I will be presenting at this year’s Pacific Symposium on November 5th in San Diego, CA. My topic will be thoracolumbar junction syndrome (TLJS), an interesting pain condition that refers pain from the thoracolumbar junction (TLJ) to the sacroiliac joint, iliac crest region, greater trochanter region, and to the groin.
It is sometimes suggested that thoracolumbar junction syndrome is not very common, but considering that it refers pain to a different region than where the pain originates, it is more likely that it is frequently missed. I think it is a fairly common condition and I regularly see it in clinic.
Cause of Thoracolumbar Junction Syndrome
Thoracolumbar junction syndrome is discussed inconsistently in the literature. It is frequently regarded as a minor intervertebral dysfunction at the region of the TLJ, which spans between T11 and L2 (Maigne 1980).
It might also be defined as a dysfunction of the facets of this region attributed to stress from a change in facet orientation that occurs from the thoracic spine to the lumbar spine, though degenerative changes are infrequent with patients presenting with this syndrome (Maigne 1980) (Aktas 2014).
There is a visceral or a pseudo-visceral component to thoracolumbar junction syndrome as patients frequently present with gynecological, testicular, urologic, and lower GI issues (Maigne 1997) (Aktas 2014). Some researches correlate this condition with the visceral complaints, while others suggest that the pain referral gives the appearance of visceral complaints.
L Zhou 2012
The pain referrals follow the trajectory of nerves, which arise from the thoracolumbar junction region. This can have a posterior referral following either the medial branch of the dorsal rami, referring pain medial to the facets which are approximately 1 cun from the spinous processes, or the pain can follow the cluneal nerves and referring pain lateral to the facets and over the iliac crest/yaoyan region. In other words, the facet joint line is considered the dividing line between pain mediated by the medial and lateral dorsal rami (Zhou, L, 2012).
There can also be a more ventral referral pattern from this condition, which follows nerve from the lumbar plexus such as the ilioinguinal, iliohypogastric and subcostal nerves; all of which wrap around the torso. These nerves become cutaneous and supply regions such as the lateral pelvis, lower abdomen and groin.
Expanded View of Thoracolumbar Junction Syndrome
Travell, J. 1999
The thing I find particularly interesting about thoracolumbar junction syndrome is comparing the pain referrals to trigger point (TrP) pain referrals.
For instance, the multifidi refer pain along the midline of the spine at the huatuojiaji points and at the sacroiliac joint region. These muscles are innervated by the medial branch of the dorsal rami. Muscles, such as the iliocostalis lumborum and longissimus thoracic, refer pain to the iliac crest and gluteal region, following the cluneal nerve trajectory and they are innervated from the lateral branch of the dorsal rami (the same as where the cluneal nerves arise).
Travell, J. 1999
This becomes more interesting and apparent when looking at muscles innervated by the ventral rami of the lumbar plexus. The quadratus lumborum (primarily innervated by the subcostal nerve) can refer pain to the greater trochanter region and groin. The lower abdominals, such as the obliques which are innervated by the subcostal, ilioinguinal and iliohypogastric nerves, refer pain to the inguinal and groin region.
All of these muscles are frequent contributors to thoracolumbar junction syndrome. The question becomes “Are these TrP referrals a different condition than TLJS? ”
It is my opinion that thoracolumbar junction syndrome involves a sensitization of this neurological segment leading to pain referral along the peripheral nerves from this segment, painful TrP formation in muscles innervated from this segment, and dysfunction in the viscera from organs innervated from this segment.
This will be expanded on in the lecture at the Pacific Symposium.
Check out this video from our class—Psoas Major: Structure, Function and Treatment, which is available on Lhasa OMS (and other places if you are outside of the U.S.).This is a muscle frequently involved in thoracolumbar junction syndrome, and knowing how to treat it is imperative. In this video, Matt Callison shows needling for GB 27 and discusses how this point relates to nerves from the lumbar plexus and, via these nerves, regulation of the psoas.
Aktas I, Akgun K, Kenan & Palamar D, Saridogan M. Thoracolumbar Junction Syndrome: An overlooked diagnosis in an elderly patient. ThurkGeriatriDergisi. 2014;17.
201. Zhou, C. Schneck and Z. Shao, “The Anatomy of Dorsal Ramus Nerves and Its Implications in Lower Back Pain,” Neuroscience and Medicine, Vol. 3 No. 2, 2012, pp. 192-201. doi: 10.4236/nm.2012.32025.
Maigne, R. Pain syndromes of the thoracolumbar junction: A frequent source of misdiagnosis. Physical Medicine and Rehabilitation Clinics. 1980;8(1):87-100
Maigne, JY, Doursounian L. Entrapment neuropathy of the medial superior cluneal nerve. Nineteen cases surgically treated, with a minimum of 2 years’ follow-up. Spine (Phila Pa 1976). 1997 May 15;22(10):1156-9. doi: 10.1097/00007632-199705150-00017. PMID: 9160476.
Travell, J. G. (1999). Myofascial pain and dysfunction. Williams & Wilkins.