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Posted on 02-12-2016
It comes as no surprise to most people that the most common complaint that we see in our practice is Low Back and Mid Back pain. What does surprise many people is that a great deal of low back pain does not originate in the lower back, that is, in the part of the spine called the lumbar vertebrae. Even more surprising to people is that the same condition that causes a good portion of the low back pain cases we see also causes other complaints. Patients that come to us with pain in areas as diverse as the lower abdomen, the pubic region, the hip, or the buttocks can all be suffering from the same basic condition. That condition is called ThoracoLumbar Junction Syndrome, or TL-Syndrome. Because TL- syndrome can appear to be so many other problems, it was named “The Great Mimicker”.
To understand TL- Syndrome, we need to understand something about the way the human spine is put together. The spine supports the weight of the body and keeps it upright. The simplest way to bear this weight would be to have only one bone, but one bone would prevent any flexibility or mobility. Ever since the first animals with a spinal cord evolved, the spine has achieved a bendable structure by being composed of many individual bones joined to each other.1 In the human spine there are 33 bones, 7 vertebrae in the cervical region (the neck), 12 in the thoracic region (the upper back), 5 n the lumbar region (the lower back) 5 fused bones into the Sacral Bone and 4 in the coccygeal region (the tale bone) called vertebrae.2
The vertebrae are grouped into five classifications based on function and their shape: the cervical vertebrae that make up the neck and support the skull, the thoracic vertebrae that hold the ribs and form the upper and mid back, the lumbar vertebrae that form the lower back, the sacrum that joins the spine to the hip bones, and the coccyx or tailbone. TLJ Syndrome occurs at the junction where the thoracic spine meets the lumbar spine(just under the ribcage).
This joint, the spot where the lowest thoracic vertebrae (called T12) meets the highest lumbar vertebrae (called L1), is a particularly vulnerable area.3 The thoracic and lumbar spine have different functions and are shaped differently so this joint is an awkward transition zone between these two parts of the spine. While the thoracic spine is mainly involved in rotation (turning side to side), the lumbar spine is mainly concern with bending forward and backwards. This leads to the involvement of the T/l region in motion throughout the day, from sitting and turning side to side, to walking, to transitioning from one position to another and even as we turn side to side in bed during sleep.
All spinal joints are complex structures because of the way individual vertebrae are formed. Each one has three parts: the body, the spinal arch and the spiny processes.4 The body of a vertebra bears the majority of the weight the spine supports and is a strong, compact roughly cylindrical shape. The spinal arch curves behind the body and protects the spinal cord. The processes are projections off the spinal arch and both help protect the spinal cord and provide attachment points for the muscles of the back. In between the bodies of each pair of vertebrae is a disk that permits motion and absorbs shock. There are also joints between the vertebrae in the area of the spinal arch called facets.5
TLJ syndrome happens because of the transitional nature of this T12/L1 joint.6 While the bodies of thoracic and lumbar vertebrae very similar, the T12 vertebra has differently shaped facets so it can join the L1 vertebra below it and the T11 vertebra above it. The upper facets are just like the other thoracic vertebrae, while the lower facets are shaped like lumbar vertebrae.7 This makes the T12/L1 junction a hinge that the entire spine flexes around so it is particularlyvulnerable to stress.
The multiple symptoms of TLJ syndrome occur because the stress at this junction causes friction and swelling against the nerves that leave the spinal cord.
Most people think that back pain is caused by “slipped disks.” What is happening in a slipped disk is that the cushioning disks between a pair of vertebra weaken. These disks have an outer ring of fibrous cartilage and a center of softer pulpy material. When the outer ring of a disk weakens or tears, it allows the softer central portion to bulge outwards.8 This puts pressure on nerves and causes pain.
TLJ Syndrome, however, rarely happens because of disk problems.9 What happens instead is that stress on the spine is causing irritation and swelling at the facets. The nerves that leave the spine from in between the T12 and L1 vertebrae send signals from a large area to the brain. When the root of the nerve is compressed, any of these areas can seem to be the origin of the pain.10 This is called “referred pain.” The pain is not being caused by any problem in the area where you feel it but by a problem somewhere else along the route of a nerve that passes through that area.
This is why TLJ syndrome is mistaken as so many other things. The nerves that emerge from the spine in the T12/L1 area supply many areas. One nerve goes through the lower back to the upper part of the buttocks. Another goes wraps around to the front of the body just above the hips, where it splits. One half continues down to the lower abdomen and pubic region, while the other goes towards the side of the hip and the upper leg.11
This means that you could come to a doctor with complaints of pain in any of these different areas, but the problem is really much higher. Many times we see patients that have gone through treatments directed at these distant areas that have failed to resolve the pain. Those treatments are in some ways doomed to fail – they are simply treating the wrong thing. Sometimes, these treatments are invasive and difficult, such as surgery for sciatica. While they may bring partial or temporary relief, the only real solution is through addressing the problem at the source.
Treatment of TLJ Syndrome is focused on making sure this joint recovers normal function and movement. Adjustment of the segment of the spine containing the T12/L1 joint will often bring complete relief, even of the distant referred pain. By specifically adjusting the alignment and mobility of the vertebrae, the doctor directly affects the pain signals being carried to the brain.12 Specific Chiropractic Spinal Adjustment also interrupts the inflammatory process at the nerve root and may even change the way the nerves in the area adjusted respond to pain signals.
Only a well trained Chiropractic Physician can tell if your pain is caused by a local disorder or it you have TLJ syndrome. The good news is that TLJ Syndrome responds well to treatment and the doctors at West Hartford Chiropractic have experience treating thousands of patients referred wither by their physicians or by friends and family following months or years of lower , mid back pain or groin pain with no relief. In fact many of the patients seeing in West hartford Chiroractic present to our practice after exhausting so many prior specialists- such as Orthopedists, Physical Therapists, Neurologists, Rehabilitation Physicians and Gastroenterologists , OBGYN’s and Urologists, due to the unusual and many variations of this pain and the diverse referred pattern of the T/L Syndrome into to one or many regions: such as the groin, the genitalia, the anterior or poster lateral thigh/s , the buttocks, the abdomen. In fact, properly diagnosing and treating TLJ Syndrome often means that long-standing aches and pains can be reduced or eliminated. Chronic back, leg, abdominal, buttock or pubic pain that has not been helped by other treatments might just be pretending to come from those areas.
If you are sure about the source of your pain you might benefit from an extensive exam by the Chiropractic Physicians at West Hartford Chiropractic, to see if you are indeed a good candidate for gentle Chiropractic Care.
1. Laerm, J. The Origin and homology of the Neopterygian vertebral centrum. Journal of Paleontology. Jan 1982; 56(1):191
2. Tortora, G. Derrickson, B. Principles of Anatomy & Physiology. 13th Ed. 2012. Hoboken, NJ. p. 233
3. Maigne R. Thoracolumbar Junction Syndrome, A source of diagnostic error. Maitrise Orthopedique. [Web Journal]. January, 1998. [Date Cited: March 17, 2012]. 1 (10): http://www.maitrise-orthop.com/index_us.php
4. Tortora Derrickson, 2012, p.235
5. Tortora Derrickson, 2012, p.235
6. Proctor, D. Dupuis, P, Cassidy, JD. Thoracolumbar syndrome as a cause of low-back pain: A report of two cases.Journal of the Canadian Chiropractic Association. June 1985. 29(2): 71–73.
7. Maigne, 1998
8. Pullman –Mooar, S. Low Back Pain in Porter, RS (ed). The Merck Manual Home Health Handbook [Online Edition]. Whitehouse Station, N.J.: Merck Sharp & Dohme Corp.;2011 [Date Updated: April 2008; Date Cited: March 17, 2012] http://www.merckmanuals.com/home/index.html
9. Maigne, 1998
10. Ferri FF (ed). Ferri’s Clinical Advisor; Instantt Diagnosis and Treatment. 2000 Edition. St. Louis: Mosby, Inc.; 2000. P. 668
11. Tortora Derrickson, 2012, p.508
12. Pickar, JG. Neurophysiological effects of spinal manipulation. The Spine Journal. Sep-Oct 2002. 2(5):357
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