A Comprehensive Review of Cluneal Neuralgia as a Cause of Lower Back Pain

Abstract

Lower back pain (LBP) is one of the most common presenting complaints in clinical adult medical patients. While most often diagnosed as “nonspecific mechanical” in etiology, several lesser known, rarer causes of LBP exist, some of which can even cause neuropathic pain. One of these infrequent causes, cluneal neuralgia (CN), is associated most often with damage or entrapment of the cluneal nerves, particularly the superior cluneal nerve (SCN) and/or the middle cluneal nerve (MCN). These nerves supply sensation to the posterior lumbar and buttock area. However, the LBP caused by CN is often difficult to recognize because it can mimic radiculopathy or sacroiliac joint (SIJ) pain or lead to symptoms in the legs. This makes CN significantly important for clinicians and surgeons to include in their differential. A thorough history proves beneficial in the diagnostic workup, as many risk factors for CN have been reported in the literature. If a CN diagnosis is made, several effective conservative measures can alleviate patients’ pain, such as nerve blocks, peripheral nerve stimulation, or high frequency thermal coagulation. Additionally, surgical treatments, such as CN release or endoscopic decompression, have resulted in fantastic patient outcomes. The purpose of the present investigation is to investigate the existing literature about CN as a cause for LBP, consider its epidemiology, discuss its pathophysiology and risk factors, elucidate its clinical presentation and diagnosis, and examine the various treatment modalities that have been reported across the world.

Stimulating Superior Cluneal Nerves via Peripheral Nerve Stimulation as a Treatment for Chronic Low Back Pain

“…Signs, such as increased tenderness, paresthesia, or allodynia along the upper part of the gluteus maximus and iliac crests, may suggest potential involvement of the superior cluneal nerve. The reproduction of pain through specific maneuvers that elongate muscles along the superior cluneal nerve pathway, such as lateral bending, stretching of the corresponding quadratus lumborum, or full flexion of the hip and knee on the same side, provides additional support for the likelihood of SCN pathology [ 2 , 4 ].…”

“…In cases resistant to these measures, local nerve blocks and ablative procedures, such as phenol neurolysis or radiofrequency ablation, may be trialed [3]. Historically, surgical decompression may be considered, targeting either the distal superior cluneal nerve branches or the involved lumbar radicular segments [3,4]. To reduce invasive therapies, previous case reports have shown that permanent PNS can provide relief for refractory SCN-induced LBP [5][6][7].…”

Superior Cluneal Nerve Entrapment as a Cause of Low Back Pain Refractory to Sacroiliac Joint Fusion: A Case Report

“…The reported incidence of superior cluneal nerve entrapment is between 1.6% and 14% in patients with LBP [ 7 ]. It is important to differentiate between the causes of LBP, in part to avoid potentially unnecessary or excessive imaging and to achieve more effective treatment and better outcomes for patients.…”

Superior Cluneal Nerve Entrapment Syndrome: Thought to Be Spondylolysis

“…The nerves then cross the iliac spine to innervate the skin and subcutaneous tissue over the gluteal region. The SCNs function as purely sensory fibers, and the superior cluneal branches provide cutaneous innervation to the gluteal and posterior parasacral regions 6 (Figure 2 ). When irritated, the nerves can cause acute and chronic lower back pain and lower extremity symptoms described as pseudosciatica.…”