Manchester University, The Medical Director, The Spinal Foundation, London, UK.
London College of Osteopathic Medicine, London, UK.
Pain Physician. 2022 Oct;25(7):E1129-E1136.
Paravertebral cluneal nerves are constrained within a tunnel consisting of the thoracolumbar fascia and the iliac crest's superior rim as they pass over the iliac crest. Their involvement in low back pain has not been presented previously.
To develop a diagnostic and therapeutic protocol for radiofrequency ablation of paravertebral and iliac cluneal trigger points.
In a prospective observational cohort study, clinically painful trigger points were anatomically defined with diagnostic local anesthetic injections containing a steroid. Validated trigger points were ablated and the resolution of low back pain was monitored and analyzed.
The Spinal Foundation, The Weymouth Hospital, London, United Kingdom.
Injections at painful trigger points were considered diagnostic if patients reported 50% or more low back pain relief sustained for 10 days or more. These patients were treated with aware state radiofrequency ablation of the trigger points if the back or referred pain remained refractory despite 3 months of core correction physiotherapy. Clinical outcomes were assessed with the visual analog scale (VAS) and Oswestry Disability Index (ODI) scores for low back pain at a minimum follow-up of 2 years.
This prospective feasibility study included 52 patients with an average age of 56.9 ± 14.9 years ranging from 29 to 83. The mean follow-up was 38.33 months ranging from 25 to 66 months. The average symptom duration before the first consultation was 54.8 months. Many patients had multiple failed chronic pain management interventions, including failed epidural steroid injections (28/52, 53.8%); failed facet injections (45/52, 86.5%); failed facet rhizotomies (20/52, 38.5%); and failed sacroiliac joint ablations (34/52, 65/4%). The majority had had spine surgery before presenting with persistent low back or radiating pain. The surgeries were microdiscectomy (38.5%), laminectomy (11.5%), laminotomy (3.8%), endoscopic transforaminal decompression (9.6%), foraminoplasty (1.9%), sacroiliac joint fusion (11.5%), total disc replacement (13.5%), and lumbar fusion (34.6%). Chief concerns were low back (69.2%), buttock pain (71.2%), groin pain (40.4%), trochanteric pain (28.8%), abdominal or flank pain (5.8%), anterior thigh pain (32.7%), and symptoms mimicking sciatica (19.2%). Validated painful trigger points were the lateral (5.7%), superior (48.1%), medial (23.1%), or a combination of 2 (23.1%). The VAS reduction was from 7.25 ± 1.79 to 1.11 ± 0.98 (P < 0.0001). The ODI reduction was from 51.23 ± 9.58 to 7.11 ± 6.69 (P < 0.001). The Prolo score was reduced from 3.59 ± 0.72 to 1.35 ± 0.59. Symptoms resolved completely in 34 (65.4%) patients but persisted slightly in 9 (17.3%) and mildly in another 8 (15.4%). There were no cases of infection, dysesthesia, numbness, or paralysis.
Our study suffers from low patient numbers and the absence of another diagnostic test definitively confirming the presence of painful cluneal nerve involvement.
Cluneal trigger points should be considered in the differential diagnosis of pain in the lower back, flank, lower abdominal, buttock, trochanteric, groin, and thigh area. It is one form of so-called "pseudo-sciatica." The authors' diagnostic injection protocol suggests that most patients with cluneal trigger points may successfully be treated with percutaneous radiofrequency ablation.
当脊肋神经从胸腰椎筋膜和髂嵴的上缘之间穿过髂嵴时，它们会被限制在一个隧道内。它们在腰痛中的作用尚未被提出。
制定脊肋触发点和髂肋触发点射频消融的诊断和治疗方案。
在一项前瞻性观察队列研究中，通过含有类固醇的诊断性局部麻醉注射来解剖学定义临床疼痛触发点。对有效触发点进行消融，并监测和分析腰痛的缓解情况。
英国伦敦韦茅斯医院脊柱基金会。
如果患者报告疼痛缓解 50%或以上，持续 10 天或以上，则认为注射到疼痛触发点的诊断性注射有效。如果背部或放射痛在 3 个月的核心纠正物理治疗后仍然没有缓解，这些患者将接受清醒状态下的射频消融治疗。至少随访 2 年，通过视觉模拟评分（VAS）和 Oswestry 残疾指数（ODI）评分评估临床结果。
这项前瞻性可行性研究纳入了 52 名平均年龄 56.9 ± 14.9 岁（年龄范围 29 至 83 岁）的患者。平均随访时间为 38.33 个月（随访时间范围 25 至 66 个月）。第一次就诊前的平均症状持续时间为 54.8 个月。许多患者经历了多次慢性疼痛管理干预失败，包括硬膜外类固醇注射失败（28/52，53.8%）；关节突注射失败（45/52，86.5%）；关节突切除术失败（20/52，38.5%）；以及骶髂关节消融失败（34/52，65/4%）。大多数患者在出现持续性腰痛或放射痛之前已经接受过脊柱手术。手术包括椎间盘切除术（38.5%）、椎板切除术（11.5%）、椎板切开术（3.8%）、内镜经椎间孔减压术（9.6%）、椎间孔成形术（1.9%）、骶髂关节融合术（11.5%）、全椎间盘置换术（13.5%）和腰椎融合术（34.6%）。主要关注的是腰痛（69.2%）、臀部疼痛（71.2%）、腹股沟疼痛（40.4%）、转子间疼痛（28.8%）、腹部或侧腰部疼痛（5.8%）、大腿前疼痛（32.7%）和类似坐骨神经痛的症状（19.2%）。验证性疼痛触发点为外侧（5.7%）、上侧（48.1%）、内侧（23.1%）或两者结合（23.1%）。VAS 评分从 7.25 ± 1.79 降至 1.11 ± 0.98（P < 0.0001）。ODI 评分从 51.23 ± 9.58 降至 7.11 ± 6.69（P < 0.001）。Prolo 评分从 3.59 ± 0.72 降至 1.35 ± 0.59。34 名（65.4%）患者的症状完全缓解，但 9 名（17.3%）患者症状略有残留，另 8 名（15.4%）患者症状轻度残留。无感染、感觉异常、麻木或瘫痪等并发症发生。
我们的研究存在患者数量少和缺乏其他诊断测试来明确确认存在疼痛性肋神经受累的局限性。
在诊断腰痛、侧腰部、下腹部、臀部、转子间、腹股沟和大腿区域的疼痛时，应考虑脊肋触发点。它是所谓的“假性坐骨神经痛”的一种形式。作者的诊断性注射方案表明，大多数脊肋触发点患者可能会成功地接受经皮射频消融治疗。
