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Newly Considered Tissue May Be Involved in Chronic Low Back Pain

Newly Considered Tissue May Be Involved in Chronic Low Back Pain
February 13, 2017 Dr. Phillip Snell

Complex problems often resemble an onion, with layers upon layers of detail that must be considered to get at the gist of the problem. Chronic lower back pain (CLBP) is certainly onion-like in that regard yet research continues to apply reductionistic thinking looking for a single item that is the magic bullet to fix back pain. Despite decades of research, we have failed in finding the smoking gun of back pain and as populations age, a wave of “boomers” with chronic low back pain have public resources creaking under the collective load of disability. Take for instance this recent article in The Guardian which notes that the direct costs associated with low back pain treatment in the US alone is over $88 billion! They note that this makes CLBP “the third highest bill for any health condition” in the US.

 

We put this site, FixYourOwnBack, together to attempt to capture the various layers of that “onion” and help folks take care of themselves since our aforementioned reductionistic medical approaches seem to failing us miserably. We see CLBP as a process rather than a disease and how you treat the process very much depends on where the person is in that process. Some exciting new studies over the past several years have shed light on one time point in the process and has doctors reconsidering a new tissue strata in the development of CLBP. That tissue strata is the superficial cutaneous neurology that allows us to feel the brush of a feather, a cool breeze or a pin prick. Each of us has felt the absurd amount of pain from a paper cut emanating from such a small, seemingly innocuous injury.

 

Imagine for a moment that you have a similar feeling in your back or upper buttocks and you have no paper cut to attribute it to. Your struggling mind tries to make sense of the ping from those superficial nerves and seeing no overt cause for the discomfort tries to “fill in the blanks” so that you can respond in some way to move away from that pain. You wonder what the reason for that aching pain is. Is it a disc? Is it arthritis? Do I need an Xray or MRI? Do I need surgery? Some Japanese researchers (1-10) have offered a new vantage point on that kind of pain in recent years which implicates superficial nerves called the cluneal nerves in CLBP.

 

Cluneal nerves are divided into 3 groups… superior, medial (or middle) and inferior and collectively provide sensation to most of the skin and superficial tissues across the buttock. The superior and medial cluneal nerves have been most extensively studied to date, and can be seen in the picture below from our sister site, YankAwayPain.com, which shows self help strategies for this type of pain in the back, hip and knees. The yellow lines in the picture are the superior cluneal nerves while the orange denotes the medial cluneal nerves.

 

In investigation of patients with CLBP, these researchers often found the presence of “neural tunnels” around these nerves where they move from deep in the low back muscles, up and over the brim of the pelvic bones. These tunnels appear to be the effect of the nerve having been irritated for some time. They found that a superficial injection of lidocaine was highly effective in reducing that pain in most. In those that didn’t have complete relief from that approach, minor surgery was needed to free up the tethered cluneal nerves and restore pain free status.

In our clinic in Portland, OR, we are not able to provide either the injections or the surgery, so we had to get creative with our hands to see if we could have effect with our patients. Delightfully, we were! (You can see how we do it on that YankAwayPain site and likely save yourself the money you’d spend to try to treat this in a medical office) We found that targeted manual therapy to lift the skin in these areas while having the person move was very helpful in reducing the pain. But remember the onion? We found over time that this cluneal neuropathic pain appeared to us to be a reaction to other perceived threat to tissues deeper down in the spine.

 

We found that many of these cases of back pain began many years earlier as a poor lifting, buckling episode that often involved lumbar disc injury. We theorize that exposure to continued rounded back postures and lifting in that original injury, initiated protective tightening of the lumbar paraspinal erector muscles and remodeling of the lumbodorsal fascia. The cluneal nerves responded nicely to the superficial treatments in our office, but we found that we then needed to help those folks with some basic lifting skills to keep them from re-injuring those deeper spinal structures. There is a bit of controversy as to whether teaching patients these types of lifting methods makes them overly vigilant and worried about the resiliency of their spines. In our office, we reinforce the message that injuries to the spine, even the discs, heal and even higher levels of function can be maintained when good quality movement is scaled in regular exercise. Once tissues knit, the occasional slumped posture while tying your shoes, etc. can be well tolerated. On occasion, those slumped, innocuous postures and movements can trigger a painful spasm if the brain perceives the movement  to be threatening. That’s a deeper topic covered elsewhere on FixYourOwnBack (see Why Bending Forward Scares the Hell Out of You).

 

 

So what’s a person to do? Well, identifying the source of the pinging discomfort in the back is a start, and treating it is the next step. You can find that process well outlined on YankAwayPain. As a bonus, you’ll learn ways to address many types of hip, knee, neck, shoulder, elbow and foot pain that people just think they need to live with until joint replacement surgery. Did I mention that site’s membership comes with a 30 day money back guarantee? 🙂 If you don’t feel confident doing that stuff to yourself, then refer your massage therapist, chiropractor or physical therapist to the site and let them help you out.

Click to Learn Manual Therapy for the Cluneal Nerves

Subscribers here to FixYourOwnBack can work at their own pace to deal with the underlying weakness around the trunk and legs using our innovative chapter-based exercise program to show what exercises to do and when. While many of us that have experienced disc herniation have heard that we should “just do any old exercise”, most of us have experienced a set back from doing certain exercises. FYOB takes the guesswork out of that by applying the same progression of exercises we’ve used to help disc herniation patients in our clinic for over 10 years. Check it out at the link below and join us as a Premium Member for a monthly cost that’s less than what you’d pay for your insurance co-pay or for the refill on the narcotic pain med Rx. If you happen to be near Portland, give our clinic a call and we’ll be happy to help you with all of this in person. Be well!

 

 

References:

1: Kokubo R, Kim K, Isu T, Morimoto D, Iwamoto N, Kobayashi S, Morita A. Superior
cluneal nerve entrapment neuropathy and gluteus medius muscle pain: Their effect
on very old patients with low back pain. World Neurosurg. 2016 Oct 27. pii:
S1878-8750(16)31085-3. doi: 10.1016/j.wneu.2016.10.096. [Epub ahead of print]
PubMed PMID: 27989968.

2: Daijiro M, Toyohiko I, Kyongsong K, Yasuhiro C, Naotaka I, Masanori I, Akio M.
Long-Term Outcome of Surgical Treatment for Superior Cluneal Nerve Entrapment
Neuropathy. Spine (Phila Pa 1976). 2016 Sep 23. [Epub ahead of print] PubMed
PMID: 27669049.

3: Aota Y. Entrapment of middle cluneal nerves as an unknown cause of low back
pain. World J Orthop. 2016 Mar 18;7(3):167-70. doi: 10.5312/wjo.v7.i3.167. PubMed
PMID: 27004164; PubMed Central PMCID: PMC4794535.

4: Morimoto D, Isu T, Kim K, Yamazaki K, Iwamoto N, Isobe M, Morita A.
[Non-Specific Back Pain due to Superior Cluneal Nerve Entrapment Neuropathy
Treated with Neurolysis: A Case Report]. No Shinkei Geka. 2016 Feb;44(2):155-60.
doi: 10.11477/mf.1436203248. Japanese. PubMed PMID: 26856270.

5: Iwamoto N, Isu T, Kim K, Chiba Y, Kokubo R, Morimoto D, Shirai S, Yamazaki K,
Isobe M. Low Back Pain Caused by Superior Cluneal Nerve Entrapment Neuropathy in
Patients with Parkinson Disease. World Neurosurg. 2016 Mar;87:250-4. doi:
10.1016/j.wneu.2015.11.043. PubMed PMID: 26700750.

6: Kim K, Isu T, Chiba Y, Iwamoto N, Yamazaki K, Morimoto D, Isobe M, Inoue K.
Treatment of low back pain in patients with vertebral compression fractures and
superior cluneal nerve entrapment neuropathies. Surg Neurol Int. 2015 Nov
25;6(Suppl 24):S619-21. doi: 10.4103/2152-7806.170455. PubMed PMID: 26693392;
PubMed Central PMCID: PMC4671138.

7: Chiba Y, Isu T, Kim K, Iwamoto N, Morimoto D, Yamazaki K, Hokari M, Isobe M,
Kusano M. Association between intermittent low-back pain and superior cluneal
nerve entrapment neuropathy. J Neurosurg Spine. 2015 Oct 13:1-5. [Epub ahead of
print] PubMed PMID: 26460754.

8: 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. doi: 10.1186/s13018-014-0139-7.
PubMed PMID: 25551470; PubMed Central PMCID: PMC4299373.

9: Kuniya H, Aota Y, Saito T, Kamiya Y, Funakoshi K, Terayama H, Itoh M.
Anatomical study of superior cluneal nerve entrapment. J Neurosurg Spine. 2013
Jul;19(1):76-80. doi: 10.3171/2013.4.SPINE12683. PubMed PMID: 23641672.

10: 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. doi: 10.3171/2013.3.SPINE12420. PubMed PMID: 23621641.

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