Cluneal Nerve Irritation

 

Cluneal Nerve Irritation – a source of back, buttock, groin or sciatic pain

 

Background

Our appreciation of the sources of back pain and sciatica has been derived from inert studies of corpses, MRI / CAT scans and anaesthetised patients undergoing surgery. Concepts have also relied upon the results of numbing injections or the insertion of fluid into the disc (discography).

Aware state feedback and endoscopy (looking at structures is showing that these many of these concepts are unreliable and we will explore these shortcomings and the solutions in subsequent articles.

Over the last 5 years this and other specialist units have been exploring the role played in the production of low back pain, buttock, groin pain and sciatic symptoms by irritation of the “Cluneal” nerves. These are small branches derived from the L3, L4, L5 and occasionally S1 nerve roots after they have left the spine. These join together to form leashes of small nerves that cross the iliac crests – the rims of the pelvis.

 

Presentation and Confusion

Surprisingly these leashes of nerves produces symptoms of aching, burning, shooting pain in the back, sacrum or the angle between the spine and pelvic rim. It may mimic so called sacro-iliac joint pain or radiate into the buttock often widely. It may be associated with outer buttock pain and be diagnosed as trochanteric bursitis.  It can also produce pain in the groin or a pain that seems to pass from lower back through the pelvis deeply into the groin.  On occasion, it causes pain that mimics sciatica down to the knee and foot.

Such symptoms are mis-diagnosed as pain arising from the facet joints, the sacro-iliac joint, the piriformis muscle or from an inflamed trochanteric bursa.  These are then injected with steroids or treated with radiofrequency ablation with only limited benefit because they are not the real origin of the symptoms.

The Cluneal nerves form three groups called the lateral / superior group, the middle and the medial or inferior group.  The Inferior group is close to the sacro-iliac joint and is usually erroneously labelled as sacro-iliac joint pain.  Pain arising from the middle group is usually mis-attributed to the L3/4 and L4/5 facet joints.

Once aware, the clinician and patient can locate the source by finding painful pain sources on the rim of the pelvis. This can be distinguished from pain arising by displacing the facet joints or manipulating the sacro-iliac joint.  However the author doubts many of the claims made regarding manipulation of the sacro-iliac joint because it is secured by such massive ligaments.  

 

Causation

Causation can be complex but commonly arises as a result of altered forward or backward rotation of the pelvis. This may arise for a variety of possibly co-existing causes such as:

Protective alteration of posture because of pain arising from a disc protrusion, a leaking disc, a high intensity zone or a ruptured disc or spinal trauma.
Narrowing of the spinal canal or the doorways through which the nerves leave the spine.
Slackness of the discs, slippage of the vertebrae and so-called “instability”
Failed back surgery
Inadequate restoration of postural control following abdominal surgery, child birth, caesarean section  

The Cluneal nerves cross the iliac crest in small sheaths and the altered rotation causes the nerves irritation as they “kink”.

 

Treatment and Outcome

Our treatment protocol starts with injection of the specific Cluneal nerve leash with steroids and local anaesthetic.  From this we can gauge the relative contribution to the the predominant presenting symptoms made by the Cluneal nerves and the remainder arising from other sources.  Indeed, an absence of benefit would suggest that the Cluneal nerves are not a “player” and the main cause lies elsewhere.

If there is a significant improvement for a short time, then we carry out a course of Muscle Balance Physiotherapy (Alexander Technique) or Reformer Pilates therapy. If this and adjunctive local soothing therapies and non-steroidal anti-inflammatory therapy fail to quell the symptoms then radiofrequency ablation of the sheaths using a tiny probe that seeks out the nerves as the cross the iliac crests, is highly therapeutic.

Our 4-year study shows that radiofrequency ablation offers sustained improvement in these often-disabling symptoms, restoring patients to mobility and sporting objectives and participating in the gym. 

 

By Martin Knight MD FRCS

 

More

Cluneal Nerve Low Back Pain

Lumbosacral or Sacroiliac Angle Pain

 

Links

http://travellingpeach.com/health-article.php?health=36

http://travellingpeach.com/expert-bio.php?expert=25

 
Keywords

Cluneal Nerves, Back pain, Buttock pain, Trochanteric Bursitis, Piriformis Spasm, Groin Pain, Sciatica