I frequently diagnose two common pain generators in the lumbar spine. Both of these conditions are often missed. Neither has consistent universally recognized hard neurological signs.
Lumbar discogenic pain is generally a flexion-intolerant problem. The usual injury is in flexion, often with a twist and/or a lift; whether recent or long ago. Bending forward often makes the pain worse.
Maigne syndrome, or irritation of the cluneal complex nerves coming from the thoracolumbar (TL) junction, is usually an extension problem. The extension intolerance is often less than obvious on the physical exam. The spinal origin of this problem is usually hidden, as the patient rarely presents with thoracolumbar pain.
Modified Lumbar Extension
The usual complaint is flank or buttock pain, or even lateral hip pain. You may or may not be able to reproduce their pain on extension or combined extension and rotation. The TL region musculature is almost always hypertonic, usually localized. Specific spinous processes are often tender; the involved facet joints are often tender.
If you trace the nerves obliquely inferior from the spinal dysfunction, you will find a tender point as the cluneal nerves pass over the iliac crest. Skin rolling will elicit changes in tissue texture along the nerve line. You can often palpate the tenderness of the irritated nerves farther down the posterolateral hip.
Maigne syndrome is so worth studying, and so poorly understood. Read my articles,1 read Robert Maigne's original work, look at William Morgan's article.2 My pandemic project was creating a free 35- minute video on Maigne syndrome; enjoy and learn: https://vimeo.com/416062071.
Understanding the Connection
Why am I writing about these two topics, these two pain generators, in the same article? Because they play into each other. Some of your most difficult low back patients have both of these conditions and require expert guidance. You are probably the only practitioner who might recognize the connection.
Let's start with discogenic pain. Discogenic pain, whether axial or with sciatic nerve irritation, can be quite debilitating. The body does its best to try to accommodate. There are two common postural strategies the body adopts for disc pain. The first is to "sit into your pain," to quote Stu McGill. The patient walks in flexed over, and sits in a flexed position. This is a type of flexion antalgia. It is not really a useful or optimal strategy, but it is a common one. Maybe the body assumes this position because this position opens the lumbar foramina, to preserve the exiting nerves.
The second disc strategy is to hyperextend the lumbar spine, turning on (and forgetting to turn off) the lumbar extensors. If you are in lumbar extension, you are going to at least have a chance of repositioning your lumbar discs, taking stress off the posterior annulus. This postural pattern is the probable mechanism for how discogenic pain contributes to or leads to Maigne syndrome.
The lumbar extensor muscles originate in the lower thoracic region. Their muscular bulk is more proximal, in the TL area, with the tendons inserting on the sacrum. When the lumbar extensors are constantly contracting, the patient ends up hyperlordotic to some degree, and is chronically jamming the facets. This pattern can also lead to irritation of the cluneal complex nerves as they exit from the TL region. This is a common cause of or contributor to Maigne syndrome. In these cases, it is secondary to the body's compensation or protection of the lumbar disc.3
Managing the Disc / Maigne Patient
The patient has the right to more than one problem! Difficult lower back pain patients, with chronic or recurrent low back and buttock and flank pain, often have both of these conditions. How can you manage this? These folks often have a narrow pain-free neutral range. They don't tolerate too much extension, as that sets off the TL facet-generated cluneal pain. They don't tolerate much flexion; that can set off the discogenic pain.
What happens in real life? The patient with disc pain finds a useful PT, chiropractor, trainer or YouTube video and learns to do McKenzie extension. They are rarely told when to stop. They tend to be taught to push into full lumbar extension, prone. Stu McGill talks about how extension exercise, long term, can irritate the facets or create spinous process jamming. Extension exercise is incredibly useful for a painful disc as a pain-relief exercise. Done long term, it can create problems for the posterior elements, facets and spinous processes. (I am not McKenzie certified; I just absorbed McKenzie principles from various teachers.)
Here is a useful modification of prone extension I learned from McGill. It is a much milder form of passive extension. The patient stacks two fists, one on top of the other, places their forehead or chin on top of the hands, and completely relaxes the back muscles. They maintain that position for 30 seconds and repeat several times.
Here are two simple post-test evaluations: 1) Is this mild extension more comfortable than more full extension? 2) Does the patient feel less pain and/or less tenderness after the extension procedure?
Another useful test for the disc is the prone instability test. You can elicit pain from an inflamed disc by applying an oscillating pressure directly over the involved spinous or interspinous space. Your hands cannot press deeply enough to actually touch the disc. You are assessing functional instability by creating a small motion at a segment that does not like to move.
I test the various decompression and/or extension exercises against this prone instability test, finding which variation works best for the patient in this moment. The prone instability test also guides my core stability work.
Standing or walking can irritate the TL facets, as they are extension activities. Monitor how long the patient can do that with comfort. Teach awareness of neutral posture. Sitting, especially prolonged sitting, irritates the disc. Again, take breaks, provide a lumbar support cushion, teach the patient to find a neutral sitting posture. So many will "sit into their pain," defaulting into a slouch posture. Any prolonged sitting is challenging for the unhappy disc. In general, variety is good, movement is good; static positions are bad.
Balance the exercise program. I introduce an abdominal exercise as a way to downregulate the overactive TL extensors in the Maigne video. Exercise the glutes to balance the ab activity.
I've taken a complicated topic and given you a few highlights. I appreciate the challenges of the complicated low back. I hope you do, too.
References
- https://www.sosas.us/professional-resources/articles-2/ (go to the Thoraco-Lumbar tab).
- Morgan W. "Maigne's Syndrome": http://drmorgan.info/clinicians-corner/maigne-s-syndrome/.
- Many of these ideas come from my studies with Stuart McGill, PhD.
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