When referring to the thoraco-lumbar region we are encompassing the area from about the tenth thoracic to the second lumbar vertebrae, not just the twelfth thoracic to first lumbar articulations. The term refers to an area rather than a specific segment.
Like all the junctional areas of the spine, there are differences from adjacent areas. As the curves are changing and the stability of one area meets the relative mobility of the other, difficulties occur. From a technique and treatment viewpoint the presence of the autonomic outflow to the coeliac plexus, and the diaphragmatic attachments, -further complicate this area. Osteochondrosis is extremely common and often causes the characteristic flexion deformity, premature arthrosis, and stiffening which make the application and choice of technique difficult. As the prostate and uterus drain through their veins into this area, the possibility of secondary meta-
static deposits from these sites must always be considered in history, examination and diagnosis.
Excessive torsion of this area in treatment can produce nausea. Poor application of technique and excessive leverage into rotation can lead to sacro-iliac joint strain. Careful consideration of appropriate modifying factors, and greater use of compression rather than rotation can help to avoid this problem.
Techniques for the area can be difficult in extremely mobile young subjects, as it is not easy to isolate the area, but high force should not be used instead of skill.
The area can be considered as part of the lumbar spine, the thoracic spine, or an area in its own right. It should be possible to employ techniques that reach the area without excessive force, but owing to the length of the levers necessary, suitable protection of adjacent areas is important.
16.1 • Articulation into sidebending sitting The patient sits across the table at one end with one arm over the operator's shoulder. Apply a side-bending force by pulling with one hand while giving a counter-force with the other. Rock from your front to your back foot to produce the desired movement.
Tips: Control of the compression through the fixing hand on the patient's shoulder is critical in this hold. Note that the patient's head remains over her pelvis. The spine is being buckled specifically at the thoraco-lumbar area.
16.3 • Articulation prone Lift the thigh just above the knee of the prone patient. Fix with the other hand over the transverse processes of the thoracolumbar area. Adduct the thigh and extend it. Force will be transmitted through to the upper lumbar area. The pull on psoas is very powerful and in most subjects it will direct forces to the area without excessively stressing the lumbar area.
Tips: Least useful in very heavy subjects where lifting the leg would be a problem. Most useful where strong articulation is necessary.
16.2 • Articulation prone Stand below the patient's pelvis and pull up against the anterior superior iliac spine. Fix with the other hand over the transverse processes at the thoraco-lumbar area. If a suitable barrier accumulates, this can be made into a rotation and extension thrust although to avoid pain the amplitude must be kept very small.
Tips: Try placing the patient in some sidebend-ing first which will have the effect of making the technique reach the deeper or more superficial tissues according to the direction of the sidebend-ing. Try asking the patient to turn her head to one side or the other. Try having her arms by her sides, under her shoulders, under her forehead or over the sides of the table. Each change will make a difference to the technique. Try applying the technique at varied phases of breathing.
16.4 • Thrust prone The patient lies prone in a 'sphinx' position. Clasp her ankles between thumb and index finger and index and middle finger of the pronated hand. Apply the other hand over the spinal level desired and initiate a rocking motion of the patient from end to end of the table. As you are rocking, increase the traction force with both hands until tension is felt to accumulate under the spinal hand. Apply a small thrust against the spinous process into extension, or against a transverse process into rotation.
Tips: Try asking the patient to stagger her elbows slightly which will introduce a preliminary sidebending or rotation to the area. It may be necessary to have the patient drop her feet over the end of the table if they are uncomfortable. Try using varied phases of respiration to find the optimum barrier.
16.5 • Thrust sideiying The patient is placed sidelying with her lower arm behind the thorax. Push backwards against the anterior aspect of the pelvis to stabilize it. Push the spine backwards from below to introduce rotation. Pull forward against the transverse processes of the vertebrae above with the other hand and use the forearm to stabilize the scapula. Rock the whole patient into a small amplitude of rotation to find the optimum point of tension and then apply the thrust with the upper hand while maintaining the lever position with the lower.
Tips: This technique requires quite firm compression with both hands into the table as well as into rotation. It is critical not to release the fixation produced by the lower hand at the moment of the thrust as the focus is liable to be lost. Try varied phases of breathing.
16.6 • Thrust sidelying The patient is sidelying in a classical lumbar roll position. Apply the levers in the usual way for the thrust with some small variations. Use a substantial element of compression through the pelvis toward the table. Use a compressive force through the shoulder toward the table and slightly toward the patient's head. The thrusting hand is pushing into compression against the lamina of the vertebral segment desired. As the forces accumulate, the thrust is applied with the lower hand pulling the vertebra and the pelvis toward you as a unit. This ensures that the force is not dissipated in rotation of the lumbar spine. This is primarily a compression thrust with a small local rotary force at the contact point at the moment of full compression.
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