Thoraco-Lumbar Dysfunction: Maigne’s Syndrome
Another hidden source of lower back pain is irritation of the superior cluneal nerve, coming from dysfunction at the thoraco-lumbar junction.
I have been working with the Maigne syndrome concept for the past several months. It has made me see the integration of the thoraco-lumbar and the lower back and pelvis more clearly. If this concept is new to you, read my article first.
Since writing the article, I have been observing my patients. Here are some thoughts. First, it is so wonderful to have a clear indicator. In this case, the clear indicator – Maigne’s gluteal point – is the hot spot, the knot, about 7–8 cm lateral to the midline, just below the iliac crest. If you don’t get rid of this knot, you have not succeeded.
It is not enough to do soft tissue work to Maigne’s gluteal point. It is usually not enough to do soft tissue work to the hot spots around the thoraco-lumbar junction. Specific mobilization of the thoraco-lumbar fixated areas is the key (a chiropractor’s dream—an adjustment that immediately changes a tender point far away).
The mobilization may need to be done in two or more directions at two or more different spinal levels. Reminds me of the AK fixation, which involves three segments counter-rotated.
If the tender spot, Maigne’s gluteal point, recurs after the next office visit, rehab is in order. Although, to be honest, almost all of the patients with this condition are going to need some kind of rehab. The rehab often needs to be in two opposite directions: 1) the patient will be stiff, and unable to extend freely through the lower thoracic spine, and 2) the patient will often have a “dorsal hinge,” an area of excessive extension in the lower thoracic spine.
Who has the dorsal hinge? One subset would be people who have had significant flexion injuries that have caused them to start avoiding lumbar flexion and to walk around in excessive extension. I happen to fit this category myself. I wonder if emotional trauma, if the startle response, is another part of this. In the DNS world (I don’t live there; I have just had a brief intro to these concepts from Craig Liebenson), they talk about an unlevel diapragm and the patient being stuck in the inspiratory position of the breath. Imagine the lower chest being lifted, as if you just took a deep breath. Now hold this for the rest of your life. Once you get this idea, these folks are pretty obvious on visual inspection. The patients who have a “hang of their ligaments posture,” whose bellies are too far forward, and who have a large C posture with excessive lordosis are also part of this pattern. The exercises of choice include working with breathing and using the dying bug series to keep the thoraco-lumbar spine more neutral and less extended.
The second half of the rehab includes exercises like the foam roller and isolating thoracic extension such as thoracic sphinx. The basic idea: Wake up and get the stiff thoracics able to extend. Think about prolonged sitting and the flexion posture it reinforces. Think about aging and the forward posture of many older folks.