipulation to be the treatment of choice for somatic dysfunctions originating from TLJ dysfunction.21 A number of randomized clinical trials have demonstrated improvements in range of motion, pain, function (ODI) and mental state (FABQ) following thrust manipulation to the TLJ.4,22-24 In addition, a number of case reports have suggested that manipulation or mobilization could be useful in the treatment of low back and/or hip pain of thoracolumbar origin and also in the management of some somatovisceral conditions.7,8,10,12,14 Notably, two case studies found that mobilization of the TLJ reduced atypical testicular pain, a phenomenon that is likely due to the ilioinguinal and genitofemoral nerves originating from T10-L1.15,25 TLJ mobilization and manipulation has also been linked to improvements in abdominal pain26 and irritable bowel syndrome.27

In patients where spinal manipulation therapy is contraindicated, corticosteroid injections into symptomatic facet joints may provide an alternative treatment strategy.3,11While acupuncture has been successfully used at the TLJ in horses and dogs,28,29 no studies have attempted to use acupuncture or dry needling on human patients with thoracolumbar dysfunction.  However, Electrotherapy,3,8 soft-tissue release and/or cupping of sensitive cutaneous regions,3 and cluneal nerve flossing12 may be appropriate. The literature further advocates a home exercise program that focuses on improving thoracic mobility, core stability, and lower trapezius and latissimus dorsi strengthening.1,7

CONCLUSION

While the TLJ is often overlooked by many clinicians, it may be a pain generator in patients that suffer from low back, hip, pubic, autonomic and/or pseudovisceral pain. A significant proportion of invasive hip and spine surgeries could perhaps be avoided if physical therapists knew how to accurately diagnose and treat TLJ Pain Syndrome.  While spinal manipulation appears to be the most promising non-invasive treatment in the majority of patients with TLJ Pain Syndrome, more clinical trials are required to fully determine its long-term effects.

AUTHORS

Dr. Kristen Schwaegerle, PT, DPT
Physical Therapist, ProCare Physical Therapy & Hand Center
Fellow-in-Training, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Portsmouth, NH

Raymond Butts, DPT, PhD, MSc, Dip. Osteopractic
Senior Instructor, American Academy of Manipulative Therapy
Coordinator, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Louisville, KY

James Dunning, DPT, PhD, MSc, FAAOMPT, Dip. Osteopractic
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Owner, Montgomery Osteopractic Physiotherapy & Acupuncture Clinic
Montgomery, AL

REFERENCES

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