Download - Thoracic Lumbar Junction
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THE CONCEPT OF PAINFUL MINORINTERVERTEBRAL DYSFUNCTION
Robert MAIGNE (PARIS)
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Current theory on spinalmanipulation:Current theory on spinalmanipulation:
� The aim of manipulation is to restore normalmobility to a hypomobile vertebral segment (orjoint)
� The diagnosis of hypo or hypermobility is basedsolely on palpation
Assessment of segmental mobility isgenerally regarded as the keystone of manualmedicine for diagnosis and treatment
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This theory is open tocriticismThis theory is open tocriticism
� Clinical assessment of hypomobility is not areliable and reproductible test
� Hypomobility is frequent in osteoarthriticcadaveric vertebral joints
– There is no evidence that it may be a source of pain– Hypomobility could be regarded as a protective mechanism
against overuse of a degenerated joint
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The R. Maigne School IThe R. Maigne School I
� If any component of the vertebral motionsegment originates pain...
� ...It is likely that stressing this motion segment byspecific maneuvers will elicit pain
� The tests we use depend solely upon elicitingtenderness or pain of the segment
� No particular attention is paid to hypomobilityper se
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The R. Maigne School IIThe R. Maigne School II
� This does not mean that hypomobility does notexist
� It means that hypomobility is not the major orprimary element regarding vertebral pain
� Hypomobility may be– a casual consequence of pain– or without relationship with the pain
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SEGMENTAL EXAMINATIONSEGMENTAL EXAMINATION
TheThe fourfour specific maneuversspecific maneuvers ofof thethe segmentalsegmentalexaminationexamination are:are:
1 - Pressure on the spinous process2 - Transverse pressure against the spinous
process3 - Longitudinal friction on the facet joints4 - Pressure on the interspinous ligament
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SEGMENTAL EXAMINATIONSEGMENTAL EXAMINATION
� Pressure on thespinous process
� Transverse pressureagainst the spinousprocess
� Longitudinal frictionon the facets joints
� Pressure on theinterspinous ligament
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SEGMENTAL EXAMINATIONSEGMENTAL EXAMINATION
� Pressure on thespinous process
� Transversepressure againstthe spinousprocess
� Longitudinal frictionon the facets joints
� Pressure on theinterspinous ligament
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SEGMENTAL EXAMINATIONSEGMENTAL EXAMINATION
� Pressure on thespinous process
� Transverse pressureagainst the spinousprocess
� Longitudinal frictionon the facets joints
� Pressure on theinterspinous ligament
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SEGMENTAL EXAMINATIONSEGMENTAL EXAMINATION
� Pressure on thespinous process
� Transverse pressureagainst the spinousprocess
� Longitudinal frictionon the facets joints
� Pressure on theinterspinousligament
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SEGMENTAL EXAMINATIONSource of errorsSEGMENTAL EXAMINATIONSource of errors
� Superficial tenderness ofthe spinous process
� Interspinous acute bursitis
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SEGMENTAL EXAMINATIONSource of errorsSEGMENTAL EXAMINATIONSource of errors
� Pressure of a sensitive orcellulalgic skin over thespinous process
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SEGMENTAL EXAMINATIONSource of errorsSEGMENTAL EXAMINATIONSource of errors
� Pressure of a cellulalgic skinor tender taut muscularbands against the z-joints
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Pain Originating from a VertebralMotion Segment Can Be Due ToMany Causes (benign or not)
Pain Originating from a VertebralMotion Segment Can Be Due ToMany Causes (benign or not)
� Some are more or less easily recognizable– Disc herniation– Acute synovitis of the Z-joints
� Others would be only recognizable with sophisticatedinvestigations
– Facet blocks– Discography + MRI
These tests– Are positive in less than 50% of the cases (Schwarzer et al, 1995)– Are not applicable in routine daily practice
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Pain from a Motion Segment Can Be DueTo Many CausesPain from a Motion Segment Can Be DueTo Many Causes
� Segmental examination focuses the intereston the painful segment
� Special attention must be paid on thissegment
� Depending on the clinical and the radiologicalcontext, further investigations may benecessary
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Painful Minor IntervertebralDysfunction (MID, R. Maigne)Painful Minor IntervertebralDysfunction (MID, R. Maigne)
TheThe diagnosisdiagnosis ofof PainfulPainful MIDMID is evokedis evoked
1 - When the segmental examination is positive2 - When the pain is considered as common3 - Whether the X-Rays films are normal or show
non significant degenerative changes
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PAINFUL MINOR INTERVERTEBRALDYSFUNCTION (R. Maigne)PAINFUL MINOR INTERVERTEBRALDYSFUNCTION (R. Maigne)
MID :MID :
� Is the result of trauma, efforts, bad postures,repeated micro-traumas...
� Is not linked to any neurological deficit or X-Rayabnormality
� The diagnosis of MID is purely clinical� It is based on segmental examination
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Painful Minor IntervertebralDysfunction (R. Maigne)Painful Minor IntervertebralDysfunction (R. Maigne)
InIn thethe frameworkframework ofof commoncommon painpainsyndromes,syndromes, thethe most frequentmost frequent causescausesof segmentalof segmental dysfunctiondysfunction are:are:
– "Painful Minor Intervertebral Dysfunction"(MID)
– Disc lesions– Synovitis of zygapophyseal joints
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Painful Minor IntervertebralDysfunctionPainful Minor IntervertebralDysfunction
� Painful minor intervertebral dysfunction may beconsidered as a selfself--sustaining sprainsustaining sprain of thevertebral segment
� The Painful MID can be active or latentactive or latent. Thesigns of MID are permanent in chronic caseseven between attacks
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Painful Minor IntervertebralDysfunctionPainful Minor IntervertebralDysfunction
Painful minor intervetebral dysfunction appears tobe the common denominator of a great numberof vertebral pain
– directly– or by intermediary of reflex manifestationsreflex manifestations
that may be determined in the correspondingmetamere : SegmentalSegmental Vertebral CelluloVertebral Cellulo --TenoTeno--PeriosteoPeriosteo--MyalgicMyalgic SyndromeSyndrome
(R. Maigne)