Treatment of low back pain elicited by superior cluneal nerve entrapment neuropathy after lumbar fusion surgery

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Abstract

Object

Low back pain (LBP) attributable to fusion failure, implant failure, infection, malalignment, or adjacent segment disease may persist after lumbar fusion surgery (LFS). Superior cluneal nerve (SCN) entrapment neuropathy (SCNEN) is a clinical entity that can produce LBP. We report that SCNEN treatment improved LBP in patients who had undergone LFS.

Methods

Between April 2012 and August 2015, we treated 8 patients (4 men and 4 women ranging in age from 38 to 88 years; mean age, 69 years) with SCNEN for their LBP after LFS. Our criteria for the diagnosis of SCNEN included a trigger point over the posterior iliac crest 7 cm from the midline and numbness and radiating pain in the SCN area upon compression of the trigger point. Symptom relief was obtained in more than 75% of patients within 2 h of inducing a local nerve block at the trigger point in the buttocks. The mean postoperative follow-up period was 28 months (range, 9-54 months).

Results

LBP was unilateral in 3 and bilateral in 5 patients. The senior author (T.I.) operated all patients for SCNEN under local anesthesia because they reported recurrence of pain after the analgesic effect of repeat injections wore off. This led to a significant improvement of their LBP.

Conclusions

SCNEN should be considered in patients reporting LBP after LFS. Treatment of SCNEN may be a useful option in patients with failed back surgery syndrome after LFS.

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Most cited references 30

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Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature.

Paul Park, Hugh Garton, Vishal Gala … (2004)

Review of the literature. Review the definition, etiology, incidence, and risk factors associated with as well as potential treatment options. The development of pathology at the mobile segment next to a lumbar or lumbosacral spinal fusion has been termed adjacent segment disease. Initially reported to occur rarely, it is now considered a potential late complication of spinal fusion that can necessitate further surgical intervention and adversely affect outcomes. MEDLINE literature search. The most common abnormal finding at the adjacent segment is disc degeneration. Biomechanical changes consisting of increased intradiscal pressure, increased facet loading, and increased mobility occur after fusion and have been implicated in causing adjacent segment disease. Progressive spinal degeneration with age is also thought to be a major contributor. From a radiographic standpoint, reported incidence during average postoperative follow-up observation ranging from 36 to 369 months varies substantially from 5.2 to 100%. Incidence of symptomatic adjacent segment disease is lower, however, ranging from 5.2 to 18.5% during 44.8 to 164 months of follow-up observation. The rate of symptomatic adjacent segment disease is higher in patients with transpedicular instrumentation (12.2-18.5%) compared with patients fused with other forms of instrumentation or with no instrumentation (5.2-5.6%). Potential risk factors include instrumentation, fusion length, sagittal malalignment, facet injury, age, and pre-existing degenerative changes. Biomechanical alterations likely play a primary role in causing adjacent segment disease. Radiographically apparent, asymptomatic adjacent segment disease is common but does not correlate with functional outcomes. Potentially modifiable risk factors for the development of adjacent segment disease include fusion without instrumentation, protecting the facet joint of the adjacent segment during placement of pedicle screws,fusion length, and sagittal balance. Surgical management, when indicated, consists of decompression of neural elements and extension of fusion. Outcomes after surgery, however, are modest.

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Comparison of anterior and posterior iliac crest bone grafts in terms of harvest-site morbidity and functional outcomes.

Elke R. Ahlmann, Michael Patzakis, Nikolaos Roidis … (2002)

Previous studies have demonstrated high complication rates after harvest of iliac crest bone grafts. This study was undertaken to compare the morbidity related to the harvest of anterior iliac crest bone graft with that related to the harvest of posterior iliac crest bone graft and to determine differences in functional outcome. The medical records of eighty-eight consecutive patients who had undergone a total of 108 iliac crest bone-grafting procedures for the treatment of chronic osteomyelitis from 1991 to 1998 were retrospectively reviewed. Demographic characteristics, the location of the harvest, the volume of bone graft that was harvested, the estimated blood loss, and postoperative complications were recorded. Fifty-eight patients completed a questionnaire pertaining to postoperative and residual pain, sensory disturbances, functional limitations, cosmetic appearance, and overall satisfaction with the bone-graft harvesting procedure. Sixty-six anterior and forty-two posterior bone-graft harvest sites were evaluated at a minimum of two years after the operation. A major complication was associated with 8% (five) of the sixty-six anterior sites and 2% (one) of the forty-two posterior sites. The rates of minor complications were 15% (ten) and 0%, respectively. In the series as a whole, there were ten minor complications (9%) and six major complications (6%). The rates of both minor complications (p = 0.006) and all complications (p = 0.004) were significantly higher after the anterior harvest procedures than they were after the posterior procedures. The postoperative pain at the donor site was significantly more severe (p = 0.0016) and of significantly greater duration (p = 0.0017) after the anterior harvests. No patient reported functional limitations at the latest follow-up evaluation. In this series, the complication rate was lower than those previously reported by other investigators. Harvest of a posterior iliac crest bone graft was associated with a significantly lower risk of postoperative complications. On the basis of the results of this study, we recommend that iliac crest bone graft be harvested posteriorly whenever possible.

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Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain.

Sohail K Mirza, Richard A Deyo (2007)

Systematic review of randomized trials comparing surgical to nonsurgical treatment of discogenic back pain. Compare research methods and results. Recent reports have increased debate about the role of surgery in the treatment of chronic back pain associated with lumbar disc degeneration. We conducted a systematic review of randomized trials comparing lumbar fusion surgery to nonsurgical treatment of chronic back pain associated with lumbar disc degeneration. A literature search identified 5 randomized trials that compared fusion to nonoperative treatment for chronic low back pain. Excluding 1 trial for spondylolisthesis, we compared study participants, interventions, analyses, and outcomes in 4 trials that focused on nonspecific chronic back. All trials enrolled similar subjects. One study suggested greater improvement in back-specific disability for fusion compared to unstructured nonoperative care at 2 years, but the trial did not report data according to intent-to-treat principles. Three trials suggested no substantial difference in disability scores at 1-year and 2-years when fusion was compared to a 3-week cognitive-behavior treatment addressing fears about back injury. However, 2 of these trials were underpowered to identify clinically important differences. The third trial had high rates of cross-over (>20% for each treatment) and loss to follow-up (20%); it is unclear how these affected results. Surgery may be more efficacious than unstructured nonsurgical care for chronic back pain but may not be more efficacious than structured cognitive-behavior therapy. Methodological limitations of the randomized trials prevent firm conclusions.

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Author and article information

Journal

Journal ID (nlm-ta): Spine Surg Relat Res

Journal ID (iso-abbrev): Spine Surg Relat Res

Title: Spine Surgery and Related Research

Publisher: The Japanese Society for Spine Surgery and Related Research

ISSN (Electronic): 2432-261X

Publication date (Electronic): 20 December 2017

Publication date Collection: 2017

Volume: 1

Issue: 3

Pages: 152-157

Affiliations

[1 ]Department of Neurosurgery, Kushiro Rosai Hospital, Hokkaido, Japan

[2 ]Department of Neurosurgery, Teikyo University Hospital, Tokyo, Japan

[3 ]Department of Neurosurgery, Chiba Hokuso Hospital, Nippon Medical School, Chiba, Japan

[4 ]Department of Neurosurgery, Nippon Medical School Hospital, Tokyo, Japan

Author notes

Corresponding author: Naotaka Iwamoto, 4649nao-iwamoto@ 123456nms.ac.jp

Article

DOI: 10.22603/ssrr.1.2016-0027

PMC ID: 6698489

SO-VID: 229d1cfa-8993-4958-bd5f-1bcddc7134e5

License:

Spine Surgery and Related Research is an Open Access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view the details of this license, please visit ( https://creativecommons.org/licenses/by-nc-nd/4.0/).

Treatment of low back pain elicited by superior cluneal nerve entrapment neuropathy after lumbar fusion surgery

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Most cited references 30

Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature.

Comparison of anterior and posterior iliac crest bone grafts in terms of harvest-site morbidity and functional outcomes.

Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain.

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