Pain physician
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The most common presentation of cluneal neuropathy is ipsilateral low back and gluteal pain. Cluneal neuralgia has been described historically in surgical contexts, with much of the description and treatment related to entrapment and decompression, respectively. Treatment options for addressing axial low back pain have evolved with advancements in the field of interventional pain medicine, though clinical results remain inconsistent. Recent attention has turned toward peripheral nerve stimulation. Nonsurgical interventions targeting the superior and medial cluneal nerve branches have been performed in cases of low back and buttock pain, but there is no known review of the resulting evidence to support these practices. ⋯ Limited studies promote beneficial effects from interventions intended to target cluneal neuropathy. Despite increased emphasis and treatment options for this condition, there is little consensus on the diagnostic criteria, endpoints, and measures of therapeutics, or procedural techniques for blocks, radiofrequency, and neuromodulation. It is imperative to delineate pathology associated with the cluneal nerves and perform rigorous analysis of associated treatment options.
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Piriformis syndrome (PS) is a painful condition caused by entrapment of the sciatic nerve within the piriformis muscle. PS is typically unilateral and mainly occurs related to entrapment of the sciatic nerve. Treatments include physiotherapy, analgesics, anti-inflammatory drugs, behavioral modifications, injection therapy with local anesthetics (LAs) and steroids, epidural injection, botulinum toxin (BT) injection, and surgery. ⋯ In patients with PS, satisfactory pain improvement can be obtained by BT, LA plus CS, LA, or CS injection therapy. Injection of LA plus CS showed the best efficacy.
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Postoperative pain management in breast surgery and video-assisted thoracic surgeries (VATS) remains challenging. Oral or intravenous infusion of opioids were early treatments, but they can result in gastrointestinal reactions, respiratory inhibition, and other adverse reactions. In recent years, various regional block techniques have been employed for postoperative analgesia of these surgeries. However, a pair-wise meta-analysis cannot comprehensively rank and evaluate the analgesic effects and adverse events of various regional blocks. ⋯ After a comprehensive evaluation of postoperative analgesic effects and adverse events based on the NMA, we hypothesize that SAPB and ICNB have distinct advantages in postoperative analgesia and reduce the incidence of nausea and vomiting, respectively. However, conclusions drawn from more RCTs may be more convincing.
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The superior and middle cluneal nerves are sources of low back, buttock, and leg pain. These nerves are cutaneous branches of the lateral branches of the dorsal rami of T11- S4. Pain arising from entrapment or dysfunction of one or more of these nerves is called "cluneal nerve syndrome." A clear understanding of the anatomy underlying cluneal nerve syndrome and its treatment has been hampered by the very small size of the cluneal nerves and their complex, varying anatomy. Because of differing methods and foci of investigation, the literature regarding cluneal nerves has been confusing and even contradictory. ⋯ Cluneal nerve syndrome is characterized by a triad of pain, tender points, and relief with local anesthetic injections. The pain is a deep, aching, poorly localized low back pain with variable involvement of the buttocks and/or legs. Tender points are localized at the iliac crest or caudal to the posterior superior iliac spine. Muscle weakness and dermatomal sensory changes are absent in cluneal nerve syndrome. If the pain returns after injections, neuroablation, nerve stimulation, or surgical release may be needed.
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Ultrasound (US) has been widely used for the diagnosis and guided interventions of peripheral nerve disorders. Although superior cluneal nerve (SCN) entrapment is an important cause of lower back pain, a relevant review as to how US can be used for imaging and guided intervention for cases of SCN entrapment is still lacking. ⋯ US imaging is helpful for guiding injections of SCN entrapment and related clinical conditions. The evidence of US imaging in diagnosing SCN disorders remains insufficient, which requires more prospective studies to validate.