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Presentation, management etc
This is a draft cheat sheet. It is a work in progress and is not finished yet.
Maignes Syndrome
- Irritation of thoracolumbar posterior ramus - T9-L2 |
- Due to facet joint dysfunction & degeneration |
- Superior cluneal nerve divided into medial, intermediate/middle, and lateral) |
- Occurs at ostefibrous orifice - nerves penetrate thoracolumbar fascia before innervating cutaneous regions of iliac crest and buttock |
- Increases neurodynamic tension on dorsal nerve root - ischemia and hyperexcitability |
- Can co-exist with double crush |
- Common in 55-68 yo population - slightly higher prevalence in females |
Presentation
- LBP |
- Pain, numbness/paestehsia to lumbosacral, iliac crest or groin |
- Chronic, constant , unilateral (can be both sides) |
- Can cause pseudovisceral pain (testicles) |
- Aggravated by activities that stress the TL junction (slouching, prolonged walking, repeated/sustained extension) + transitional movements (arising from a seated position, squatting, rolling in bed) |
- TTP of TL junction and site of entrapment
posterior iliac crest 3-4cm (medial branch)
7-8cm (middle branch) from the midline |
- Side to side shear + PA shear painful |
- Contralateral LF relieves |
- Hyperextesion movements (slump) |
- SKin rolling/pinching over iliac crest can cause hyperalgesia over flank and iliac crest |
- Tapping over entrapped nerve may produce shock like symptoms |
- Assess for dysfunctional breathing - contributes to TL stress |
- Assess for gait dysfunction (diminished/asymmetrical arm swing (loss of GH motion) , loss of hip extension, short stride length) |
- MP can reveal hyper/hypomobile of spine |
Imaging
Not usually needed unless red flags are present |
DDx
- Mechanical pathology of SI/LS (joint dysfunction, facet syndrome, disc lesion, spondylolysis, spondylolisthesis, degeneration, stenosis) |
- Myofascial pain |
- F# |
- Infection |
- Neoplasm |
- Viscero-somatic referral - GU system (UTC, kidney stone) |
As the TL junction pain is a red flag, caution should be advised |
Management
- Electrical stimulation |
- Ice |
- NSAIDs |
- If hypermobile - build stability - if hypomobile , open intervertebral foramen |
- Myofascial release of TL aponeurosis + distribution of cluneal nerve |
- Nerve mobilisation of dorsal rami and cluneal nerve |
- Early rehab - flexability exercises of erectors and iliopsoas |
- Standing hip flexor stretch |
- Half kneeling psoas stretch |
- Lats stretches |
- Pelvic tilt exercises |
- Prone plank |
- Core stability |
- Dysfunctional breathing |
- SMT/EMT of Lx, Tx, costovertebral regions |
- Mulligan's NAGs/SNAGs |
- Anesthetic nerve blocks and steroid injections if no improvement |
- If no improvement with injections, surgery may be considered |
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