A recently published review of Maigne syndrome indicates that it is still an underrecognized and undertreated cause of back and hip pain, despite being treatable.

Maigne syndrome was first described in the 1980s as a poorly understood but treatable cause of back and hip pain.1,2 At the time, the authors reported 10 cases of pain in lateral hip related to injury to the perforating lateral branch of the subcostal or iliohypogastric nerve. Treatment was generally successful, and consisted of local infiltration, although one patient underwent successful surgery.

Further investigation showed that there was a possibility of canal neuropathy.3 Supposing that some "pseudocoxalgias" might be due to a neuralgia of the lateral rami leaving the subcostal and iliohypogastric nerves above the lateral edge of the iliac crest, the authors undertook an anatomic study of their pathways and pattern of distribution.

There are rami supplying the skin below the iliac crest, and rami arising from the subcostal nerve by perforating the internal and external oblique abdominal muscles and arising from the iliohypogastric nerve a little lower.

Both of these rami can create a bony groove palpable in patients who are thin. This bony groove can become an osseo-membranous tunnel by the aponeurosis of these muscles, resulting in an entrapment syndrome.

The 2 rami are of unequal length. Frequently, the ramus arising from the subcostal nerve is short, not exceeding 10 cm, below the iliac crest. The ramus from the iliohypogastric nerve descends further, passing 3 to 5 cm anterior to the great trochanter. It ends either at this level or 8 to 10 cm lower, accounting for the distribution of the pain. At this intersection, which is directly subcutaneous, there is exposure to possible friction and trauma, including from wearing tight clothing.

In further review of anatomical and clinical studies, the authors of one study went on to describe a tunnel syndrome involving the lateral cutaneous branch of the iliohypogastric nerve as it emerges above the iliac crest.3 Irritation of the compressed nerve causes pain over the lateral aspect of the hip. In 7 cases where local infiltration failed, neurolysis was carried out and produced excellent results.

Touzard et al,4 in 1989, further described pain in the trochanteric region caused by tunnel compression of the lateral cutaneous perforating branch of the iliohypogastric nerve. They reported 10 cases of pain in the outer surface of the hip related to damage of the perforating lateral branch of the subcostal or iliohypogastric nerve.

In 7 cases where local infiltration failed, neurolysis was carried out and produced excellent results in 5 patients, thus confirming the pathophysiology of this syndrome.

In their latest review, Randhawa et al5 emphasized again that Maigne syndrome is an often unrecognized but treatable cause of low back pain. They noted that it can be separated into 2 distinct entities. The central variant is a result of nerve afferent input secondary to changes of facet joint arthropathy at the thoracolumbar junction. The peripheral variant is a result of impingement of the medial branch of the superior cluneal nerve, which arises from the posterior rami of the lower thoracic and upper lumbar nerve roots, and results in similar clinical symptoms and signs.

A literature search initially generated 52 articles. After review, 28 articles were considered relevant, most of which consisted of case reports published in rehabilitation and, chiropractic journals. The articles discussed topics such as anatomy, cluneal nerve imaging, and treatment of nerve entrapment and facet-related back pain syndromes.

The authors concluded that key to the diagnosis of Maigne syndrome requires an awareness of the mechanical causes of back-dominant pain, an understanding of the relevant anatomy, a specific clinical examination, and focused radiological guided anesthetic blocks. Treatment is possible and, as in all back pain etiologies, is most effective in the early stages of the disease.

References