Gracie Schneider

Professor Workman

English 1201

March 25 2020

Superior Cluneal Nerve Entrapment Broken Down

A young New Zealand girl, 22 years, had spent four years of her life in

unbearable lower back and abdominal pain. Going to one doctor after the next. Being

sent from one specialist to another, doctors were stumped as to what was causing this

intolerable pain. One day she got in contact with specialist Krishna Boddu and had

received the answer she had been searching for, for many years. The superior cluneal

nerve is a cutaneous nerve that is sensory meaning it works with the central nervous

system. Superior cluneal nerve entrapment causes lower back pain that can spread to

other areas of the body such as the iliac crest and legs, and there are three main ways

to treat the pain from the condition, injections and surgical release are proven to be

most effective, and a third but not as reliable and successful way of treatment is

chiropractic methods.

This nerve condition has been around for some time and is not a brand new

discovery even though it is not well known. People have been suffering from lower back

pain for many many years, and doctors from many periods have worked to discover the

many different reasons that can cause pain. “In 1957, Stong and Davila, reported that

the superior cluneal nerve and the middle cluneal nerve can be entrapped around the
iliac crest”(Isu et al.). These two doctors made the first major step towards determining

was exactly superior cluneal nerve entrapment was and how that can lead to pain.

Since their discovery, many new ways of diagnosing, treating, and explanations for this

condition have been made. Jumping foward to now, those two doctors discoveries are

still very relevant today and are used in modern research. Now, there are just more

modern ways to approach diagnosing and treating superior cluneal nerve entrapment.

Superior cluneal nerve entrapment primarily causes pain in the lower back area

but can travel to other areas of the body. While it starts at the pressure point of the

nerve, it can move to the iliac crest, lumbar area, and down the legs. In an article by DC

William E. Morgan, he discusses the scientific reasoning for SCN-E, “The superior

cluneal nerve originates from the posterior rami… then descends inferior to cross over

the crest of the ilium in three branches… the medial branch travels through an

osteofibrous tunnel which has been cited as a site of entrapment”(Morgan 1). This

simply means that the superior cluneal nerve can get trapped between the different

branches which are surrounded by fascia which compresses the nerve, causing pain.

“Lower back pain due to SCN-E is exacerbated by lumbar movement such as

extension, bending, rotating, prolonged standing, sitting, walking, and rolling”(Isu et al.).

Superior cluneal nerve entrapment can affect daily life for many people and cause

issues by doing basic activities such as doing the dishes, cleaning, or exercising, all of

which require prolonged movement of certain areas. It affects people in everyday

activities, especially in those who work and could be affected drastically to the point

where their job could not be done due to the condition. “It produces led symptoms in

47%-84% of patients and 82% of lower back pain patients…”(Isu et al.). Superior
cluneal nerve entrapment includes the many branches of the superior nerve. Since

there are many branches, this means that the pain can radiate the lower part of the

body, going from the buttocks, hips, and down the person's leg. The pain is not always

right at the point of the nerve, and in many cases, the more time someone goes without

treatment, the more the paint is likely to travel to other areas of the body.

Before any steps can be taken to treat superior cluneal nerve entrapment, it must

first be properly diagnosed. The diagnosing process goes hand in hand with treating the

symptoms too. In an article by MD James Inklebarger, he discusses how a diagnosis is

made, “[a diagnosis] is made by palpation of the iliac crest… resulting in marked local

tenderness and pain relief after the local anesthetic injection”(1). First, the pressure is

applied to the area of the lower back, then an injection of some steroid or anesthetics is

given to the area to pinpoint the pain. If the injection provides immediate pain relief, then

it was a successful diagnosis. “Diagnosis of superior cluneal nerve entrapment was

confirmed when the patients experienced symptoms of relief of >75% reduction in pain

within 2 hours following the nerve block”(Miki et al.). After an injection is done, while

there is no specific way to measure the percentage of pain, patients are asked to give a

percentage of improvement. If the pain did not subside after the injection, then the

patient may be tested for similar causes of lower back pain such as lumbar disc disease

of middle cluneal nerve entrapment. If the patient's pain was treated after the shot, then

they are one step closer to finding a cure for their pain and beginning the treatment

process.
 This visual explains the areas of where the superior cluneal nerve entrapment

takes place and how the pain travels. In the dotted circle area, like talked about in the

previous paragraph shows where the superior cluneal nerve becomes entrapped, and is

the site of where the injection is done at to determine if someone is suffering for this

condition. The two arrows are pointing to the branches of the super cluneal nerve, which

is how the pain travels to various parts of the body. The shaded gray area is the gluteus

medious and the muscle which is a common area for a person suffering from superior

cluneal nerve entrapment to experience pain. A person is diagnosed with this condition
if their areas of pain are similar to the areas shown in the figure above. Once they are

diagnosed then the patient starts the next step of the process by choosing a method of

treatment.

The first method to treat superior cluneal nerve entrapment starts with cluneal

nerve block injections. A nerve block is intended to treat chronic pain caused by

inflammation of a nerve or a nerve that is having constant pressure applied. It is most

commonly a local anesthetic that is injected, similar to what is used when diagnosing

the issue, lidocaine is used in most cases. The injection is delivered to the trigger point

of the nerve, “where the SCN passes and courses of the iliac crest through the

thoracolumbar fascia, 3-4 cm, and 7-8 cm from the midline on the iliac crest”(Isu et al.).

The injection provides a cushion-like effect for the superior cluneal nerve. Although it

may provide immediate relief, it does not always last, in most cases, it involves

conservative injections to the patient. In the article, “Superior and Middle Cluneal Nerve

Entrapment as a Cause of Low Back Pain, it discusses the results from a study, “They

delivered one block in 20 [people], 2 blocks in 3, and 3 blocks in two instances… 68% of

their patients experienced lower back pain relief by more than 50% after 1-3 SCN

blocks”(Isu et al.). After 1-3 SCN blocks, the pain should subside and go away after a

couple of injections. If the pain comes back or persists after the nerve blocks then there

are further steps taken to relieve the pain.

While superior nerve blocks may work half the time or provide temporary relief for

many, when that no longer solves the solution, surgery is the next step. ‘“[In patients]

whose pain is not relieved by conservative treatment with repeated SCN blocks,

surgical release of the entrapment is performed”(Miki et al.), according to the medical

journal, “Characteristics of Low Back Pain due to Superior Cluneal Nerve Entrapment

Neuropathy”. Surgical releasement of the nerve is more invasive than the nerve block

injections but is generally an outpatient procedure. To begin, surgeons see where the

tender points were above the skin and marked with a marker. The patient is put under

general anesthesia, laid on their stomach, and a 7cm incision is made over the iliac

crest. “While being careful not to injure nerve branches passing through the

subcutaneous tissue, the superficial layer of the thoracolumbar fascia was

opened”(Hiroshi et al.). The thoracolumbar fascia is the layer of “padding” surrounding

the superior cluneal nerve. During the surgery, fascia is cut from around the nerve to

release the pressure being put on the SPN. Next, using a surgical drill part of the iliac

crest is removed under the nerve to ensure complete decompression of the nerve. In a

study done by Toyohiko Isu and his team, they found that “... in 13 of 19 patients with

SCN-E; their follow up lasted 3.2 years… [they] also reported that in 34 operated

patients with SCN-E; their Roland-Morris Disability Questionnaire(RDQ) and Japanese

Orthopedic Association(JOA) scores improved from 14.1 to 7.3 and from 13.9 to

21.1”(Isu et al.). The Roland-Morris Disability Questionnaire is a self-administrated

disability measure, where a higher number means a greater level of disability in the

person, and the Japanese Orthopedic Association is a similar system to measure pain

and disability with a different grading scale. In this particular study, after the surgery

scores from both tests drastically improved, and on average did not experience pain for

at least 3.2 years post-surgery. Surgery is the most invasive and last known way that is

medically proven to treat superior cluneal nerve entrapment. In some cases, the surgery

may have to be repeated in some patients. The second surgery follows the same
process and steps, the surgeon will just find more branches of the superior cluneal

nerve and decompress more branches of the nerve.

The last method of easing pain from superior cluneal nerve entrapment involves

chiropractic methods. While there are methods used by chiropractors to ease the pain

of SCN-E, it is a common misconception that these practices guarantee long term pain

relief. “While there is little evidence to validate this treatment as being effective in the

treatment of this condition, there is no evidence that it is not effective”(Morgan). The

goal of going to chiropractors is to ease or eradicate pain in the least invasive ways.

From the Journal of Prolotherapy, MD Inklebarger and Galanis, they write that,

“Regional massage, spinal manipulation, and soft tissue mobilization may… be

trialed”(Inklebarger and Galanis). These three methods all involve deep tissue and

muscle massages around the area of pain. Spinal manipulation and soft tissue

mobilization involve manual therapy to move and jolt the joints near the spine, the goal

is to break tensions and maximize the use of the patient's muscle. Another MD talks

about his ways of treatment in his medical journal, “[I] use a motorized prone distraction

table to elongate the fascia as I perform either a pin and stretch type release or use a

myofascial mobilization instrument”(Morgan). These techniques include using special

tables designed to apply or reduce pressure on certain areas of the back, and unique

tools used to rub and massage out the skin above the superior cluneal nerve. While

there are no medical studies to provide substantive evidence that these methods cure

the pain of superior cluneal nerve entrapment, it is still a reliable source and idea to

entertain. “While I feel this technique is effective, it is based solely on anecdotal

experience… research is needed to substantiate its effectiveness…”(Morgan). The

practitioner acknowledges that while there is no research to prove that their methods

work medically, there has been success among his patients treated using chiropractic

methods. While this method may work for some people, it has not been proven to be a

sure way of treating superior cluneal nerve entrapment, and if not done properly could

cause someone to continue to live in pain.

Superior cluneal nerve entrapment is becoming much more common, and being

seen by many more doctors. Although, it is a common misconception that all lower back

pain is due only from superior cluneal nerve entrapment. “Many patients with

Parkinson's disease suffer lower back pain whose treatment can be difficult… 8 patients

with PD and SCN-E who suffered severe LBP that was alleviated by SCN-E

treatments…”(Isu et al.). While these patients suffered from SCN-E it was not the one

and only reason for back pain. It is common to see people suffering from Parkinson's

disease and back pain to later develop SCN-E. People often assume superior cluneal

nerve entrapment, and middle cluneal nerve entrapment is the same thing. While there

are many similarities, middle cluneal nerve entrapment has different areas of pain and

involves different nerve branches. While the SCN involves the thoraco-lumbar fascia

over the iliac crest, the MCN involves being trapped under the posterior sacroiliac

ligament. While many lumbar lower back pain conditions can go hand in hand with

superior cluneal nerve entrapment, it is not always the one reason causing issues in

people with back pain.

The young New Zealand girl, after many years, received the answer she had

been searching for. She was diagnosed with superior cluneal nerve entrapment and

went through the surgical replacement of the nerve. She now lives every day feeling
healthy and pain-free. This girl is now able to go back to her daily life and enjoy doing

basic activities like working, walking, and sitting. Superior cluneal nerve entrapment is

becoming more common every day, and new information is being discovered and tested

to help alleviate this pain. What has been learned and tested by medical professionals

is already helping people of many ages and lifestyles from all over the world.

Entrapment of the superior cluneal nerve can cause pain to the lower back, legs, iliac

crest, and other areas of the lower body, and so far steps taken to ease pain are

injections, surgery, or chiropractic methods.

Works Cited

Hiroshi Kuniya, et al. “Prospective Study of Superior Cluneal Nerve Disorder as a

Potential Cause of Low Back Pain and Leg Symptoms.” Journal of Orthopaedic Surgery

& Research, vol. 9, no. 1, Dec. 2014, pp. 37–61. EBSCOhost, doi:10.1186/s13018-014-

0139-7.

Inklebarger, James, and Nikforos Galanis. “The Management of Cluneal Nerve Referred

Pain with Prolotherapy.” Journal of Prolotherapy, 31 Aug. 2018,

journalofprolotherapy.com/management-cluneal-nerve-referred-pain-prolotherapy/.
Isu, Toyohiko et al. “Superior and Middle Cluneal Nerve Entrapment as a Cause of Low

Back Pain.” Neurospine vol. 15,1 (2018): 25-32. doi:10.14245/ns.1836024.012

Miki, Koichi et al. “Characteristics of Low Back Pain due to Superior Cluneal Nerve

Entrapment Neuropathy.” Asian spine journal vol. 13,5 772-778. 14 May. 2019,

doi:10.31616/asj.2018.0324

Morgan , William E. “Cluneal Nerve Entrapment.” Cluneal Nerve Entrapment - Dr.

William E. Morgan, 2013, drmorgan.info/clinicians-corner/cluneal-nerve-entrapment/.