Low Back Pain: Cluneal Nerve Entrapment

At the Centeno-Schultz Clinic we acknowledge that low back pain can arise from the lumbar facets, intervertebral disc and the sacroiliac joint.

An overlooked cause of low back pain is entrapment of the superior cluneal nerve.

The cluneal nerve is compromised of the posterior rami of L1, L2 and L3 and provides sensation to the upper buttocks.

Three distributions of the cutaneous branches of the nerve exist.   Lu et al described the anatomical relationship of the superior cluneal nerve to the posterior iliac crest.  The medial branch of the superior cluneal nerve is confined within a tunnel consisting of fascia and the superior rim of the iliac crest.    The location is 7-8 cm lateral to the spinous process on the iliac crest.  It is lateral and superior to the posterior superior iliac spine.

The nerve can be entrapped between the fascia and the iliac crest causing pain and restriction in motion.  This is similar to carpal tunnel syndrome where the fascia constricts the median nerve.

Case reports  have documented the entrapment of the superior cluneal nerve as a cause of unilateral back and buttock pain.  Patients who have undergone iliac crest bone grafts for lumbar fusions are at risk for entrapment.  Stem cell therapy is an alternative to spinal surgery and fusions.

The Centeno-Schultz Clinic is committed to establishing an accurate diagnosis so effective treatment can be started and you can return to your passions.

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Low Back Pain: Think Lumbar Facet

At the Centeno-Schultz Clinic we are committed to identifying the source of a given patient’s pain.  Back pain can arise from many sources which include dysfunctional muscles, structural instability, facet joint, sacroiliac joint and  disc degeneration.  Ortho 2.0 details the importance of function and stability.

The lumbar facet joint is a small joint in the posterior portion of the spine that is composed of the superior articular process of one vertebrae and the inferior articular process of vertebrae directly below it.  Similar to the knee-joint,  the facet joint is lined with cartilage which allows for  smooth and  painless motion.  It functions to limit the movement of each spinal  motion segment.  Trauma, instability and degeneration can cause damage to the cartilage lined joint resulting in pain.  Conventional radio-graphic studies often times fail to demonstrate facet injury.  Diagnosis is made by injection of local anesthetic into the joint (intra-articular facet injections) or medial branch blocks.

AB is 36 y/o patient with 10year history of low back pain, constant in duration, progressive in nature over the last 11 months, localized in lumbar region right>left with radiations into hips.  Pain was sharp and throbbing.  Aggravating factors included prolonged walking, sitting and running.

Alleviating factors:  percoset, ice and rest.

Treatment to date included PT, chiropractic care, oral narcotics and muscles relaxants.  Patient had undergone two  lumber epidural steroid injections without significant benefit.

MRI of lumbar spine was significant for mild disc degeneration at L4/5, L5/S1 and facet degeneration at L4/5 and L5/S1.

Patient presented to Centeno-Schultz Clinic frustrated with the treatment to date and lack of  improvement.  She underwent x-ray guided injection into the lumbar facet joints which has provided her significant and sustained benefit.

Rather than relying exclusively on the MRI which demonstrated degeneration of the lumbar discs we took history and performed a thorough physical examination which was significant for lumbar facet dysfunction.

Comprehensive care is our commitment at the Centeno-Schultz Clinic.  In order to save a joint not only do you need to know how to help that joint, but you also need to know how it got that way in the first place.

Lumbar Discography

Lumbar Discography is a pre-surgical procedure to identify whether one of more of the lumbar discs is a “pain generator’.  It is a procedure that should only be undertaken if all other possible sources of pain have been excluded and the patient is prepared to undergone surgery.  Other sources of lower back pain include lumbar facets, sacroiliac joint dysfunction, ligamental instability and trunal dystonia.  At the Centeno-Schultz Clinic we are committed to evaluating all possible sources of pain prior to proceeding with discography.

Lumbar discography involves placing a needle under sterile conditions into the center of the disc at two or more levels.  For example, one would place one needle at the L5/S1 level and another at the L4/5 level.  Once the needles have been successfully placed, a small but increasing amount of pressure is applied to a single disc by injecting contrast through a hand held manometer.  The patient is awake and asked a series of questions which include whether or not the increasing pressure recreates his or her daily pain.

A surgeon will use this information to plan the appropriate surgery.   A lumbar fusion is most common, involving one or more levels where the supporting muscles are resected from the bone and the lumbar disc is removed and replaced with bone.  Screws and rods are often utilized to stabilize the fusion.

Lumbar Fusion with Hardware

An alternative is to use bone marrow-dervied stem cells to regenerata the disc.  Regenexx is a simple needle-in, needle-out procedure which allows the patient to forgo the risks of surgery, anesthesia and the extensive and painful rehabilitative period. Regnexx enables a patient to use their own stem cells thereby eliminating the risk of disease transmission and rejection.

Please review the MRI below of a patient who had undergone lumbar surgery without reduction in their pain. The L5/S1 disc is outlined by the dashed circle.  The picture on the left is pre-procedure whereas the image on the right is 13 months after injection of patient’s own stem cells.  Note that the disc has gone from dark (dehydrated) to bright(holding onto the fluid).  The more the disc is able to hold onto water, the better the disc is able to absorb the forces of daily activity. Finally the red arrow on the left,  points to a disc bulge which contacted the traversing nerve root.  13 months after therapy, as seen on the image on the right, the bulge and nerve root irritation is gone.

Axial Images Pre and Post Stem Cell Therapy

Chronic Back Pain

Chronic lower back pain can arise from many sources.  Unfortunately many patients are not provided a thorough examination and evaluation by a physician specializing in pain management.  Often times patients are reflexively placed on muscle relaxants and narcotics with no effort to identify the source of  back pain.  If the pain does not resolve some patients are offered low back surgery.  Regrettably both of these options to treat chronic back pain have the potential of making it worse.  At the Centeno-Schultz Clinic we are committed to identifying the source of  lower back pain so the correct treatment plan is selected.

For example, chronic back pain due to a disc bulge with compression on the nerve can be successfully treated with a stem cell injection into the disc. Patients now have the option of using their own stem cells to repair lumbar disc bulge at Regenexx.

Below is an MRI of the lower back.  On the left, note a disc bulge.  On the right, following a stem cell injection there is a marked reduction in the disc bulge.  The patient had 100% pain relief.

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