another reason to strive to avoid back surgery: the thoracolumbar fascia

WHY SHOULD YOU WORK TO AVOID BACK SURGERY / BACK INJURY?
THE THORACOLUMBAR FASCIA

Thoracolumbar Fascia

Dr. Helen Langevin is back as part of a yet another team of researchers from several universities studying the THORACOLUMBAR FASCIA.  The Thoracolumbar Fascia — the football-sized diamond-shaped area of fascia in the small of the back — is unique because it’s made up of several layers of musculo-tendinous attachments and fascia from around the body.  To show you how complex the TLF is both structurally and functionally, take a gander at this CHERRY-PICKED paragraph from a five year old issue of the Journal of Anatomy (The Thoracolumbar Fascia: Anatomy, Function and Clinical Considerations).  Don’t stress; I’ll break it down for you momentarily.

The TLF is a girdling structure consisting of several aponeurotic and fascial layers that separates the paraspinal muscles from the muscles of the posterior abdominal wall. The superficial lamina of the posterior layer of the TLF (PLF) is dominated by the aponeuroses of the latissimus dorsi and the serratus posterior inferior. The deeper lamina of the PLF forms an encapsulating retinacular sheath around the paraspinal muscles. The middle layer of the TLF (MLF) appears to derive from an intermuscular septum that developmentally separates the epaxial from the hypaxial musculature. This septum forms during the fifth and sixth weeks of gestation. The paraspinal retinacular sheath (PRS) is in a key position to act as a ‘hydraulic amplifier’, assisting the paraspinal muscles in supporting the lumbosacral spine. This sheath forms a lumbar interfascial triangle (LIFT) with the MLF and PLF. Along the lateral border of the PRS, a raphe forms where the sheath meets the aponeurosis of the transversus abdominis. This lateral raphe is a thickened complex of dense connective tissue marked by the presence of the LIFT, and represents the junction of the hypaxial myofascial compartment (the abdominal muscles) with the paraspinal sheath of the epaxial muscles. The lateral raphe is in a position to distribute tension from the surrounding hypaxial and extremity muscles into the layers of the TLF.  This complex composite of fascia and aponeurotic tissue is continuous with paraspinal fascia in the thoracic and cervical regions, eventually fusing to the cranial base. Numerous trunk and extremity muscles with a wide range of thicknesses and geometries insert into the connective tissue planes of the TLF, and can play a role in modulating the tension and stiffness of this structure

Although this is a lot to digest, I want you to take away three main concepts: firstly, that the Thoracolumbar Fascia is intimately related to structures as distant as the CERVICAL FASCIA.  Secondly, “what is traditionally labeled as TLF is in reality a complex arrangement of multilayered fascial planes and aponeurotic sheets“.  In other words, the Thoracolumbar Fascia is made up of at least three large layers of fascia and “APONEUROSES” that are not strictly attached together, but actually glide on each other.  Or at least they should glide on each other in people not struggling with chronic low back pain (take 10 seconds to play THESE VIDEOS side by side in order to see the difference in the TLF of those with low back pain -vs- those without).  And thirdly, fascia is used as a leverage tool to gain mechanical advantage for both movement and structural support (FASCIA IN BIOMECHANICS).

Thanks to our national OBESITY EPIDEMIC, the fact that we are the INFLAMMATION NATION (which always ends up causing scar tissue and fibrosis — HERE), too much sitting and staring at screens, sedentary lifestyles, spending way to much time on CONCRETE or other hard surfaces, etc, etc; not only are back problems common, but back surgeries are common as well.  This most recent study (Acute Surgical Injury Alters the Tensile Properties of Thoracolumbar Fascia in a Porcine Model), published in the October 2018 issue of Journal of Biomechanical Engineering, came to some conclusions which, if you’ve been following research on the TL spine, will not surprise you.

In this study, pigs were used because their Thoracolumbar Fascia has been shown to “produce similar results to those observed in humans“.  It’s now common knowledge that injured fascia (it doesn’t matter how the fascia is injured — acute, chronic, surgical, etc) becomes thickened and dense (HERE and HERE).  Controls were compared to pigs with “microsurgically induced local injury,” with only one side of the TLF of the experimental group of pigs being ‘injured’. After a healing process, tissue was harvested from the “noninjured side of vertebral level L3-4 in pigs randomized into either control or injured groups.”  What did the team discover?

After putting the harvested tissues through a wide range of intricate tests to check the biomechanical integrity of the TLF, it was determined that the uninjured side of the experimental group’s thoracolumbar fascia had “more tissue stiffness, less energy dissipation, and less stress decay [it took longer for the injured TLF to dissipate the energy it could dissipate].”   Bottom line, the authors stated that “These findings suggest that a focal thoracolumbar injury can produce impairments in tissue mechanical properties away from the injured area itself. This could contribute to some of the functional abnormalities observed in human LBP.”  Bear in mind that while the “injuries” for this study were created surgically, the gist of the study was not necessarily surgery but back injuries in general.

I realize that in some cases surgery is inevitable — I get it.  However, studies like this show that disruption of the fascia can screw people up in ways that no one (particularly those in the surgical field) was thinking about just one short decade ago.  And here’s the kicker — creating problems in the Thoracolumbar Fascia can mimic signs of disc problems (chronic severe pain and SCIATICA), the very reason people tend to have surgery in the first place.  Listen to this piece taken from the 2015 book, Nerves and Nerve Injuries: Pain, Treatment, Injury, Disease and Future Directions (Vol 2)…..

The superior cluneal nerves arise from the dorsal rami of the first three levels of the lumbar spine. There are typically three superior cluneal nerves…. The medial superior cluneal nerve arises from the L1. The intermediate superior cluneal nerve arises from the L2 and the lateral superior cluneal nerve arises from the L3. Each of these pass through the psoas major muscle and then the paraspinal muscles to run in the plane between the quadratus lumborum muscle and the anterior layer of the thoracolumbar fascia. They then pierce the inferior aspect of the latissimus dorsi muscle and travel through the thoracolumbar fascia before crossing the posterior iliac crest.”

I show you this because PIRIFORMIS SYNDROME is frequently mistaken for disc herniations (MOST OF WHICH ARE HARMLESS ANYWAY).  Furthermore, PS is frequently not recognized for what it really is, CLUNEAL NERVE ENTRAPMENT.  Where could the three cluneal nerve branches become entrapped?  As you saw in the quote above, the TLF would be the most likely culprit (see link).  There are two ideas I want you to take away from this study.

The first is that as you learn more and more about FASCIA, you start to see why years ago Dr. Langevin (a Harvard-trained neurologist and renowned acupuncturist) was already saying that problems in the fascia are at the very root not only of pain, but of sickness and disease as well (HERE).  Secondly, there are action steps you can be taking to either avoid ending up with serious back issues, or just as importantly, taking control of your life if you’ve already had a back surgery. 

Although I would strongly suggest you talk to your physician before reading any further, THIS POST ON THE THORACOLUMBAR FASCIA happens to have a list that could help you in this endeavor — a list that is actually a specialized portion of THIS LIST.  If you like what you are seeing on our site, be sure to spread the wealth by showing us some love on FACEBOOK.  And for those of you who consider yourself “fascia hounds,” you might want to take a look at our FASCIA SUPER-POST — it contains all 175+ posts I’ve written on the subject neatly categorized for easy access.

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