Superior Kluneal Sinir Sıkışması: Kronik Bel ve Bacak Ağrısının Nadir ve Teşhisi Az Bilinen Bir Nedeni

Öz

Giriş: Superior kluneal sinir tuzaklanması (SKST) kronik, radiküler bel-bacak ağrısının az teşhis edilen, bu nedenle hastaların çoğunun non-spesifik bel ağrısı olarak değerlendirildiği, nadir görülen, periferik sinir kaynaklı bir sebebidir. Metod: SKST tanısı alan ve Süperior Kluneal Sinir’e (SKS) blok uygulanan 18 hasta dosyası incelendi. Hastalara uygulanan girişimsel işlemler, işlem öncesi (NRS-1, DN4-1), işlemden 2 hafta sonra (NRS-2, DN4-2) ve 3 ay sonraki (NRS-3, DN4-3) ağrı düzeyleri ve nöropatik ağrı semptomlarını içeren kayıtlar çalışmamız için kullanıldı. Sonuç: NRS değerlerine bakıldığında NRS-1 ile NRS-2 arasında (p=0.000162) ve NRS-1 ile NRS-3 (p=0.000186*) arasında anlamlı fark vardı. Hastaların NRS skorları girişimsel tedaviden önce 8.94 iken, girişimsel tedaviden 3 ay sonra 2’ye düşmüştü. DN4 değerlerine bakıldığında DN4-1 ile DN4-2 arasında (p=0.000399*) ve DN4-1 ile DN4-3 (p=0.001*) arasında anlamlı fark vardı. Hastaların DN4 skorları girişimsel tedavi öncesi 2.77 iken, sinir bloğu sonrası 0.5’e düşmüştü. Tartışma: SKST klinik olarak bel-bacak ağrısı yapan diğer sebeplerle benzer bir klinik oluşturur. Ayırıcı tanıda akla gelmez ise lomber disk hernisi gibi patolojilerin eşlik ettiği hastalarda gereksiz cerrahilere sebep olabilir. Bazı hastalarda tek blok, bazı hastalarda tekrarlayan bloklar uygulayarak ağrıyı azaltmak mümkündür. Gereksiz cerrahilerin önlenmesi, hastalığın farkındalığının artması ve risk faktörlerinin daha detaylı belirlenebilmesi için prospektif, geniş katılımlı çalışmalara ihtiyaç olduğu kanısındayız.

Anahtar Kelimeler

• superior kluneal sinir
• bel ağrısı
• kronik ağrı

Superior Cluneal Nerve Entrapment: A Retrospective Study of This Rare and Underdiagnosed Cause of Chronic Low Back and Leg Pain

Abstract

Introduction:Superior cluneal nerve entrapment (SCNE) is a rare, peripherally mediated cause of chronic radicular low back and leg pain that is underdiagnosed, leading most patients to be evaluated as having nonspecific low back pain. Method:The files of 18 patients diagnosed with SCNE and treated with a superior cluneal nerve (SCN) block were examined. Records pertaining to interventional procedures performed on these patients, pain levels before the procedure (Numeric Rating Scale [NRS]-1) and Douleur Neuropathique 4 [DN4]-1), two weeks after the procedure (NRS-2 and DN4-2), and three months after the procedure (NRS-3 and DN4-3), as well as neuropathic pain symptoms, were used for this study. Results:Evaluation of NRS values showed a significant difference between NRS-1 and NRS-2 (p=0.000162) and between NRS-1 and NRS-3 (p=0.000186). The mean NRS score was 8.94 before interventional treatment and decreased to 2 three months afterward. Evaluation of DN4 values showed a significant difference between DN4-1 and DN4-2 (p=0.000399) and between DN4-1 and DN4-3 (p=0.001). The mean DN4 score was 2.77 before interventional treatment and decreased to 0.5 following the SCN block. Conclusion:Clinically, SCNE presents similarly to other causes of low back and leg pain.If not considered in the differential diagnosis, it may lead to unnecessary surgeries in patients with coexisting pathologies such as lumbar disc herniation.Pain may be reduced with a single block in some patients, while repeated blocks may be necessary in others. We believe that prospective, large-scale studies are needed to prevent unnecessary surgeries, increase awareness of the condition, and better define risk factors.

Keywords

• superior cluneal nerve
• back pain
• chronic pain

Kaynakça

1. Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best Pract Res Clin Rheumatol. 2010 Dec;24(6):769-81. [Crossref]
2. Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, et al. The rising prevalence of chronic low back pain. Arch Intern Med. 2009 Feb 9;169(3):251-8. doi: 10.1001/archinternmed.2008.543. PMID: 19204216; PMCID: PMC4339077. [Crossref]
3. Freynhagen R, Baron R, Gockel U, Tölle TR. painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin. 2006 Oct;22(10):1911-20. doi: 10.1185/030079906X132488. PMID: 17022849. [Crossref]
4. Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ. 2006 Jun 17;332(7555):1430-4. [Crossref]
5. Erdem HR, Koçak FA, Şaş S. Bel Ağrısının Göz Ardı Edilen Nedenlerinden Biri: Superior Kluneal Sinir Tuzaklanma Nöropatisi. J PMR Sci. 2020;23(1):41-7. [Crossref]
6. Maigne JY, Lazareth JP, Guérin Surville H, Maigne R. The lateral cutaneous branches of the dorsal rami of the thoraco-lumbar junction. An anatomical study on 37 dissections. Surg Radiol Anat. 1989;11(4):289-93. doi: 10.1007/BF02098698. PMID: 2533408. [Crossref]
7. Lu J, Ebraheim NA, Huntoon M, Heck BE, Yeasting RA. Anatomic considerations of superior cluneal nerve at posterior iliac crest region. Clin Orthop Relat Res. 1998 Feb;(347):224-8. [Crossref]
8. Tubbs RS, Levin MR, Loukas M, Potts EA, Cohen-Gadol AA. Anatomy and landmarks for the superior and middle cluneal nerves: application to posterior iliac crest harvest and entrapment syndromes. J Neurosurg Spine. 2010 Sep;13(3):356-9. [Crossref]

9. Talu GK, Ozyalçin S, Talu U. Superior cluneal nerve entrapment. Reg Anesth Pain Med 2000;25:648-50. [Crossref]
10. Strong EK, Davila jC. The cluneal nerve syn drome; a distinct type of low back pain. Ind Med Surg. 1957;26:417-29.
11. Kim K, Isu T, Morimoto D, Iwamoto N, Kokubo R, Matsumoto J, et al. Common diseases mimicking lumbar disc herniation and their treatment. Mini-Invasive Surg. 2017;1:43 51. [Crossref]
12. Kuniya H, Aota Y, Nakamura N, Kawai T, Tanabe H, Saito T. Low back pain patients with suspected entrapment of the superior cluneal nerve. J Spine Res. 2011;2(6):1032-1035. Japanese.
13. Konno T, Aota Y, Kuniya H, Saito T, Qu N, Hayashi S, et al. Anatomical etiology of "pseudo-sciatica" from superior cluneal nerve entrapment: a laboratory investigation. J Pain Res. 2017 Nov 1;10:2539-2545. [Crossref]
14. Aizawa Y, Kumaki K. [The courses and the segmental origins of the cutaneous branches of the thoracic dorsal rami]. Kaibogaku Zasshi. 1996;71(3):195-210. Japanese.
15. Engel R, Bogduk N. The menisci of the lumbar zygapophysial joints. J Anatomy. 1982;135(Pt 4):795-809. Isu T, Kim K, Morimoto D, Iwamoto N. Superior and Middle Cluneal Nerve Entrapment as a Cause of Low Back Pain. Neurospine. 2018 Mar;15(1):25-32. [Crossref]
16. Ermis MN, Yildirim D, Durakbasa MO, Tamam C, Ermis OE. Medial superior cluneal nerve entrapment neuropathy in military personnel; diagnosis and etiologic factors. J Back Musculoskelet Rehabil. 2011;24(3):137-44. [Crossref]
17. Kuniya H, Aota Y, Kawai T, Kaneko K, Konno T, Saito T. Prospective study of superior cluneal nerve disorder as a potential cause of low back pain and leg symptoms. J Orthop Surg Res. 2014 Dec 31;9:139. [Crossref]
18. Morimoto D, Isu T, Kim K, Imai T, Yamazaki K, Matsumoto R, Isobe M. Surgical treatment of superior cluneal nerve entrapment neuropathy. J Neurosurg Spine. 2013 Jul;19(1):71-5. [Crossref]
19. Chauhan G, Levy I, DeChellis D. Superior Cluneal Neuralgia Treated With Wireless Peripheral Nerve Stimulation. Cureus. 2022 Mar 31;14(3):e23711. [Crossref]