Low back pain is a very common complaint, but non-specific in 85% of sufferers. We’re learning that Cluneal neuralgia is often a common cause this pain, which is often dismissed as a Gluteal Trigger Point, SI Joint Pain, or Facet Pain.
Dr. David Rosenblum, a regional anesthesiologist specializing in pain management, recently presented a webinar during which he presented four ultrasound-guided interventions to help his patients cope with chronic pain, including lower back pain, “Head to Toe Analgesia: Ultrasound-Guided Subacromial, Cluneal Nerve, Knee, and Tarsal Tunnel Injections“.Watch the full webinar or read on for highlights about cluneal nerve injections.
When to use the Cluneal Nerve Injection
In fellowship, in training, and even afterwards, I would dismiss this as a trigger point gluteal bursitis as an SI joint, as lumbago, as even L5-S1 facet maybe”
Patients with Superior Cluneal Nerve (SCN) neuralgia present with:
- Low back pain to the Iliac crest and buttocks
- Symptoms exacerbated by lumbar puncture or posture
- Trigger point over the PSIS (corresponding to nerve compression zone)
- Numbness and radiating pain in the SCN area when trigger point compressed (Tinel’s)
- Relief with SCN block
Isu T, Kim K, Morimoto D, Iwamoto N. Superior and Middle Cluneal Nerve Entrapment as a Cause of Low Back Pain. Neurospine. 2018;15(1):25–32. doi:10.14245/ns.1836024.012
The Superior Cluneal Nerve (SCN) branches across the posterior iliac crest and can become entrapped between the fascia and bone. This will correspond to a trigger point over the posterior iliac crest, 7cm from the midline.
Dr. Rosenblum shows an interesting technique using ultrasound to image a nerve stimulator in a patient with failed back surgery. He had a positive Tinel’s of the SCN just lateral to his PSIS.
The ultrasound shows a shadow from the stimulator lead, which can be traced all the way down to the iliac crest where the cluneal nerves is located. Dr. Rosenblum injects 1 ml of Lidocaine 2% with a 25-gauge spinal needle, to provide pain relief and make the diagnosis of SCN neuralgia.
Patients with Middle Cluneal Nerve (MCN) neuralgia present with:
- Low back pain to the buttocks, often dismissed as SI joint pain
- Symptoms exacerbated by lumbar puncture or posture
- Trigger point 35 mm caudal to the PSIS and lateral to the edge of the iliac crest
- Numbness and radiating pain in the MCN area when trigger point compressed (Tinel’s)
- Relief with MCN block
Isu T, Kim K, Morimoto D, Iwamoto N. Superior and Middle Cluneal Nerve Entrapment as a Cause of Low Back Pain. Neurospine. 2018;15(1):25–32. doi:10.14245/ns.1836024.012
Video Demonstration: Cluneal Nerve Injection
In this video, Dr. Rosenblum performs cryotherapy ablation of the SCN for a patient with chronic superior cluneal neuralgia who was earlier diagnosed with a nerve block.
Dr. Rosenblum places the scanner just lateral to the sacral foramina to locate the sacroiliac ligament. It’s this location where the middle cluneal nerves can impinge, and the target for his injection.
Ultrasound-guided nerve block to the cluneal nerves at the entrapment site, specifically at the trigger point, can be used to diagnose cluneal neuralgia, when symptoms disappear after the nerves are blocked. This can then be followed by advanced therapies like cryoablation and peripheral neuromodulation.
Watch the full webinar, “Head to Toe Analgesia: Ultrasound-Guided Subacromial, Cluneal Nerve, Knee, and Tarsal Tunnel Injections“, as he describes in detail cluneal nerve blocks, cryotherapy, and others.
About Dr. Rosenblum
Dr. Rosenblum is the Director of Pain Management at the Maimonides Medical Center in New York. A prolific educator, he hosts the Pain Exam Podcast and created a Pain Exam Board Review, which has helped more than 3,000 pain management physicians become board certified. He uses the Clarius L7 HD3 scanner to guide his procedures.
Interested in more ultrasound training? Visit www.Painexam.com/events for upcoming courses by Dr. Rosenblum.
There is no CME credit for watching this webinar however one may reflect upon the knowledge discussed and obtain CME credit via NRAPpain.org.
Clarius For Ultrasound-Guided Pain Procedures
To learn about how easy and affordable it is to add Clarius wireless ultrasound to your practice, visit our Pain Management Speciality Page. Or contact us today to request a demo.
