Yatreyu: Created page with "'''Multifidus''' is the intermediate layer of the deep paraspinal (transversospinal) group, lying deeper than the semispinalis thoracis and superficial to the rotatores. Its trigger points (TrPs) refer pain primarily to the region around the spinous process of the vertebra adjacent to the TrP, and may also refer pain anteriorly to the abdomen — easily misjudged as visceral in origin. Multifidus TrPs at the S₁ level project pain downward to the coccyx and ren..."

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Created page with "'''Multifidus''' is the intermediate layer of the deep paraspinal (transversospinal) group, lying deeper than the semispinalis thoracis and superficial to the rotatores. Its trigger points (TrPs) refer pain primarily to the region around the spinous process of the vertebra adjacent to the TrP, and may also refer pain anteriorly to the abdomen — easily misjudged as visceral in origin. Multifidus TrPs at the S1 level project pain downward to the coccyx and ren..."

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'''Multifidus''' is the intermediate layer of the deep paraspinal (transversospinal) group, lying deeper than the semispinalis thoracis and superficial to the rotatores. Its trigger points (TrPs) refer pain primarily to the region around the spinous process of the vertebra adjacent to the TrP, and may also refer pain anteriorly to the abdomen — easily misjudged as visceral in origin. Multifidus TrPs at the S1 level project pain downward to the coccyx and render the coccyx hypersensitive to pressure (referred tenderness), a condition often identified as coccygodynia. TrPs in the multifidus mimic the symptoms of lumbar facet or sacroiliac syndromes.

The deep group of paraspinal muscles is believed to function primarily for '''fine adjustments''' between vertebrae, rather than for gross spinal movements. The multifidi are stabilisers rather than prime movers of the vertebral column as a whole.

==Anatomy==

The multifidi are arranged so that the fibres that move a particular segment are innervated by the nerve of that segment. The fibres of the lumbar multifidus are divided by distinct cleavage planes into five segmental bands. Each band arises from a lumbar spinous process and is innervated unisegmentally.

Multifidus fibres cross 2 to 4 segments throughout the thoracic and lumbar spine, and sometimes extend to S4. The multifidi and rotatores continue beyond the lumbosacral junction where they fill the multifidus triangle of the sacrum, and are covered by the tendinous extensions of the more superficial longissimus and iliocostalis muscles.

The deeper multifidi and rotatores muscles attach '''medially''' and '''above''' near the base of a vertebral spinous process. '''Laterally''' and '''below''' they attach to a transverse process, spaced as follows: the semispinalis thoracis fibres cross at least five vertebrae and extend caudally to the tenth thoracic vertebra.

Detailed mechanical measurements established that the principal action of the lumbar multifidus muscle is posterior sagittal rotation (extension without posterior translation). It had no translatory action. The only axial rotation effect was a minor secondary action which must be coupled to the extension movement.

'''Primary function:''' The deep group functions primarily for fine adjustments between vertebrae rather than for gross spinal movements. Specifically, the deepest transversospinal (rotatores) muscles act as dynamic ligaments that adjust small movements between individual vertebrae. Acting bilaterally, the semispinalis thoracis, thoracic and lumbar multifidi, and rotatores extend the vertebral column. When these muscles act unilaterally, they can rotate the vertebrae to the contralateral side.

'''Innervation:''' Medial branches of the dorsal primary divisions of the spinal nerves. In the lower thoracic and lumbar regions, the nerve, the rotator muscle, and the tip of the spinous process, which has the same number as the nerve, are at the same level. The lumbar multifidi are arranged so that the fibres moving a particular segment are innervated by the nerve of that segment.

==Referred Pain Patterns==

'''Local pain near spinous process:''' Multifidi TrPs refer pain primarily to the region around the spinous process of the vertebra adjacent to the TrP (Fig. 48.2A).

'''Anterior abdominal referral:''' Multifidus TrPs located from L1 to L5 may also refer pain anteriorly to the abdomen, which is easily misjudged as visceral in origin (Fig. 48.2B).

'''Coccyx referral:''' Multifidus TrPs at the S1 level project pain downward to the coccyx and render the coccyx hypersensitive to pressure (referred tenderness). The condition is often identified as coccygodynia (Fig. 48.2B).

The severe aching "bone" pain from TrPs in any of the deep group of paraspinal muscles is persistent, worrisome, and disabling.

==Activation and Perpetuating Factors==

* '''Sudden overload:''' A quick awkward movement combining bending and twisting of the back, especially when muscles are fatigued or chilled
* '''Sustained overload:''' Sustained contraction in a fully shortened (hyperlordotic) position
* '''Structural asymmetries:''' Lower limb-length inequality, pelvic asymmetry; these perpetuate TrPs and must be corrected
* '''Excessive or absent lumbar lordosis:''' Deep lumbar paraspinal TrPs are likely to occur in patients with either an excessive or absent lumbar lordosis
* '''Articular dysfunction:''' TrPs in the multifidi are more likely to induce articular dysfunction involving two or three adjacent segmental levels; TrPs at any level will usually be associated with four to six segmental levels of dysfunction
* '''Disc herniation:''' An L4–L5 lateral disc herniation produces tightness of the left L4–L5 multifidus muscle, causing a segmental motion block; Schneider emphasised that the symptoms caused by multifidus TrPs mimic those of lumbar facet or sacroiliac syndromes

==Clinical Examination==

===Deep Paraspinal Examination===

Active TrPs in the deep paraspinal muscles cause guarded movements and restrict side bending, rotation, and hyperextension of the trunk.

During flexion, a hollow or flat area develops in the smooth curve formed by the spinous processes. The flattening usually spans one to three vertebrae. Involvement of a multifidus or rotator muscle on either side produces midline tenderness over the adjacent spinous process. This tenderness is easily located by tapping each spinous process in succession; it disappears after inactivation of the responsible TrPs, which may be located on either or both sides of the spine.

'''Deep paraspinal examination technique:'''
# Patient is recumbent (as above) or seated and leaning forward to flex the spine
# A flattened region or slight hollow extending over one to three vertebrae indicates the probable TrP source of trouble
# The examiner taps or presses on the tips of successive spinous processes to elicit tenderness
# When a spinous process in the flat area is hypersensitive, the deep musculature on each side of it is palpated by firm pressure in the groove between the process and the longissimus muscle
# Deep finger pressure is directed along the side of the spinous process to exert pressure on the rotatores against the underlying laminae, to locate a spot of maximum tenderness
# If two or three spinous processes are tender, one expects to find adjacent TrPs on at least one side at each level of tenderness

'''General examination note:''' The deep paraspinal group is more likely to show isolated muscle involvement, whereas the more superficial paraspinal muscles are likely to accumulate associated TrPs in functionally related muscles, especially the contralateral superficial muscles.

==Differential Diagnosis==

{| class="wikitable"
! Condition !! Distinguishing features
|-
| Lumbar facet (zygapophysial) syndrome || Referred pain characteristic of lumbar facet joints overlaps pain referred from multifidi muscles; manual release techniques for these articular dysfunctions are as effective for releasing the tense deep spinal muscles as they are for releasing restricted joint movement
|-
| Sacroiliac syndrome || Multifidus TrPs mimic sacroiliac syndrome; an L4–L5 disc herniation can produce tightness of the left L4–L5 multifidus and cause a segmental motion block
|-
| Coccygodynia || Multifidus TrPs at the S1 level refer pain to the coccyx and render it hypersensitive to pressure (referred tenderness) — often identified as coccygodynia; inactivation of the responsible TrPs resolves the coccygeal hypersensitivity
|-
| Visceral disease (abdominal pain) || Multifidus TrPs from L1–L5 may refer pain anteriorly to the abdomen; easily misjudged as visceral in origin
|-
| Radiculopathy || When radiculopathy activates TrPs, they may persist long after nerve root compression has been relieved; these TrPs produce symptoms of stiffness and pain similar in distribution to the radicular pain, and may explain the complication known as the postlumbar-laminectomy pain syndrome, or failed-back syndrome
|-
| Fibromyalgia || Any patient with chronic low back pain and additional widespread pain should be examined for fibromyalgia; each diagnosis requires its own therapeutic approach
|}

==Treatment==

===Trigger Point Release — Deep Paraspinal Muscles===

To stretch the multifidus and rotatores muscles, the seated patient's spine is flexed and simultaneously rotated, turning the chest toward the side of the involved muscle (Fig. 48.7):
# After initial sweeps of vapocoolant spray, the operator takes up the slack that develops and repeats the process several times as needed to achieve full normal range of motion
# To incorporate PIR (postisometric relaxation), the patient looks first toward the contralateral side (toward the left if the TrPs are on the right) while the examiner resists any attempt to turn the torso; the patient then relaxes and turns toward the right
# Release of the tense deep paraspinal muscles is augmented through reciprocal inhibition if the patient gently voluntarily assists rotation to the right
# A tight left iliocostalis thoracis may need to be released by adding sweeps of spray over that muscle before full release of the deeper muscles can be realised

Many manual release techniques directed toward spinal articular dysfunctions are as effective for releasing the tense deep spinal muscles as they are for releasing restricted joint movement.

===Trigger Point Injection — Deep Paraspinal Muscles===

The TrPs in the deep paraspinal thoracic muscles are injected by directing the needle caudally (not upward) and slightly medially (Fig. 48.8). When it is necessary to inject the deepest muscles (rotatores), which lie against the laminae of the vertebrae and attach at the base of each spinous process, a needle that is at least 5 cm (2 in) long is used. It is directed somewhat caudally and medially, nearly parallel to the long axis of the spine and toward the base of the spinous process, but '''not between''' the spinous processes.

This angle of the needle, while reaching the tender spots in the deepest paraspinal muscles, eliminates the possibility of introducing the needle between the ribs into the pleural cavity, or between the vertebrae into the epidural space. The caudal slant of the needle is indicated because of the shingle-like overlap of the laminae. Penetration to a depth greater than the laminae is unnecessary and undesirable.

===Corrective Actions===

See [[Muscle:Longissimus_Thoracis#Corrective_Actions|Longissimus Thoracis — Corrective Actions]] for the full programme. For deep paraspinal TrPs:
* Passive stretch exercises for the paraspinal muscles
* Graded active strengthening exercises for the abdominal muscles
* Correction of structural inadequacies (leg-length discrepancy, small hemipelvis)

==Satellite Trigger Points==

* [[Muscle:Rotatores|Rotatores]] — deepest layer; co-active; TrPs in rotatores can induce a concurrent single-level articular dysfunction
* [[Muscle:Semispinalis_Thoracis|Semispinalis Thoracis]] — more superficial of the deep group; co-active at thoracic levels
* [[Muscle:Iliocostalis_Lumborum|Iliocostalis Lumborum]] — superficial group; frequently develops associated TrPs
* [[Muscle:Gluteus_Medius|Gluteus Medius]] / [[Muscle:Gluteus_Minimus|Gluteus Minimus]] — satellite TrPs induced by key lumbar paraspinal TrPs

==Related Pages==

* [[Muscle:Rotatores]] — deepest layer of the deep paraspinal group
* [[Muscle:Semispinalis_Thoracis]] — outermost of the deep paraspinal group
* [[Muscle:Longissimus_Thoracis]] — superficial group; frequently co-involved
* [[Muscle:Iliocostalis_Lumborum]] — superficial group; frequently co-involved
* [[Pain:Low_Back]] — diagnostic algorithm for lumbago

==References==

* Travell JG, Simons DG. ''Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 2: The Lower Extremities''. Baltimore: Williams & Wilkins; 1992. Chapter 48.

[[Category:Muscle]]
[[Category:Vol2_Ch48]]
[[Category:Torso]]

Muscle:Multifidus - Revision history