Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

43. Thoracolumbar Syndrome
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Groin pain should be examined with standard inguinal examination
to rule out inguinal hernia. Thoracolumbar syndrome has two clinical
features that are characteristic: a positive pinch–roll test and tenderness
on the superior aspect of the pubis. Palpation of the periosteum of the
pubis should cause tenderness on the affected side. The pinch–roll test
should be performed in a supine position in the inguinal area [ 2 ].
Workup and Diagnosis
Plain films of the thoracolumbar region should be obtained to rule out
gross segmental instability. Computed tomography (CT) and MRI of the
spine can evaluate for masses, disk herniation, spinal stenosis, and fractures.
CT scan of the abdomen can be useful to rule out intra-abdominal
pathology. Thoracolumbar syndrome is diagnosed clinically and most
radiological studies will be normal [ 6 ].
Clinical criteria for diagnosis include (1) a positive pinch–roll test ,
(2) a positive posterior iliac crest point, (3) localized tenderness over the
affected thoracolumbar segment, and (4) tenderness in the facet joints at
the affected level [ 3 ]. A diagnostic nerve block can also be performed to
confirm the diagnosis either at the bedside or with fluoroscopic guidance.
The needle is inserted over the painful facet about 1 cm from the
midline. Lidocaine 1 % is injected around the joint and laterally around
the dorsal ramus. One can also inject lidocaine at the posterior iliac crest
point. The pain should be gone within minutes of injection [ 2 ].
Treatment
Treatment of thoracolumbar syndrome is directed at the vertebral
column. Spinal manipulative therapy directed at the correct thoracolumbar
posterior joint is a first-line treatment. Manipulation is a forced
movement applied to the joint and is contraindicated in severe osteoporosis
[ 2 ]. If manipulative therapy does not cause relief of symptoms,
then injections of corticosteroids around the painful facet joint and
posterior iliac crest may help. Nonsteroidal anti-inflammatory agents,
massage, and physical therapy have also been shown to be helpful.
Surgical treatment is rarely indicated. Concern for nerve entrapment as
the cause of the problem and failure of medical management would be
an indication for surgery and nerve release [ 4 ].