Back Pain Due to Cluneal Nerve: Entrapment Cryptogenic Back Pain. When the Problem is NOT the Disc

Back pain that refuses to respond to “standard” spine care is often labeled nonspecific or degenerative. One under-recognized culprit is injury or entrapment of the cluneal nerves – the superior, middle, and inferior sensory branches that carry pain from the lower back and buttock skin. When these nerves are irritated or compressed, patients can develop surprisingly severe pain that mimics lumbar disc disease, sacroiliac (SI) joint dysfunction, or even sciatica, yet the spine itself may be structurally normal.NCBI+1

Causes of Damage to the Cluneal Nerves

This problem does not occur by chance. It usually follows some type of trauma, most commonly diagnosed well after the trauma has become a memory. That is, the latency of onset is frequently measured in years rather than minutes or weeks.

This nerve group can be damaged through direct trauma, although the precise nerve that is damaged can be predicted based upon the nature of the trauma. That is, some things are more likely to cause certain pain syndromes, in predictable ways.

The most commonly damaged of the Cluneal Nerves is the Superior Cluneal Nerve group. The nerves travel over the hip bone, the Iliac Crest, and it is at this point that they are most vulnerable.

Typical Causes:

1. Surgical Trauma from a stainless steel retractor used during laminectomy.

2. Swelling following lumbar surgery

3. Bone harvest (Iliac Crest) necessary to do non-cadaveric 'fusion surgery.'

4. Blunt compression from hard surfaces, such as radiology tables, hard surfaces

5. Lastly, compression trauma from direct injury, such as being kicked, punched

6. Motor vehicle injury.

Injury to the Inferior Cluneal Nerve is the next most common of the group to be injured.

Typical Causes:

1. Pressure following prolonged surgery in the supine position

2. Repeated pressure from sitting, direct weight bearing on the nerve as it passes over bone.

3. Radiation Therapy to the perineum, including prostate and rectal cancer

Injury to the Middle Cluneal Nerve:

Typical Causes:

1. Blunt trauma to the posterior pelvis

2. Surgery to the Sacrum or Cauda Equina

3. Prolonged postural changes from lower extremity gait abnormality

4. Radiation Therapy to the Pelvis

Anatomy: the three cluneal nerve groups

The superior cluneal nerves (SCN) arise from the dorsal rami of approximately L1–L3 and descend through the thoracolumbar fascia to cross the posterior iliac crest in tight osteofibrous tunnels before supplying the upper buttock skin. Entrapment most commonly occurs where these branches cross the iliac crest, making them particularly vulnerable to mechanical irritation, fascial thickening, or scar formation.NCBI+1

The middle cluneal nerves (MCN) originate from the dorsal rami of S1–S3 and course through or under the long posterior sacroiliac ligament to supply the medial buttock. Their entrapment often produces deep aching or burning pain over the sacrum with radiation toward the posterior thigh – sometimes diagnosed as “pseudo-sciatica.”PubMed+1

The inferior cluneal nerves (ICN) are distal branches of the posterior femoral cutaneous nerve. They innervate the lower buttock, just below the gluteal fold, and may be injured with trauma, pelvic or hip surgery, prolonged sitting on hard surfaces, or local compression. Neuropathy of these branches (sometimes termed clunealgia) causes focal pain in the lower gluteal region and may radiate along the proximal posterior thigh.ScienceDirect+1

Clinical presentation and pain distribution

Cluneal neuropathy typically presents as unilateral, localized buttock and low back pain that is worse with specific postures or mechanical loading and better with rest or local anesthetic block.

• Superior cluneal nerve pain

  • Burning, stabbing, or aching pain over the posterior iliac crest and upper buttock, often 7–8 cm lateral to the midline.

  • Exacerbated by lumbar extension, prolonged standing, walking, or lumbar rotation.

  • Frequently misdiagnosed as facet arthropathy, L5 radiculopathy, or SI joint pain.Surgical Neurology International+1

    
    

• Middle cluneal nerve pain

  • Deep aching pain over the sacrum and medial buttock, sometimes radiating to the posterior thigh.

  • May mimic sacroiliitis or piriformis syndrome; often described as “sciatica” despite normal imaging. Sciatica ALWAYS presents with pain all the way to the toes.

  • Provoked by pressure over the long posterior sacroiliac ligament about 3–4 cm below the SCN trigger zone.SpringerLink+1

    
    

• Inferior cluneal nerve pain

  • Focal pain in the lower buttock/inferior gluteal crease, aggravated by sitting, cycling, or direct compression.

  • Can be confused with hamstring tendinopathy, ischial bursitis, or pelvic floor pain.ScienceDirect+1

    
    

Neurologic exam is generally normal aside from tender trigger points and allodynia or hyperalgesia over the cutaneous territory, emphasizing the purely sensory nature of these nerves.NCBI+1

Diagnosis

1. History and physical examination

Diagnosis is primarily clinical:

• Focal tenderness along the iliac crest (SCN), over the long posterior SI ligament (MCN), or at/below the gluteal fold (ICN).

• Reproduction of the patient’s typical pain with sustained pressure or specific provocative maneuvers (e.g., lumbar extension or lateral bending to the contralateral side).Pain Physician

• Pain that does not follow a classic dermatomal pattern and lacks associated motor deficit or reflex changes.

Importantly, cluneal neuropathy should be considered in patients with:

• Chronic low back or buttock pain with normal or inconclusive lumbar imaging.

• Persistent pain after lumbar surgery or sacroiliac fusion despite anatomically satisfactory procedures.Neurospine+1

  
  

2. Diagnostic nerve blocks

The gold-standard confirmatory test is a diagnostic cluneal nerve block:

• Small volume local anesthetic (with or without steroid) is injected at the suspected entrapment site under ultrasound or fluoroscopic guidance.

• Temporary, substantial pain relief (commonly defined as ≥50–80% reduction) strongly supports the diagnosis and identifies the symptomatic nerve group.SpringerOpen+2Neurospine+2

  
  

3. Imaging and electrodiagnostics

Conventional MRI, CT, and EMG are often normal but play a role in excluding competing diagnoses (disc herniation, spinal stenosis, sacroiliitis, hip pathology). High-resolution ultrasound and MR neurography can sometimes visualize the cluneal branches or fascial entrapment, but these are adjunctive rather than primary tools.SpringerOpen+1

Treatment strategies

Management is stepwise, from conservative care to targeted interventional and surgical procedures.

Conservative measures

• Activity modification to avoid prolonged extension, repetitive lumbar flexion, or pressure over the iliac crest/gluteal fold.

• Physical therapy aimed at core stabilization, hip abductor strengthening, and mobilization of the thoracolumbar fascia and SI region.

• Pharmacologic therapy, including NSAIDs, neuropathic agents (gabapentinoids, SNRIs, tricyclics), and topical lidocaine or capsaicin, may provide partial relief but rarely resolve focal entrapment alone.Orthopedic Reviews+1

  
  

Cluneal nerve blocks

Therapeutic nerve blocks serve both diagnostic and treatment roles:

• Injection of local anesthetic plus corticosteroid around the SCN, MCN, or ICN can produce days to months of pain relief.

• Repeated blocks are reasonable if benefit is substantial but temporary, particularly in patients not yet ready for ablative or surgical options.Neurospine+2wpain.com.au+2

  
  

Radiofrequency and neuromodulatory techniques

For patients with confirmatory blocks and recurrent pain, radiofrequency (RF) procedures are a logical next step:

• Thermal or pulsed RF ablation of the cluneal branches can provide sustained analgesia, frequently in the range of many months or longer, with low complication rates.PMC+2ResearchGate+2

• A structured RF treatment pathway has shown “excellent or good” outcomes in the vast majority of appropriately selected patients with cluneal nerve disorders.ResearchGate+1

• In rare, refractory cases, peripheral nerve stimulation has been described as an emerging modality, though evidence remains limited.Wiley Online Library

  
  

Surgical decompression or neurectomy

When pain is clearly localized, repeatedly responsive to blocks, and refractory to less invasive approaches, surgical options include:

• Decompression/neurolysis of the superior or middle cluneal nerves at their entrapment sites along the iliac crest or posterior SI ligament.

• Neurectomy of inferior cluneal branches or posterior femoral cutaneous nerve with implantation of the proximal stump into muscle for severe sitting pain syndromes.Pure+3Neurospine+3PMC+3

  
  

Reported series indicate high rates of long-term pain improvement and functional recovery in carefully selected patients, with minimal sensory loss limited to a small patch of buttock skin.

Practical diagnostic pearls

1. Think cluneal neuropathy in focal buttock/iliac crest pain with normal spinal imaging and poor response to facet, SI joint, or epidural injections.

2. Carefully palpate the iliac crest, sacral sulcus, and gluteal fold for discrete trigger points that reproduce the patient’s pain.

3. Use targeted diagnostic blocks to differentiate superior, middle, and inferior cluneal involvement and guide subsequent treatment.

4. Combine successful interventional procedures with rehabilitation and postural correction to address underlying biomechanical drivers and reduce recurrence.

References

1. Paracha U, Freeman K. Cluneal Neuralgia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023.NCBI

2. Anderson D, McCormick Z, Mattie R, Plastaras C. A comprehensive review of cluneal neuralgia as a cause of lower back pain. Orthop Rev (Pavia). 2022;14(1):53–62.Orthopedic Reviews

3. Isu T, Kim K, Morimoto D, et al. Superior and middle cluneal nerve entrapment as a cause of low back pain. Neurospine. 2018;15(1):25–32.Neurospine+1

4. Fujihara F, Aota Y, Niimura T, et al. Clinical features of middle cluneal nerve entrapment neuropathy. Acta Neurochir (Wien). 2021;163(4):973–980.PubMed+1

5. Aota Y, Niimura T, Yoshikawa K, et al. Entrapment of middle cluneal nerves as an unknown cause of low back pain. J Orthop Surg Res. 2016;11:119.PMC

6. Wu WT, Chang KV, Özçakar L. Enhancing diagnosis and treatment of superior cluneal nerve entrapment: an ultrasound-guided perspective. Insights Imaging. 2023;14(1):54.SpringerOpen

7. Visnjevac O, Costandi S, Patel B, et al. Radiofrequency ablation of the superior cluneal nerve: a novel minimally invasive approach for lower back pain. Pain Med. 2022;23(8):1444–1451.PMC+1

8. Knight M, Inklebarger J, Kamel M, et al. A radiofrequency treatment pathway for cluneal nerve disorders. Pain Physician. 2020;23(5):E481–E490.ResearchGate

9. Kasper JM, Young AB, Haims AH, et al. Clunealgia: CT-guided therapeutic posterior femoral cutaneous nerve block for neuropathic inferior cluneal nerve pain. Reg Anesth Pain Med. 2014;39(3):215–218.ScienceDirect+1

10. Özüberk B, Doğan NÖ, Yılmaz A, et al. Effect of exercise on cluneal nerve entrapment neuropathy: a case series and literature review. J Med Case Rep. 2024;18:50.BioMed Central

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