Topics in neurologyRehabilitative Principles in the Management of Thoracolumbar Syndrome: A Case Report
Introduction
Back pain consistently ranks highest among conditions resulting in pain and disability. It is the most prevalent musculoskeletal condition1 and has been noted as having a lifetime occurrence of between 59% and 84%.2 With a wide range of reported health costs extending upward of $100 billion,3 it is necessary to refine management strategies that lead to improved outcomes and reduce the economic burden on health care systems. The literature continues to place chiropractic services as a more cost-effective approach to common back conditions.4, 5 One such study by Liliedahl et al concluded that care initiated by a chiropractor (DC) rather than care initiated by a medical doctor (MD) was 20%-40% less expensive to manage.6
There are many potential causes of back pain including those that originate from fascial strain and associated entrapment of various muscles and nerves. Entrapment neuropathies are often considered clinically based on their anatomic location and distribution of the nerve. For example, the sciatic nerve (and later the tibial nerve) is derived from the sacral plexus and extends inferiorly down the posterior of the leg. Along this course, it lies anterior to the piriformis muscle, exposes itself at the semitendinosus/bicep femoris split, and falls deep through the tendinous arch of the soleus. Neurogenic symptoms along the course of the nerve can lead examiners to assess not only the originating area (sacral plexus), but also these common entrapment locations for the recreation of symptoms. Specific to this case, there are neural branches from the posterior primary rami of the upper lumbar and lower thoracic nerves that have been found to be affected as they penetrate the lumbar fascia.7 Irritation to these nerves, also known as the cluneal nerves, will manifest as referred pain to the cutaneous and subcutaneous areas of innervation to include the low back over the upper gluteal region, the ipsilateral inguinal crease, and the lateral hip region (Fig 1).7
The cluneal nerves were first explored as etiological agents of low back pain in Maigne’s early work from 1980 to 1991, which described the full course of the nerve.8, 9, 10 It was observed that “constricting fascial rings” occurred in the cluneal nerve pathway through the osteofibrous tunnel between the thoracolumbar fascia and the iliac crest.8, 9, 10 Based on these findings and associated clinical presentations, Maigne and Doursounian proposed diagnostic criteria to include: (1) pain in the distribution of the nerve (Fig 1); (2) trigger point/tunnel compression pain; and (3) relief of symptoms following nerve block.11 Since then, more recent investigations continue to show examples of cluneal nerve entrapment as a possible cause of not only low back pain, but also gluteal and leg pain.12, 13 Medical approaches for cluneal nerve entrapment include anesthetic nerve block injections and anti-inflammatory steroid injections and, if these treatment approaches are unsuccessful, then surgery.8, 11, 13, 14, 15
There are few cases in the literature investigating cluneal nerve entrapments11, 13, 14, 15 and even fewer exploring its management with manual therapies.16, 17 As the evidence base supports chiropractic treatment options for lumbosacral back pain,18, 19, 20, 21, 22 this case explored chiropractic care to include manipulative therapy, active care exercise progressions, and soft tissue mobilizations to treat thoracolumbar back pain originating from cluneal nerve entrapment. From a rehabilitation perspective, this case also used a test-retest approach for functional outcomes and exercise prescription.
Section snippets
History
A 33-year-old Caucasian woman with a 3-week history of thoracolumbar pain following a motor vehicle accident presented to the office for evaluation and conservative management. She was initially evaluated by her medical doctor, who ordered radiographs and magnetic resonance imaging (MRI) of her lumbar spine. Imaging demonstrated no acute osseous pathology, dislocation, fracture, or mass. She received an anesthetic nerve block injection in the lumbar spine without experiencing any relief, which
Discussion
To the best of our knowledge, this is the first published case report to describe chiropractic management using multimodal care for a patient with thoracolumbar junction syndrome (Maigne syndrome). Back pain is a common musculoskeletal condition that can improve without treatment, but if the pain persists, then there is a possibility of developing chronic back pain.26 Typically, chronic back pain has a poor prognosis and accounts for the majority of health care costs associated with back pain
Conclusion
The case report described approaches to clinical diagnosis of thoracolumbar syndrome in a chiropractic office. Following a combination of regional adjustments and progressive home care exercises, this patient reported reduced pain, alleviated symptoms, and improved physical function.
Funding Sources and Conflicts of Interest
No funding sources or conflicts of interest were reported for this study.
Contributorship Information
Concept development (provided idea for the research): M.E.D.
Design (planned the methods to generate the results): M.E.D.
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): M.E.D.
Data collection/processing (responsible for experiments, patient management, organization, or reporting data): M.E.D.
Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): M.E.D.
Literature search (performed
References (72)
- et al.
Cost of care for common back pain conditions initiated with chiropractic doctor vs medical doctor/doctor of osteopathy as first physician: experience of one Tennessee-based general health insurer
J Manip Physiol Ther
(2010) - et al.
Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis
J Manip Physiol Ther
(2008) - et al.
Chiropractic management of myofascial trigger points and myofascial pain syndrome: a systematic review of the literature
J Manip Physiol Ther
(2009) - et al.
A review of economic factors related to the delivery of health care for chronic low back pain
Neuromodulation
(2014) - et al.
Assessment of pain
Br J Anaesth
(2008) - et al.
Repeat assessment improves the prediction of prognosis in patients with low back pain in primary care
Pain
(2006) Pathophysiology of nerve compression
Hand Clin
(2002)- et al.
Therapeutic techniques to enhance nerve gliding in thoracic outlet syndrome and carpal tunnel syndrome
Hand Clin
(1991) - et al.
Comparison between the effectiveness of expiration and abdominal bracing maneuvers in maintaining spinal stability following sudden trunk loading
J Electromyogr Kinesiol
(2016) - et al.
Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial
Lancet
(2011)