Robert Maigne is a medical orthopaedist who is widely known for his work on common disorders of the spine. It was he who created the concept of Painful Minor Intervertebral Dysfunction (PMID). He was involved in the setting up of the French Physical Medicine Society, and has contributed to the development of physical medicine and rehabilitation.

 

Rober MaigneM.O. What is the Maigne syndrome?
R.M. It was not I who coined that term. I drew attention to the existence of pain referred from the thoracolumbar junction, and to the fact that this sort of pain is by no means uncommon. The clinical pictures caused by this condition may be very misleading. I merely described the signs and symptoms. The general heading I chose was Thoracolumbar Junction Syndrome. However, it would appear that the condition is now better known by the name you were quoting just then. So - yes, it is my syndrome.

The syndrome consists first and foremost of low back pain, which, as a rule, is unilateral. It is to all intents and purposes like low back pain of lumbosacral origin, and is, in fact, frequently mistaken for that condition. Unilateral low back pain is the most frequently observed feature; I first identified and described it back in 1972.

Thereafter, more features were added: The condition may be associated with abdominal or testicular pain that mimics intestinal or urological conditions; above all, the pain may be suggestive of gynaecological problems, which is very deceptive and may lead to repeated investigations; in a smaller number of cases, there may be pubic pain.

The one important point is that the patients never complain of pain at the thoracolumbar junction. Also, radiographs of the junction usually fail to produce evidence of anything abnormal at that site. The manifestations are purely clinical. However, the lumbosacral region will often show radiographic evidence of major degenerative disease or may have undergone surgery in the past. These findings suggest - wrongly - that the lumbosacral region is the source of the problem. However, mixed low back pain patterns are not that infrequent.


M.O. How did you trace all these diverse manifestations back to the thoracolumbar junction?
R.M. I had trained as a rheumatologist, and had become interested in common back pain, what was then called back pain sine materia, because there was nothing that could have objectively accounted for the pain which frequently prompted the patients to seek medical advice. It had also been noticed that this pain was only rarely relieved by physical therapy or drug treatment.

Often, though by no means always, the patients were young women. These patients would complain of stubborn pain between the shoulderblades, made worse by work to the extent that these tasks would be very difficult if not impossible to perform.

Since the usual investigations did not produce any hard and fast evidence of something amiss, and because of the very dramatic descriptions given by the sufferers - "like a red-hot poker down my back" - many doctors thought that the pain was psychogenic. In some cases, psychotherapy and relaxation brought relief; however, as soon as these patients started working again, the pain would recur.

I started examining these cases in a little more detail, and was struck by the fact that all these patients had a strictly localized tender point at the level of T5. Pressure on this point would reproduce the patients' usual symptoms; at the same time, there was a strip of skin running from that point towards the acromion that was "cellulalgic" - i.e. thickened and very painful when examined with the pinch-and-roll test.

I had also noticed previously that one of the most common complications of badly performed cervical spine manipulation was the kind of back pain complained of by my patients, and the same signs on examination. I also found these features in cervicobrachial neuralgia, a condition that frequently starts with isolated back pain.

It was becoming increasingly obvious that the back pain was due to a disturbance in the lower cervical spine. On examination, I consistently found tenderness over the facet joints at C5/C6 or C6/C7, on the side of the tender T-spine point and the thickened and tender skin fold. The X-rays were normal or showed only mild and insignificant lesions.

Only very rarely did these patients complain of anything wrong with the neck. And yet, when the facet joint was infiltrated with local anaesthetic, the symptoms would almost instantly disappear; the T5 point would no longer be tender; and the pinch-and-roll test of the adjoining skin would not cause pain. Equally, in cases where manipulation was possible, it immediately relieved the signs and symptoms. This pattern was seen in scores of patients.

What it meant was that there were reversible micromechanical "lesions" of the spinal segment. These lesions could give rise to pain at a distant site by causing neurotrophic disturbances in the tissues - in this case, "cellulalgia", undoubtedly via the posterior rami of the spinal nerves.

This drew my attention to the posterior rami, and demonstrated to me the importance of pain provocation by the pinch-and-roll test in a limited unilateral zone. Often, this cellulalgic zone will be found to correspond to the cutaneous distribution of the nerve on the trunk.

M.O. Did you apply the same reasoning to low back pain?
R.M. Yes, but that was a gradual process.

I had observed that some forms of low back pain were associated with a cellulalgic zone in the upper part of the buttock, and that patients who did not respond very well to epidural infiltrations and physiotherapy would be relieved by the infiltration of a local anaesthetic into this cellulalgic zone, followed by a little superficial kneading.

This made me think that perhaps the posterior rami had been irritated; however, the anatomy textbooks describing these branches stated that the cutaneous nerve supply of the upper gluteal area is provided by L2 and L3; and these segments were strictly normal when I examined them.

There was, however, a tender point over the iliac crest, at a distance of 7 or 10 centimetres from the midline; infiltration of that point would frequently provide relief - not lasting relief, but good while it lasted. The American authors thought that this tender point was in the iliolumbar ligament, which had been strained by the fifth lumbar vertebra. I felt that this was not a very likely explanation, because the iliolumbar ligament is on the inside of the iliac wing and, therefore, inaccessible to palpation; whereas the "crest point" is very superficial.

I took some time to realize that the infiltration of that point also made the cellulalgic tissues on the buttock supple and non-tender.

This brought me back to the idea of posterior branch involvement, and I went looking a little higher up. I found that, on examination, there was indeed a tender segment at the thoracolumbar junction. The segment concerned was usually T12/L1; however, in some cases, it was T11/T12; and, yet more rarely, L1/L2.

When the tender facet joint was infiltrated with local anaesthetic, the signs and symptoms would instantly disappear. This was particularly dramatic in the acute form of this low back pain, which looks very much like classical acute lumbago, with major spasm and immobility, but normally without an antalgic attitude. In patients who could undergo manipulation, the same result was seen.

My colleagues and I did two series of cadaver studies, which showed conclusively that the cutaneous branches of the posterior rami of T12 and L1, together with L2, provide most of the supply to the skin of the upper buttock, in the zone where cellulalgia is observed. We also found that these nerves cross at right angles to the iliac crest, at a distance of 7 to 10 centimetres from the midline; which accounts for the "crest point."

"High-origin low back pain" had become a common diagnosis in our Department, and I decided to communicate my findings to the French Physical Medicine Society and the Rheumatology Society.

M.O. How was the news received?
R.M. At the Physical Medicine Society, very well indeed. I was, by the way, the Society's secretary, and most of the members knew my work. Some of the consultants in the provinces regularly sent me their junior and senior registrars, to spend some time on my unit at the Hôtel-
Dieu.

I also had junior doctors who came from all over the world - from Italy, Spain, the Eastern countries, and also from the United States and, above all, from Canada. For over 15 years, until the time I left the Hôtel-Dieu, we had Canadians in training almost non-stop.

At the University of Paris, thanks to Dean Milliez and Dean Grossiord, I had been able to set up a one-year course leading to a University Diploma in Medical Orthopaedics and Manual Medicine. The format was one of lectures, practical classes, and teaching clinics. This meant that the students took part in the life of our Department, and could get a very thorough introduction to our way of diagnosing and treating common pain of spinal origin.

At the Rheumatology Society, things went less smoothly.

My communication was very well received by the consultants from the provinces, who - either at first hand or through their juniors who had trained at the Hôtel-Dieu - had been following the work at my Department. The great majority, though, were sceptical; and some were downright hostile.

One of the leading lights of rheumatology in those days got up to speak and said, "If I have understood you correctly, my dear Maigne, you inject a facet joint and you relieve low back pain. Take it from me, the time when a facet joint injection can cure low back pain has not yet come."

M.O. Why was that?
R.M. It was nothing personal. This man had volunteered to write an extremely complimentary foreword to my first book on Vertebral Manipulation - a very sensitive subject, back in the 60s. However, at the time of my communication, the in thing was Disks. The time was not yet ripe for a rediscovery of the facet joints, which had been forgotten since Putti's days - and Putti himself had only concerned himself with the facet joints of the lumbosacral spine.

M.O. But what is the trouble at the thoracolumbar junction?
R.M. You mean, what is it that causes the pain in the thoracolumbar junction segment? That is the question.

It should be noted that imaging techniques do not really show anything. Very, very rarely does one find a herniated disk that is causing only lumbar or abdominal pain.

This painful segment constitutes what I call a "painful minor intervertebral dysfunction." This condition may be seen anywhere in the spine. This "painful minor intervertebral dysfunction" - or PMID, for short - is usually brought on by exertion, a false movement, poor posture, etc. This condition is the cause of most common backaches.

PMID may be transient, and remit spontaneously; however, it may also persist for months and even years, and give rise to continuous or episodic pain. Equally, it may cause no symptoms at all, and be a coincidental finding when the patient is undergoing examination.

The hallmark of the condition is its reversibility. Relief may be obtained by resting the segment. In the majority of cases, the condition is abolished by manipulation; in fact, PMID is the indication of choice for manipulation. Facet joint infiltration may abolish the pain; etc.

PMID has another feature (which is, however, also encountered in other conditions), and that is the production of neurotrophic manifestations in the distribution of the spinal nerve corresponding to the facet joint on the painful side. The phenomenon caused is what I have termed "cellulalgia" - tenderness of the skin and subcutaneous tissues - in the cutaneous distribution of the nerve. This is what we find in thoracolumbar junction syndrome. There may be "myalgic cords" in some of the muscles; and the tendon insertions may be excessively tender. These manifestations can produce a pattern of local or referred pain, which may mimic other disorders. The patient is not spontaneously aware of the condition, which is demonstrated only on examination. The manifestations disappear as soon as the vertebral segment responsible has become non-tender on examination.

These, then, are the clinical findings. The actual mechanism of PMID is less clear. It could be considered as a self-perpetuating mini-sprain of the vertebral segment concerned.

M.O. At any rate, you think that it is a disorder of the facet joint, rather than of the disk?
R.M. The disk has definitely nothing to do with it. At the lumbar level, disk insufficiency may contribute to PMID; however, this is less likely in the thoracic and the cervical spine. The disk is certainly not directly involved.

M.O. Could we take it that if manipulation plus infiltration work, then it is the facet joint that is responsible?
R.M. It is true that there is no PMID without facet joint pain. However, the question is whether that pain is the cause, the consequence, or simply one of the features, of the dysfunction of the segment.

The supraspinous and the interspinous ligaments will often be found to be tender, and their infiltration may relieve the signs and symptoms.

M.O. But surely, the frequently seen response to facet joint infiltration would plead in favour of a facet joint pathology?
R.M. Obviously, the facet joint plays an important role. However, a facet joint infiltration also works on other structures. Anaesthetic is introduced also into the posterior ramus which supplies the posterior parts of the segment.
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We could say that the response to facet joint infiltration, which abolishes the reflex phenomena, is , first of all, an excellent test. Apart from is value as a test, it can also provide lasting relief. In general, though, its effect is not as complete as that of well-performed manipulation.

I think that PMID is a dysfunction of the vertebral segment. The story could be like this: A false movement, or poor posture, place a vertebral segment into an extreme position that causes pain in one of the parts of the segment. Most often, that part will be the facet joint. This will make the deep muscles, especially the rotators, go into spasm. This, then, will interfere with the proper production of joint movement. This condition will be perpetuated, because spinal movements are completely automatic, and with every movement that stresses the affected segment, the irritation will be repeated.

The joint as such is intact and undamaged. However, since the joint has the richest nerve supply of all the structures in the segment, it is the bit that will shout loudest when something has gone wrong. I may have got this completely wrong. However, there definitely is such a thing as segmental dysfunction, and this dysfunction has reflex repercussions, and it is involved in the generation of common back pain of vertebral origin.

M.O. If patients obtain pain relief from manipulation, is this something that happens instantly?
R.M. Yes - in fact, there are two patterns: Instantaneous relief is the general rule; however, a patient may become immediately pain-free; then, shortly afterwards, have a mild pain reaction; and eventually, 24 hours later, become definitively pain-free. In almost all cases, there is an immediate change. In the most favourable cases, one session may be enough; usually, though, it takes 2 to 3 sessions; and in some very long-standing cases, as many as 5 or 6 may be required.

M.O. What made you take an interest in manipulation?
R.M. Undoubtedly, it was because I have always been a bit of a maverick; and it also had to do with things I had seen in my younger days . When I as a child, living in rural Auvergne, I knew a bone-setter who, by all accounts, was doing a lot of good to the maimed and the halt. Of course, he did not work miracles all the time, but I was shocked to see that the local doctor could not do as well as this unqualified practitioner. Later on, I did a lot of judo; and the Japanese master, behind his curtain, would apply some secret manoeuvres that could be very effective. He revealed some of his tricks to his black belts, of which there were not many in those days. I was only a brown belt then. By the time I made it to black belt, he had left. Meanwhile, however, I had asked around among all and sundry, and had managed to reconstruct the way some of these manoeuvres were performed; and I had thought out a couple of others for myself. I had devised a little system that worked reasonably well and allowed me to provide some service to the members of my club.

All this had convinced me of the merit of these procedures. What motivated me all the more was the incredible things people were saying about such treatments.

My own teachers Albert Netter and Jean Lacapère prompted me to explore the matter further. First, they let me work on some patients, and, later, they put me in charge of a clinic in their departments.

At the same time, I was also interested in rehabilitation. Grossiord and Jean Pierre Held had done sterling work at Garches, in the field of neurology. Rheumatology and orthopaedics, however, were lagging behind, although efforts had been made here and there.

In the English-speaking countries, rehabilitation appeared to be much more advanced. I had been awarded a scholarship, and decided to go to London for a year, to learn more about physical medicine and rehabilitation - and also about manipulation, since a branch of the American schools of osteopathy had just opened there. This school was for European doctors only. However, they were only taking five students a year. I was lucky enough to be one of them.

The American osteopaths were hoping to use this school for the conversion of European doctors to their theories, which had not gone down too well with the allopathic medics in the States. Undoubtedly, that was a vain hope.

M.O. Was there no training in manipulation?
R.M. In the United States, manipulation was not taught in the schools of traditional medicine. In Europe, it was regarded by the medical schools as quackery. Also, very few people knew anything about the subject; and those that did, kept themselves to themselves. I knew the people involved just before I went to London. They were associated with Lavezzari, and trying to re-invent osteopathy. I was very glad I was off to London.

M.O. What did you learn in London?
R.M. I learned a lot about physical medicine and rehabilitation, and I acquired a new approach to painful mechanical and degenerative conditions of the musculoskeletal system, mainly from James Cyriax.

From M.C. Beal, a marvellous teacher, I learned osteopathy and the techniques involved. I very rapidly jettisoned the "philosophy" of osteopathy, to concentrate on the gentle manual techniques taught by Beal, who later became one of the most important figures in osteopathy in the United States.

Since I already had some experience with manipulation, I was able to pick up the techniques very quickly, to distance myself from the theories of osteopathy, and even to distinguish between what was and what was not so useful among the techniques I was being taught.

Later on, I came to devise a different system of manipulation, which did, however, embody the same techniques and recognize the same (limited) indications. Lescure, Waghemacker, and myself worked out the details of this system.

Manipulation did enable me to evolve a more sophisticated technique of spinal examination; it also gave me a different outlook on mechanical disorders, even in cases where manipulation is not the answer.

When I came back from London, I resumed my work in Lacapère's department and my clinics with A. Netter. A few years later, René Brunet, who was head of the Department of Electrophysiotherapy at the Hôtel-Dieu Hospital, contacted me on Mr. Grossiord's suggestion with a view to setting up a physical medicine and rehabilitation unit in his Department. The department itself had been founded by the famous clinician Carnot, who entrusted it to Dausset, the father of the Nobel laureate.

Shortly after Brunet's retirement, the hospital administration decided to put us into new premises, which were subsequently twice enlarged to keep up with the growing numbers of patients: We were seeing cases from all over the country.

The department became an independent entity, and I was in charge until my retirement. In all, I spent almost 30 years at the Hôtel-Dieu.

M.O. It's a bit confusing in the States, what with chiropractors and osteopaths ...
R.M. The osteopaths came first. The first school to award a degree of Doctor of Osteopathy (D.O.) was founded in 1874, by A.T. Still. The subjects taught were medicine and minor surgery - a bit like the summary training given to the low-level officiers de santé in France, in the last century. There was much emphasis on manual medicine, including visceral massage. Graduates from this school had limited rights of practice. By and by, the medical content of the syllabus was enhanced, and the level of qualification improved. The main development was in the 30s and the 50s. Finally, some twenty years ago, a stage was reached when D.O.s became equally licensed with M.D.s (Doctors of Medicine). There are now no limitations on the medical or surgical disciplines that D.O.s may practise. The younger generations of osteopaths have abandoned the philosophical notions of the way in which the spine affects the viscera, and have, in so doing, also abandoned manipulation even for conditions where we feel that manipulation has a role to play.

There is, however, still a small group, fewer than 5% of American osteopaths, who are being deliberately different. They practise "cranial osteopathy," and claim that they can correct such conditions as deviation of the sphenoid, and use their technique to treat all manner of disorders, including trisomy 21!

Incidentally, there are schools in the United Kingdom that award D.O.s; however, these degrees have nothing to do with the American qualifications.

Chiropractors or D.C.s (Doctors of Chiropractic) are nowadays recognized by the law, after a somewhat chequered history. They provide manipulative treatments only, and are not allowed to prescribe. For a long time, they were claiming vociferously that the only prevention and cure of all disease was treatment of "vertebral subluxation", which they diagnosed with the aid of a thermocouple, the so-called neurocalometer.

Since then, there has been progress. Future chiropractors are now being taught a bit more medicine.

M.O. Did you associate with bone-setters?
R.M. Associate is too strong a term. However, I did seize every opportunity of meeting well-known bone-setters.

The ones I saw apparently had a lot of common-sense and a flair for avoiding the riskier sort of cases. As you well know, not all bone-setters are like that.

Bone-setters do all sorts of things:-

- Some get the diagnosis wrong, but, with some skilled manoeuvres, may do some good. I remember the one who showed me an ankle sprain in which, he said, the fibula was displaced backwards by two centimetres! However, he performed some extremely quick manipulation, which gave visible relief.

- Others perform manoeuvres that resemble what a practitioner of manual medicine or an orthopaedist would do, although the range of the bone-setters' techniques is more limited.

- Yet others (and there are few of them) use non-traumatic manoeuvres to work on the muscles or tendons. Some do a few slow thumb strokes of the gluteal muscles, the hamstrings, and the calf muscles in sciatica; or brief stretching of the paraspinal muscles in patients with neck or low back pain. We have other means of achieving the same, or even better, results; however, it makes one think about the mechanism of common spinal pain.

M.O. What is your opinion of the development of manipulative medicine in France?
R.M. I introduced the first postgraduate qualification at Paris University, in 1969-70. There are now over a dozen other universities in France that run such courses. Incidentally, France is the only European country to provide this sort of postgraduate education. I am very happy to see this, especially as the curriculum and the qualification are now being standardized nation-wide.