“My back has been bothering
me….”
William C. Scott, D.O.
Louisiana State University Health Sciences Center
Physical Medicine and Rehabilitation
The Agenda
• Case Presentation
• Discuss pertinent physical exam findings.
• Discuss three syndromes described in the
literature.
• Review a treatment plan for one of those
syndromes which may involve physiatric,
interventional, and Osteopathic techniques.
Case Presentation
• An 32 year old male “weekend warrior”,
was playing flag football with his college
buddies.
• His team was down by 6 points and they
needed a touchdown to win the game.
• The patient was open for the reception and
running towards the end zone when he awkwardly
stepped with his left foot into a depression in the
ground that was on the field.
• He did not injure his ankle, but felt his
outstretched left leg push up into his pelvis with
an associated jolt of pain in his left low back that
resolved temporarily several minutes later.
• Over the next several days, the pain from
his bumps and bruises during the game
resolved, but a nagging focal left low back
pain developed and persisted.
• Two weeks later, he went to his primary
physician with his dramatic and traumatic
tale of the football tragedy
What did the primary doc do?
– Imaging –
• X-ray of L/S –Spine read “mild degenerative
changes of the Lumbosacral spine”
• MRI or the L Spine showed, “bulging of L4/5 and
L5/S1 discs without stenosis of the central canal or
Neuronal foramen. Mild degenerative facet
arthropathy of b/l L4/5 L5/S1 facets.”
PMD DX?
• PMD diagnosed the patient with
“mechanical low back pain”
• Prescribed
– Motrin 600mg po 6h prn
– Flexeril 10mg po qhs
– Diazepam 5mg po q6h prn
• The patient followed up with his PMD 4 weeks later with
no significant relief of his symptoms.
• He stated that he went to the ER on two occasions because
of pain and received Demerol with short term relief.
• The PMD is now referring this patient to you for his low
back pain
• He is obviously frustrated, and has missed several days of
work already…..
What do you want to do next?
• TAKE A HISTORY! …Ask Questions – Describe the
pain.
– Started 2 months ago shortly after the football game
– The pain is located over the left posterior iliac crest in the
region of the Posterior Superior Iliac Spine (PSIS)
– It feels focal and sharply tender pain to palpation
– Now a 5/10
– Range of 4-8/10 , does not wake him from sleep
– Worse with SB R>L, and a little worse with Flexion
– Slightly better with supine position and Icy-hot
What do you want to do next?
• Ask more questions – Does it limit his function?
• The patient tries to go to work, but has called in 14 sick days
over the past 2 months
• Hurts after walking a few blocks, standing, and sitting.
– Any neurological changes?
• No weakness
• No numbness or tingling
• No bowel or bladder incontinence
What do you want to do next?
• Ask more questions!
– PMH – none
– Surgeries – Denies
– Allergies - None
– Family history – Non-contributory
What do you want to do next?
• Ask more questions!
– Social History
• Denies any history of TOB, ETOH, or drug use/abuse
• He is a machine worker for several years which requires him to
lift 30-50lbs. He is happy with his job, likes his boss, and was
recently promoted 6 months ago.
• Happily married with two children.
– Medications:
•
•
•
•
Motrin 600mg 6-7 times a day
Tylenol 650mg 8-10x a day
Icy – hot
Ben gay
What do you want to do next?
• Ask more questions!
– Review of systems –
• Unremarkable except for his back pain, which is
getting worse while sitting in the chair and
answering all these questions.
So, what’s the differential
diagnosis?
•
•
•
•
•
•
•
•
•
Discal and segmental degeneration May include facet arthropathy from
osteoarthritis
Myofascial, muscle spasm, or other
soft-tissue injury/disorders
Disc herniation - May include
radiculopathy
Radiographic spinal instability with
possible fracture or spondylolisthesis May be due to trauma or degeneration
Fracture of bony vertebral body or trijoint complex - May not reveal overt
radiographic instability
Spinal canal or lateral recess stenosis
Primary of metastatic neoplasm,
including myeloma
Osseous, discal, or epidural infection
Primary of metastatic neoplasm,
including myeloma
Inflammatory spondyloarthropathy
• Referred pain
• Gastrointestinal disorders
• Genitourinary disorders, including
nephrolithiasis, prostatitis, and
pyelonephritis
• Gynecologic disorders, including
ectopic pregnancy and pelvic
inflammatory disease
• Abdominal aortic aneurysm
• Hip pathology
• Somatoform pain disorder
• Psychiatric syndromes, including
delusional pain
• Drug seeking
• Abusive relationships
• Seeking disability or out-of-work
status
Physical Exam
• 6’2 120lb male who is pleasant, cooperative, well
groomed, a good historian, and appears in
moderate distress and can’t seem to sit still
secondary to pain.
• No neurological findings were appreciated.
–
–
–
–
No Atrophy
Sensation intact to LT and PP
Normal reflexes
Strength of left hip flexion/extension limited by pain,
otherwise strength testing is normal
• The rest of the findings were unremarkable except
for the musculoskeletal exam
Surface Anatomy of the Sacrum
and Pelvis
Surface Anatomy of the Sacrum
and Pelvis (Lateral)
The postero-anterior lumbar
spine X rays of 163 patients
undergoing investigation for
back pain were reviewed
and the spinal level marking
the intersection of a line
joining the iliac crests was
determined. This point
coincided with the L4
spinous process or the L4-5
interspace in 78.6%
•
Anesthesia. 1996 Nov;51(11):1070-1.
The reproducibility of the iliac crest
as a marker of lumbar spine level.
Render CA.
Musculoskeletal Exam - Standing
• - Left iliac crest was slightly HIGHER THAN the Right
– Increased lumbar lordosis
– Painful to palpation over LEFT medial iliac crest
– Forward flexion was associated with some pain, but the ROM was not limited.
– Pain with lateral bending towards the RIGHT
– Standing flexion test was positive on the LEFT
– PSIS was higher on the LEFT
– Functional “S” curve of the spine (In group curves SB/Rot are to
opposite sides!)
• Lumbar Convex right (Lumbar is rotated RIGHT side bent LEFT)
• Thoracic Convex left (Thoracic area is rotated LEFT side bent RIGHT)
Musculoskeletal Exam - Supine
– The ASIS is Lower on the Left
– The pubic tubercle is Lower on the Left
– Palpating the medial Malleoli, the left leg appeared longer
• 3 test maneuvers cause low back pain on the left side
– Straight leg raising – Pain is reported in the distribution of the
Left iliac crest or slightly below
– FABER – Causes low back pain on the left side
– Hip flexion with the knees flexed through full ROM – causes pain
on the left side
– If root compression was suspected this test would be negative as the maneuver
should relax the sciatic nerve
Ligament Anatomy of the
Sacrum and Pelvis
Biomechanics of Pelvic Motion
• Pelvic position and motion is
influenced by the mechanics of
the lower extremities
• Pelvic motion/position may then
influence spinal motion/position
in part via the iliolumbar
ligament because of it’s
attachments to the L5 (L4) TP
Biomechanics of Pelvic Motion
• Physical exam of the Pelvis
• Step 1 –
– Standing flexion test
– Side that moves the furthest is
positive (your reference)
• Step 2 –
– Anterior landmarks
– ASIS and Pubic Tubercle
• Step 3 –
– Posterior landmarks
– PSIS
– Foundations for Osteopathic Medicine,
1997
Biomechanics of Pelvic Motion and
the Influence on Leg Length
• Anterior pelvic tilt
and inferior pelvic shear
both result in a ipsilateral
increase in functional leg
length
• Posterior tilt and
superior shear both result
in a ipsilateral decrease in
leg length
Functional Leg Length
Discrepancy Influences Lumbar
Mechanics
• Functional Leg length
discrepancy-
– Results from muscular
imbalance causing pelvic
tilt
– Reversible with balanced
mechanics
– Long leg side
• Elevated iliac crest
• Side bending of lumbar
spine to the same side
• Compensatory scoliosis at
thoracic and cervical
spine.
Effect of Pelvic Obliquity on the
Iliolumbar Ligament
• Functional or anatomic leg
length discrepancies may
cause a stressed iliolumbar
ligament
• Calcification may be seen
in one or both of these
ligaments with longstanding postural strain
– Wolfe’s Law – Calcium is
laid down along lines of
stress
Wolf’s Law Exemplified by
Chronic Iliolumbar Strain
• Calcification of the
iliolumbar ligament is
an excellent example
of structural change
resulting from
excessive functional
demand.
Iliolumbar Ligament Anatomy
The development of the iliolumbar ligament and its
anatomy and histology were studied in cadavers from
the newborn to the ninth decade
The structure was entirely muscular in the newborn and
became ligamentous only from the second decade,
being formed by metaplasia from fibers of the
quadratus lumborum muscle
•
J Bone Joint Surg Br. 1986 Mar;68(2):197-200.
The iliolumbar ligament. A study of its anatomy, development and clinical
significance. Luk KD, Ho HC, Leong JC.
Iliolumbar Ligament Anatomy
By the third decade, the definitive ligament was well
formed; degenerative changes were noted in older
specimens
The iliolumbar ligament may have an important role in
maintaining lumbosacral stability in patients with
lumbar disc degeneration, degenerative
spondylolisthesis and pelvic obliquity secondary to
neuromuscular scoliosis.
J Bone Joint Surg Br. 1986 Mar;68(2):197-200.
The iliolumbar ligament. A study of its anatomy, development and clinical significance.
Luk KD, Ho HC, Leong JC.
The Role of the Iliolumbar
Ligament
Iliolumbar ligament is important in restraining flexion,
extension, and lateral bending of L5 on S1
The results indicated that the ligament was important in
maintaining torsional stability of the lumbosacral
junction
•
Spine. 1989 Jun;14(6):611-5.
Torsional stability of the lumbosacral junction. Significance of the iliolumbar
ligament. Chow DH, Luk KD, Leong JC, Woo CW.
Biomechanical Functions of the
Iliolumbar Ligament
Five fresh cadaver specimens were used.
In L5 spondylolysis, flexion and axial rotation of L5 on S1 are
significantly regulated by the anterior and posterior bands of the
iliolumbar ligaments
The integrity of the ligament may determine the stability of the
lumbosacral junction and the amount of forward slipping of the L5
vertebra.
•
J Orthop Sci. 2000;5(3):238-42.
Biomechanical functions of the iliolumbar ligament in L5 spondylolysis.
Aihara T, Takahashi K, Yamagata M
Iliolumbar Ligament Anatomy
The anatomy of the ligament and its orientation with respect to the
sacroiliac joints were studied in 17 cadavers.
Dissection showed the existence of several distinct parts of the
iliolumbar ligament, among which is a sacroiliac part.
This sacroiliac part originates on the sacrum and blends with the
interosseous sacroiliac ligaments. Together with the ventral part of
the iliolumbar ligament it inserts on the medial part of the iliac
crest, separate from the interosseous sacroiliac ligaments.
• The existence of this sacroiliac part of the iliolumbar ligament
supports the assumption that the iliolumbar ligament has a
direct restraining effect on movement in the sacroiliac joints.
•
J Anat. 2001 Oct;199(Pt 4):457-63.The sacroiliac part of the iliolumbar ligament.PoolGoudzwaard AL, Kleinrensink GJ, Snijders CJ, Entius C, Stoeckart R.
Iliolumbar Ligament Anatomy
found the ligament to consist of only two parts: the
anterior part and the posterior part, both attaching to the
L5 transverse process
Both parts of the ligament were found to insert to the
upper part of the iliac tuberosity, significantly lower
than the iliac crest.
also found no evidence of any ligament part attaching
to the L4 transverse process
•
Arch Phys Med Rehabil. 1994 Nov;75(11):1245-6.
The anatomy of the iliolumbar ligament.
Hanson P, Sonesson B.
Iliolumbar Ligament Anatomy
Thirty iliolumbar ligaments of 15 volunteers were
analyzed with magnetic resonance
The portion of the iliolumbar ligament originating from
the L-5 transverse process is made up of two bands
(anterior and posterior).
This posterior band is thinner than the anterior, with a
smaller insertional base on the iliac crest, which
explains its lesser resistance to torsional overloading
and also explains the frequency of this painful
syndrome.
•
Am J Phys Med Rehabil. 1996 Nov-Dec;75(6):451-5. Anatomy of the
iliolumbar ligament: a review of its anatomy and a magnetic resonance
study. Rucco V, Basadonna PT, Gasparini D.
Iliolumbar Ligament Anatomy
The insertion manner of iliolumbar ligament posterior
band in the iliac crest allows us to confirm the
possibility of existence of the lumbar painful syndrome
termed iliolumbar syndrome and confirms the
possibility of examining its insertional site manually
Am J Phys Med Rehabil. 1996 Nov-Dec;75(6):451-5. Anatomy of the iliolumbar
ligament: a review of its anatomy and a magnetic resonance study. Rucco V,
Basadonna PT, Gasparini D.
Iliolumbar Anatomy Affecting
Disc Degeneration
Dissected 25 male and 27 female cadavers and measured the length
and cross-sectional area of the anterior and posterior bands of the
iliolumbar ligament
If the iliolumbar ligaments (especially the posterior band of the
ligament) are short and have a large cross-sectional area
– 1) the lumbosacral junction can be stabilized by the ligaments,
with the L5-S1 disc being protected from degeneration
• The L4-L5 disc may be prone to degeneration.
– Spine. 2002 Jul 15;27(14):1499-503.
Does the morphology of the iliolumbar ligament affect lumbosacral disc degeneration? Aihara
T, Takahashi K, Ono Y, Moriya H.
Iliolumbar Ligament Causing
Back Pain
The iliolumbar ligament appears to be a major
stabilizing component between the vertebral spine and
the pelvis
It is the weakest component of the multifidus triangle
There is increased susceptibility to injury due to its
angulated attachment
It is a primary inhibitor of excess sacral flexion
It is a highly innervated nociceptive tissue
It plays an increased role with progressive disc
degeneration.
•
Med Hypotheses. 1996 Jun;46(6):511-5.The role of the iliolumbar ligament in low
back pain. Sims JA, Moorman SJ.
Iliolumbar Syndrome
• First Described by Gerald G. Hirschberg, MD
• “In our experience the chronic iliolumbar
syndrome is the most common cause of permanent
or recurrent low back disability”
• Iliolumbar Syndrome As a Common Cause of
Low Back Pain: Diagnosis and Prognosis
Hirschberg G., Arch Phys Med Rehabil; Vol 60, pp
415-419. Sept 1979
Research in Iliolumbar Syndrome
The authors studied the files of 440 patients with low back pain
over a period of 8 years
The constant absence of signs of lumbar sciatica led them to
study the etiology of such a pain
Pain in the ilio-lumbar ligament is due to the development of a
syndesmo-periostitis (syndesmos = ligament) from the ligaments
continual traction on the postero-medial iliac crest
Iliolumbar syndrome. A syndesmoperiostitis of the iliac crest. Clinical, radiologic and therapeutic
summary. Diagnosis with lumbar sciatica. 440 cases]Rev Rhum Mal Osteoartic. 1982 Oct;49(10):6938. Broudeur P, Larroque CH, Passeron R, Pellegrino J.
British Literature
In 100 patients with mainly chronic low back pain (LBP) signs
and symptoms were evaluated prospectively
Characterized by 'typical local tenderness' and associated with
specific clinical features
Iliolumbar Syndrome occurred in 43% of the patients
Br J Rheumatol. 1990 Oct;29(5):354-7. Clinical epidemiological study in low back pain.
Description of two clinical syndromes.
Collee G, Dijkmans BA
More Foreign Literature
• Domljan Z, Curkovic The iliolumbar syndrome]
Lijec Vjesn. 1983 Jul-Aug;105(7-8):287-9. Croatian.
• Schapira D. [The iliolumbar syndrome]
Harefuah. 1987 Dec 1;113(11):352-4. Review. Hebrew.
• Broadhurst N. The iliolumbar ligament syndrome.
Aust Fam Physician. 1989 May;18(5):522.
Onset Mechanism of Iliolumbar
Syndrome
• Ex #1
– Lifting Accidents – frequently present with acutely disabling pain, unable to
walk or move
• Ex # 2
– Patients are immediately aware of a pull or snap in the low back and then the
pain remits, and later it reoccurs more or less severe
• Ex #3
– Patients may have no immediate awareness of a back injury, and then
gradually increases in severity. – falls or rear end collisions
– Ex #4
• The patient does not recall any injury and the pain starts insidiously
•
Iliolumbar Syndrome As a Common Cause of Low Back Pain: Diagnosis and Prognosis Hirschberg G., Arch Phys
Med Rehabil; Vol 60, pp 415-419. Sept 1979
Symptoms of Iliolumbar
Syndrome
• Pain localized at the posterior portion of one iliac crest.
• The patient is typically able to put their finger on the
exact site of the low back pain
• At times patients present with pain across the iliolumbar
area bilaterally
•
Iliolumbar Syndrome As a Common Cause of Low Back Pain: Diagnosis and Prognosis Hirschberg G., Arch
Phys Med Rehabil; Vol 60, pp 415-419. Sept 1979
Symptoms of Iliolumbar
Syndrome
• Pain may be extremely severe or a constant dull ache
aggravated by activity
• Some complain of pain with prolonged standing or sitting
• Pain may radiate into the hip, groin, anterior, lateral, or
posterior aspects of the thigh
•
Iliolumbar Syndrome As a Common Cause of Low Back Pain: Diagnosis and Prognosis Hirschberg G., Arch Phys
Med Rehabil; Vol 60, pp 415-419. Sept 1979
Findings of Iliolumbar Syndrome
• On exam while standing
–
–
–
–
One iliac crest is frequently higher than the other
A discrepancy of leg length may be seen
Usually, the painful crest is the higher one
Forward flexion is usually associated with some pain,
but frequently the ROM is not limited.
– Pain with lateral bending.
• Usually, the pain is worse when laterally bending away from
the painful side
•
Iliolumbar Syndrome As a Common Cause of Low Back Pain: Diagnosis and Prognosis
Hirschberg G., Arch Phys Med Rehabil; Vol 60, pp 415-419. Sept 1979
Findings of Iliolumbar Syndrome
• On exam in the supine position – 3 test maneuvers
cause low back pain on the involved side
– Straight leg raising – Pain is reported in the
distribution of the iliac crest or slightly below
– FABER – Causes low back pain on involved side
– Hip flexion with the knees flexed through full ROM –
causes pain on involved side
– If root compression was suspected this test would be negative as
the maneuver should relax the sciatic nerve
•
Iliolumbar Syndrome As a Common Cause of Low Back Pain: Diagnosis and Prognosis
Hirschberg G., Arch Phys Med Rehabil; Vol 60, pp 415-419. Sept 1979
Findings of Iliolumbar Syndrome
• Examination in the prone position
– The most typical sign is tenderness to palpation of the iliac crest on
the involved side
– Tenderness is usually limited to the insertion of the iliolumbar
ligament, but at times may be across the whole length of the crest
with maximum tenderness in the posterior third
•
Iliolumbar Syndrome As a Common Cause of Low Back Pain: Diagnosis and Prognosis Hirschberg G., Arch Phys
Med Rehabil; Vol 60, pp 415-419. Sept 1979
X-ray in Iliolumbar Syndrome
• X-rays of the lumbosacral spine are frequently
normal or show degenerative changes of the
lumbar spine.
–
Iliolumbar Syndrome As a Common Cause of Low Back Pain: Diagnosis and Prognosis Hirschberg G.,
Arch Phys Med Rehabil; Vol 60, pp 415-419. Sept 1979
Imaging of the Iliolumbar
Ligament
Studied MRI of iliolumbar ligaments in cadavers
• Routine imaging of the intervertebral disc region as well as
contiguous axial imaging of the spine depicted only limited segments
of the iliolumbar ligament.
• Only images of the iliolumbar ligament obtained through computer
reformatting of three-dimensional volume averaging from L3 to the
sacral ala correlated with the ligament's structural characteristics.
– The Iliolumbar Ligament: Three-Dimensional Volume Imaging and Computer Reformatting
by Magnetic Resonance: A Technical Note.
Spine. 25(9):1098-1103, May 1, 2000. Hartford, James M. MD *; McCullen, Geoffrey M. MD +;
Harris, Robert MD ++; Brown, Cameron C. MD [S]
Iliolumbar Syndrome – Injection
to Confirm the Diagnosis
• X-rays after infiltration of the
iliac crest with a few cc’s of
lidocaine and radiopaque
material showed it spread all
along the iliolumbar ligament
from the iliac crest to the
transverse process of L-4 and L5. This resulted in relief of all
signs and symptoms.
•
Iliolumbar Syndrome As a Common Cause of
Low Back Pain: Diagnosis and Prognosis
Hirschberg G., Arch Phys Med Rehabil; Vol 60,
pp 415-419. Sept 1979
Treatment of Iliolumbar
Syndrome
• Not many studies on this specifically.
• Based on what has been presented, treatment should
involve:
– A) Patient education on back saving practices, i.e. proper
lifting technique, work modification, HEP, smoking cessation
etc.
– B) Relief of symptoms with NSAIDS, PT, modalities,
interventional techniques, RF?.
– C) Restoration of body mechanics
• Address muscle imbalance between anterior and posterior musculature
• Treat pelvic obliquity
Treatment of Iliolumbar
Syndrome
Thirty patients with low-back pain of at least one month's duration
were included in a double-blind controlled study and treated with
either methylprednisolone mixed with lidocaine or isotonic saline,
injected at the site of the iliolumbar ligament.
In the methylprednisolone group, significant decreases in pain
score and in patients' self-assessments were found. The range of
spinal flexion did not undergo any significant change. No
significant changes were found in the control group
•
Scand J Rheumatol. 1985;14(4):343-5.
Injection of steroids and local anesthetics as therapy for low-back pain.
Sonne M, Christensen K, Hansen SE, Jensen EM.
Osteopathic Manipulation for
Pelvic Obliquity
• Rationale based on anatomy supports a restoration of a
level pelvis to decrease strain on the iliolumbar ligament.
• Treatment of L4 and L5 rotation and SB along with
lumbar and thoracic compensatory curves should also be
addressed.
• The following techniques are helpful
– Muscle Energy
– High Velocity Low Amplitude
Muscle Energy-How Does It
Work?
• A patient provides a contraction in a already tight muscle,
acting against equal resistance provided by the physician,
results in pulling on the Golgi tendon receptors producing a
reflex relaxation of that muscle’s extrafusal muscle mass
through the Golgi tendon reflex mechanism.
• When the patient is completely relaxed, the operator
advances the joint to the new restrictive barrier. At each
new length, the Golgi receptor is stretched again and the
muscle’s length is again increased.
Muscle Energy Schematic
Research in Osteopathy
• OMT in low back pain appears to decrease
the need for other co-treatment modalities
such as medications
– Anderson GB, Lucente T, Davis AM, Kappler RE, Lipton JA,
Leurgans S. A comparison of osteopathic spinal manipulation with
standard care for patients with low back pain. N Engl J Med.1999;
341:1426 -1431.
– Williams NH, Wilkinson C, Russell I, et al. Randomized osteopathic
manipulation study (ROMANS): pragmatic trial for spinal pain in
primary care. Fam Pract.2003; 20:662 -669.
– Licciardone JC, Stoll ST, Fulda KG, Russo DP, Siu J, WinnW, et al.
Osteopathic manipulative treatment for chronic low back pain: a
randomized controlled trial. Spine.2003; 28:1355 -1362
• “In the absence of consensus as to the
etiology of nonspecific low back pain, it
seems important for us to rely on clinical
data to identify specific syndromes”
•
Iliolumbar Syndrome As a Common Cause of Low Back Pain: Diagnosis and
Prognosis Hirschberg G., Arch Phys Med Rehabil; Vol 60, pp 415-419. Sept 1979
A Word About Iliac Crest
Syndrome
• Pain is usually of sudden onset after repeated
flexion/extension activity.
• Characterized by an extremely discrete localized area of
pain without radiation. No associated thoracolumbar pain.
– Location corresponds to the lateral border of the origins of the
gluteus maximus and sacrospinalis
Spine 1983 vol 8, The iliac crest syndrome JT Fairbank
• Magnetic resonance imaging is normal in the iliac crest pain
syndrome
–
J Rheumatol. 1993 Feb;20(2):407-8.
Magnetic resonance imaging is normal in the iliac crest pain syndrome. Reynierse M, Dijkmans BA, Collee
G, Bloem JL, Kroon HM.
A Word on Iliac Crest Syndrome
Prospectively studied 204 consecutive patients with LBP from a
general practice (n = 40), an occupational health service (n = 124)
and a rheumatology clinic (n = 40).
ICPS was found in 53%, 33% and 58%, respectively (41% of the
total group).
Typical was local tenderness over the medial part of the iliac crest
•
J Rheumatol. 1991 Jul;18(7):1064-7.
Iliac crest pain syndrome in low back pain: frequency and features.
Collee G, Dijkmans BA, Vandenbroucke JP, Cats A.
Treatment of Iliac Crest Pain
Syndrome
41 patients with the iliac crest pain syndrome (ICPS),
In a 2-week, double blind, randomized study, the authors
compared the efficacy of a single local injection of 5 ml lidocaine,
0.5% with 5 ml isotonic saline
Effect of a local injection with lidocaine - 53% improved,
versus 8% with saline
• J Rheumatol. 1991 Jul;18(7):1060-3.
Iliac crest pain syndrome in low back pain. A double blind, randomized study of
local injection therapy. Jollee G, Dijkmans BA, Vandenbroucke JP, Cats A.
A Word on Cluneal Nerve
Entrapment
The authors describe a case of longstanding low back pain related to entrapment
neuropathy of the L1-L2 dorsal ramus (innervates posterior somatic structures)
over the iliac crest.
3 local anesthetic pain blocks (at the trigger point, 7 cm left of the L5 spine
process and just above the iliac crest) were successful for 3 weeks each.
A surgical procedure was then performed which corrected patient stricture of a
voluminous dorsal ramus within a rigid osteofibrous orifice between the upper
rim of the iliac crest and the thoracolumbar fascia
Pain decreased dramatically the same day and disappeared completely within
less than a week.
•
J Rheumatol. 1996 Dec;23(12):2179-81.
A potentially under recognized and treatable cause of chronic back pain: entrapment neuropathy
of the cluneal nerves. Berthelot JM, Delecrin J, Maugars Y, Caillon F, Prost A.
A Word About Maigne Syndrome
The diagnosis is made on pure clinical grounds
Classic signs are: a positive "iliac-crest point" test, a positive skinrolling test, localized tenderness over a certain spinous process at
the thoracolumbar junction and tenderness over the involved
apophyseal joint.
The diagnosis is confirmed by a periapophyseal joint block using a
local anesthetic
•
Arch Phys Med Rehabil. 1980 Sep;61(9):389-95.Low back pain of thoracolumbar origin.
Maigne R.
A Word About Maigne Syndrome
Of 350 patients seen in a back pain clinic, 40% were
found to have pain of thoracolumbar origin
Treatment included manipulation, infiltration with
corticosteroids, electrocoagulation and/or surgical
denervation of the involved apophyseal joint.
Arch Phys Med Rehabil. 1980 Sep;61(9):389-95.Low back pain of thoracolumbar origin.
Maigne R.
A Word About Maigne Syndrome
The authors performed 37 dissections
The authors claim the iliac insertion of the iliolumbar ligament is
inaccessible to palpation, being shielded by the iliac crest
The dorsal rami of L1 or L2 nerve roots, however, cross the crest
at 7 cm from the midline, and this distance closely correlates with
the dorsal projection of the iliolumbar ligament insertion
Arch Phys Med Rehabil. 1991 Sep;72(10):734-7.Trigger point of the posterior iliac crest:
painful iliolumbar ligament insertion or cutaneous dorsal ramus pain? An anatomic study.
Maigne JY, Maigne R.
A Word About Maigne Syndrome
In two of the 37 dissections performed, some rami were found to
be narrowed as they crossed through an osteofibrous orifice over
the crest, thus being susceptible to an entrapment neuropathy
The authors conclude that the trigger point sometimes localized
over the iliac crest at 7 cm from the midline likely corresponds to
elicited pain from a cutaneous dorsal ramus originating from the
thoracolumbar junction rather than from the iliac insertion of the
iliolumbar ligament.
Arch Phys Med Rehabil. 1991 Sep;72(10):734-7.Trigger point of the posterior iliac crest:
painful iliolumbar ligament insertion or cutaneous dorsal ramus pain? An anatomic study.
Maigne JY, Maigne R.
• “…the question is whether that pain is the
cause, the consequence, or simply one of
the features, of the dysfunction”
• Robert Maigne
Conclusion
• The diagnosis of “Mechanical Low Back Pain” may be too
vague given the surfacing of specific back pain etiology.
• While pain generators may be identified and important to
treat, broader biomechanical factors must also be addressed
to aim for a potentially sustained therapeutic solution.
• Studies have yet to link and fully explain the complex
interrelationships of biomechanical models and
musculoskeletal pathology as it relates to onset of various
pain generators.
• More research is needed