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      Middle cluneal nerve entrapment neuropathy attributable to lumbar disc herniation

      case-report

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          Abstract

          Background:

          Middle cluneal nerve entrapment neuropathy (MCN-EN) is a known cause of low back pain (LBP). Here, we succeeded in treating a patient with a lumbar disc herniation who actually had MCN-EN with a nerve block and neurolysis.

          Case Description:

          A 52-year-old female presented with severe left lower back and lateral thigh pain making it difficult to walk. The lumbar MRI revealed a disc herniation on the left at the L5/S1 level. On palpation, we identified a trigger point on the buttock where the MCN penetrates the long posterior sacroiliac ligament between the posterior superior and inferior iliac spine. Two left-sided MCN blocks, followed by the left MCN neurolysis procedure, were performed under local anesthesia. At the last follow-up, 10 months after surgery, the LBP has not recurred, and she requires no medications for pain control.

          Conclusion:

          Here, a patient with a left-sided L5S1 disc herniation and low back/leg pain was successfully treated for MCN-EN with nerve block followed by neurolysis.

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          Most cited references14

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          Prospective study of superior cluneal nerve disorder as a potential cause of low back pain and leg symptoms

          Hiroshi Kuniya, Yoichi Aota, Takuya Kawai … (2014)
          Background Entrapment of the superior cluneal nerve (SCN) in an osteofibrous tunnel has been reported as a cause of low back pain (LBP). However, there are few reports on the prevalence of SCN disorder and there are several reports only on favorable outcomes of treatment of SCN disorder on LBP. The purposes of this prospective study were to investigate the prevalence of SCN disorder and to characterize clinical manifestations of this clinical entity. Methods A total of 834 patients suffering from LBP and/or leg symptoms were enrolled in this study. Diagnostic criteria for suspected SCN disorder were that the maximally tender point was on the posterior iliac crest 70 mm from the midline and that palpation of the tender point reproduced the chief complaint. When patients met both criteria, a nerve block injection was performed. At the initial evaluation, LBP and leg symptoms were assessed by visual analog scale (VAS) score. At 15 min and 1 week after the injection, VAS pain levels were recorded. If insufficient pain decrease or recurrence of pain was observed, injections were repeated weekly up to three times. Surgery was done under microscopy. Operative findings of the SCN and outcomes were recorded. Results Of the 834 patients, 113 (14%) met the criteria and were given nerve block injections. Of these, 54 (49%) had leg symptoms. Before injection, the mean VAS score was 68.6 ± 19.2 mm. At 1 week after injection, the mean VAS score significantly decreased to 45.2 ± 28.8 mm (p < 0.05). Ninety-six of the 113 patients (85%) experienced more than a 20 mm decrease of the VAS score following three injections and 77 patients (68%) experienced more than a 50% decrease in the VAS score. Surgery was performed in 19 patients who had intractable symptoms. Complete and almost complete relief of leg symptoms were obtained in five of these surgical patients. Conclusions SCN disorder is not a rare clinical entity and should be considered as a cause of chronic LBP or leg pain. Approximately 50% of SCN disorder patients had leg symptoms. Electronic supplementary material The online version of this article (doi:10.1186/s13018-014-0139-7) contains supplementary material, which is available to authorized users.
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            Superior and Middle Cluneal Nerve Entrapment as a Cause of Low Back Pain

            Toyohiko Isu, Kyongsong Kim, Daijiro Morimoto … (2018)
            Low back pain (LBP) is encountered frequently in clinical practice. The superior and the middle cluneal nerves (SCN and MCN) are cutaneous nerves that are purely sensory. They dominate sensation in the lumbar area and the buttocks, and their entrapment around the iliac crest can elicit LBP. The reported incidence of SCN entrapment (SCN-E) in patients with LBP is 1.6%–14%. SCN-E and MCN entrapment (MCN-E) produce leg symptoms in 47%–84% and 82% of LBP patients, respectively. In such patients, pain is exacerbated by lumbar movements, and the symptoms mimic radiculopathy due to lumbar disorder. As patients with failed back surgery or Parkinson disease also report LBP, the differential diagnosis must include those possibilities. The identification of the trigger point at the entrapment site and the disappearance of symptoms after nerve block are diagnostically important. LBP due to SCN-E or MCN-E can be treated less invasively by nerve block and neurolysis. Spinal surgeons treating patients with LBP should consider SCN-E or MCN-E.
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              Entrapment of middle cluneal nerves as an unknown cause of low back pain.

              Yoichi Aota (2016)
              Entrapment of middle cluneal nerves induces low back pain and leg symptoms. The middle cluneal nerves can become spontaneously entrapped where this nerve pass under the long posterior sacroiliac ligament. A case of severe low back pain, which was completely treated by release of the middle cluneal nerve, was presented. Entrapment of middle cluneal nerves is possibly underdiagnosed cause of low-back and/or leg symptoms. Spinal surgeons should be aware of this clinical entity and avoid unnecessary spinal surgeries and sacroiliac fusion. This paper is to draw attention by pain clinicians in this unrecognized etiology.
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                Author and article information

                Contributors
                Juntaro Matsumoto
                Toyohiko Isu
                Kyongsong Kim
                Koichi Miki
                Masanori Isobe
                Journal
                Journal ID (nlm-ta): Surg Neurol Int
                Journal ID (iso-abbrev): Surg Neurol Int
                Title: Surgical Neurology International
                Publisher: Scientific Scholar (USA )
                ISSN (Print): 2229-5097
                ISSN (Electronic): 2152-7806
                Publication date Collection: 2021
                Publication date (Electronic): 30 March 2021
                Volume: 12
                Electronic Location Identifier: 132
                Affiliations
                [1 ]Department of Neurosurgery, Kushiro Rosai Hospital, Kushiro, Hokkaido, Japan.
                [2 ]Department of Neurosurgery, Nippon Medical School, Chiba Hokuso Hospital, Inzai, Chiba, Japan.
                Author notes
                [* ] Corresponding author: Juntaro Matsumoto, Department of Neurosurgery, Kushiro Rosai Hospital, Kushiro, Hokkaido, Japan. juntaro.matsu@ 123456gmail.com
                Article
                Publisher ID: 10.25259/SNI_167_2021
                DOI: 10.25259/SNI_167_2021
                PMC ID: 8053461
                SO-VID: 53d23cc9-3645-4dbf-b5eb-90d85f51153f
                Copyright © Copyright: © 2021 Surgical Neurology International
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

                History
                Date received : 15 February 2021
                Date accepted : 27 February 2021
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Surgery
                Keywords: lumbar disc herniation,middle cluneal nerve,mimic
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: lumbar disc herniation, middle cluneal nerve, mimic

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