The middle layer of the thoracolumbar fascia lies between the erector spinae and the quadratus lumborum, attaching medially to the lumbar transverse processes and laterally to the iliac crest. It forms the lateral raphe with the posterior layer and provides a fascial compartment for the lateral lumbar muscles.
The middle thoracolumbar fascial layer is disrupted during transforaminal lumbar interbody fusion (TLIF) and posterior lumbar approaches that require lateral retraction. Its disruption allows the erector spinae to shift laterally, reducing their mechanical advantage. In quadratus lumborum syndrome, dysfunction of the middle fascial layer alters force transmission between the lumbar spine and the iliac crest.
Fascial compartment disruption during posterior lumbar surgery or direct lateral lumbar trauma, contributing to post-operative erector spinae atrophy and altered lumbopelvic force transmission.
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